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Legal guidelines for documentation include:
- Always start with day and time.
- Legibility.
- Do NOT use correction tape or black out errors.
- To insert omitted data label as "late entry" Include time and date charting done and specific time charge reflects.
- Sign with Signature and Title when making entry
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General guidlines for documentation include
- Accuracy.
- Completeness.
- Conciseness.
- Objectivity.
- Organization.
- Timeliness.
- Legibility
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Important Documentation Rules
- No Interpretaiton - Just Facts.
- Never Assume.
- Chart in "quotes" what pt states.
- Keep it Pertinent to clients car & Dx.
- Chart all teaching/education of client/family.
- Always start with date & time.
- Never leave blanks.
- Chart for yourself only.
- No generalized statements - ie., unchanged.
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Documentation should reflect:
- Assessment.
- Interventions.
- Evaluations performed by the person signing entry.
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Documentation Formats include:
- Flow Chart.
- Narrative Documentation Records.
- Charting by Exception (CBE)
- Clinical Pathways.
- Problem Orientated(POMR)
- Computerized Documentation.
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Use of Flow Charts Records and Shows Trends for:
- Vital Signs.
- Blood Glucose Levels.
- Pain Level.
- Frequently Performed Assessments.
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Narrative Documentation records:
Information as a sequence of events.
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Problem-Orientated Medical Records (POMR) Include:
- database.
- problem list.
- care plan.
- progress notes.
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Forms of Problem-Oriented Medical Records (POMR) Include:
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SOAPIE Stands for
- Subjective Data
- Objectie Data.
- Assesment (includes Nursing Dx)
- Plan
- Intervention
- Evaluation
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PIE stands for:
- Problem
- Intervention
- Evaluation
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Computerized documentation Advantages Include;
- Standardiazation.
- Accuracy.
- Convidentiality.
- Ease of Acess for Multi users.
- Transfer of Client Information.
- Access of data from other disciplines
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Computerized documentaiton Challenges includes:
- Learning new system.
- Knowing how to correct errors.
- Maintaing security.
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Therapeutic Communication Techniques Include:
- *Offering Self
- *Open Ended Questions
- *Opening Remarks
- *Restatement
- *Reflection
- *Focusing
- *Encouraging Elaboration
- *Seeking Clarification
- *Giving Information
- *Looking at Alternatives
- *Silence
- *Summarizing
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The Therapeutic Communicaiton Technique Opening Remarks is the:
Use of general staements based on observations and asesments about the client.
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The Therapeutic Communication Technique Focusing is the:
Asking of goal-directed questions to help the client focus on key concerns.
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The Therapeutic Communication Technique Reflection is:
Identifying the main emotional themes contained in a communication and directing these back to the client.
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Intrapersonal Communication is
Communication that occurs within an individual. "Self-Talk"
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Intrapersonal Communication is:
Communication that occurs between two people.
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Public Communication is:
Communication that occurs within a large group of people.
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Transpersonal Communication is:
Addressing spiritual needs and provides interventions to meet these needs.
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Small Group communicaiton is:
Communication within a group of people
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Communication Channels are:
method of transmitting and receiving a message (received via sight, hearning, and/or touch.)
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Ethics Frameworks include
- Utilitarian Framework.
- Deontology Framework.
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Utilitarian Framework is:
- The proposal that the value of something is determined by its usefulness.
- Good of the Community.
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Deontology Framework is:
- Defind actions as right or wrong
- Greater good - w/o regard to consequences.
- Morally Obligated to Fulfill.
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Principles of Healthcare Ethics include:
- Beneficence.
- Nonmaleficence
- Respect fo Autonomy
- Justice
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Beneficence Means:
- Act on best interest of the patient.
- Agreement that the care given is in the best interest of the client.
- Taking positive action to help others.
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Nonmaleficence means:
- Do no Harm.
- Avoidance of harm or pain as much as possible when giving treatments.
- Extention of beneficence.
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Respect for Autonomy
- Ability of the client to make personal decisions, even when those decisions may not be in the client's own best interest.
- Patient Bill of Rights
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Justice means:
- Moral obligation
- Fairly.
- Equal.
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Specific procedures of Advance Directives (DNR)
- Employee of Healthcare provider prohibited from being a witness.
- Can be recinded at any time for any reason.
- Legal advice not required.
- Know resuscitation status.
- Must initiate CPR until code status is verified if code status unknown.
- Once no-code status verified CPR can be stopped.
- If there is not a code order and the client wishes for end o life care are not followed because of this lack of order, the nurse is esponsible for ensuring that the order is obtained.
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Basic Learning Principles include:
- Motivation to learn.
- Ability to learn.
- Learning environment.
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Domains of Learning include:
- Cognitive.
- Affective.
- Psychomotor.
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Cognitive Learning means:
- Refer to rational thought .
- Includes all intellectual behaviors
- Thinking
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Affective Learning means:
- Refers to emotions or feelings.
- Deals with expressions of feelings and acceptance of attitiudes, opinions, or values.
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Psychomotor learning means:
- Muscular movements.
- Learning to perform new physical skills and procedures.
- Involves acquiring skills that require integration of mental and muscular activity.
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Methods for Evaluating Outcomes of Teaching and Learning Include:
- Writtent Test.
- Oral Test.
- Return demonstrations.
- Check off list.
- Questionaires.
- Simulations.
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Verbal Methods Of Communication Include:
- Handoff Reporting
- Change of Shift Reporting
- Nursing Rounds
- Telephone Report
- Report to Primary Care Provider
- Interdisciplinary Team
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The best way to conduct Verbal Communication is to use which method?
- SBAR
- S-Situations
- B-Background
- A-Assessment
- R-Recommendations
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SBAR Means
- Situations - What is happening at the present time?
- Background - What are the circumstances leading up to this situations?
- Assessment- What do I think the problem is?
- Recommendations - What should we do to correct the problem?
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The purpose of Flowsheets Is:
- Document Routine Nursing Procedures.
- Gives graphic on Vitals so trends can be evaluated.
- Allows nurse to make checkmark that assessment findings and care fall w/n agency standards.
- Documentation required when change of status or changes from standards occurs.
- N/A may be required for infomraion not completed.
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The Purpose of Plans of Care is:
- Organized in a practical, concise format for daily use.
- Less specific details.
- Rationales are not documented.
- Individualized for each client.
- Uses findings from Nursing Assessment and Indentified Nursing Dx.
- Exact written form can very.
- Identify Problems & Establish plan of care.
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Documentation in Plans of Care Include
- Indentify problems & establis plan of Care
- Resolve with a highliter or draw a line.
- Write date resolved
- Never erase or get rid of plan.
- Add new plans as they arise.
- Usually Numbered.
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Consultation is:
- One professional caregiver gives formal advice about the healthcare of a client to another caregiver.
- "Tell me what you recommend."
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Referral is:
- Request for serices by another provider to determine appropriate client care.
- "Could I manage this pt or should you take this one?"
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How are you to handle error in documentation:
- No white out.
- No "scratching" out.
- Do NOT hide error.
- Draw a line through error and initial!
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Malpractice happens when:
- Failure to record nursing actions.
- Failure to record administration of medications.
- Failure to record drug reaxtions or changes in pt's condition.
- Writing illegible or incomplet records.
- Failure to document a discontinued med.
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The purpose of Critical Pathways includes:
- A guide for care of clients who have specific and generally predicible conditions.
- Serve as models for ensuring quality of care.
- Serves as multidisciplinary tool to view continuing needs
- Identifys the expected progression to discharge.
- Provides direction about major interventions.
- VARIANCE - documented in detail usually with use of narrative notes.
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Basic Learning Principles Motivation to learn is:
Addresses the client's desire or willingness to learn.
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Basic Learning Principle Ability to Learn Depends on:
- Physical abilities
- Cognitive abilities
- Developmental level.
- Physical wellness.
- Thought process.
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Basic Learning Principles of Learning Enviornment is:
Allows a perosn to attend instruction.
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4 Domains of Barriers to Learning include:
- External Barrier - Enviornmental
- External Barrier - Sociocultural
- Internal Barrier - Psychological
- Internal Barrier - Physiological
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External Environmental Barriers to learning are:
- Interruptions.
- Lack of Privacy.
- Multiple Stimuli.
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Exteral Sociocultural Barriers to learning are:
- Language
- Value Systems
- Educational Background.
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Internal Psychological Barriers to learning are:
- Anxiety.
- Fear.
- Anger.
- Depression.
- Inability to Comprehend.
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Internal Physicological Barriers to learning are:
- Pain.
- Fatigue.
- Sensory deprivation.
- Oxygen deprivation.
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5 step Teaching Process Is:
- 1.Collection of data, Analyze learning strenths and deficits.
- 2.Make educational diagnoses.
- 3.Prepare teaching plan
- 4.Implement teaching plan
- 5.Evaluate client learning based on achievement of learning outcomes.
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To prepare a Teaching plan you must:
- Wright learning outcomes.
- Select content and time frame.
- Select teaching strategies.
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5 steps to Nursing Process
- 1.Collect data analyze clients strengths and deficits.
- 2.Make nursing diagnoses.
- 3.Plan nursing goals/desired outcomes and select interventions.
- 4. Implement nursing strategies.
- 5.Evaluate client outcomes based on achievment of goal criteria.
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