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What is documentation?
The written or typed, legal record of all pertinent interactions with the patient.
What is a Kardex?
A summary of information
What are soap notes and who uses this format?
A format of documentation used by most physicians
Are consults part of the medical record?
Are physicians orders part of the medical record?
Which part of an xray report is important?
the impression isthe important piece
What kind of graphs are important in medical records?
Graphs that show trends
When are I&Os documented?
every 8 hrs unless specified
What are all of the components of a medical record?
- Plan of care
- Nurses notes
- Nursing admission assessment
- Consent forms
- Client education record
- Advance directives
- Operative report
- Pathology report
- Transfusion record
- Restraint record
- Critical pathway
What is the mechanism for PRO review?
Should you always document the results of intervention?
What are the elements of effective documentation?
- Ensure you have the correct chart
- Sign each entry with name and credentials
- Make early first entries on your shift
- Chart at least every 2 hours
- Document all telephone calls related to clients case
- Chart client resonse to meds
- Chart precautions or preventative measurses
- Data from visits by physicians
- Refusal of treatment
- NA for info that doesnt apply
- Chart often enough to tell whole story
- Discharge, referrals, patient teaching
- written instructions
- date and time
What should you always do with calls to physicians?
What else should be charted when charting a symptom?
What you did about it
How should errors in charting be fixed?
cross out with oneline, write mistaken entry, and initial
What type of offense is altering a record?
a criminal offense
What is in a change of shift report?
- Basic identifiying information and current diagnosis
- Current appraisal of patients health status
- Current orders
- Summary of each newly admitted patient
- Report on patients who've been transferred or discharged
What is included in a transfer within an institution?
What is included in telephone reports?
- Self, pt, and relationship to pt
- concise and accurate changes in pt condition of concern and resonse to condition
- current vitals and clinical manisfestations
- havepts record at hand
- record time, date of call, what was communicated, physicians response
What do you needfor client admission?
Authorization from a physician for treatment
On client admissiong what should be the nurses activities?
- Obtain report
- Prepare clients room
- welcome client
- orientate client to area
- safeguard valuables and clothing
- compile nursing data base
- nursing care plan
On cliet discharge, what are the nurse's responsibilities?
- obtain a written medical order
- provide discharge instructions
- notify pertinent departments
- ensure/arrange transportation
- escort client
- gather belongings
- write discharge summary
If a patient leaves against medical advice, what will happen and what should the nurse do?
Insurance won't pay, and the nurse should explain the procedure if the pt wont sign
What should the nurse do in the event of a client transfer?
- inform client and family for need of transfer
- communicate with agency or unit to be transferred to
- photocopy medical record and send with client or fax ahead
- collect client's belongings
- accompany ems or paramedics if necessary
- assist with transfer to stretcher
What has research shown about medical errors?
Disasters result largely from failures in design and organization that can cause operator errors. Bad systems lead to problems with patient safety
What does PDSA stand for?
plan, do , study, act
what is an incident report?
an agency recordofan accident or near miss
Who is at risk for falls?
- 65 and older
- hx of falls
- impaired vision/balance
- altered gait or posture
- meds: diurectics, sedatives, hypnotics, analgesics
- postural hypotension
- slow reaction time
- impaired mobility
- weakness/physical fraility
- unfamiliar environment
Why are many falls unreported?
pt fears independence loss
What is included in the assessment for fall prevention?
- ability to ambulate and transfer
- sensory impairment
What are some inpatient methods used to prevent falls?
- bed rails
- non skid socks
- bed in lowest position
- bed side commode
- call light in reach
- bed alarm
- bedside mats
- clear floors
- proper lighting
- walking aids in reach
- ableto reach any needs
- wheelchair wheels locked
- respond to call lights
- frequent checks
What are some in home fall preventions?
- telephone in reach
- hand held grabbers
- sturdy chairs
- communicate high riskto neighbors
- good kitchen ventilation to prevent glasses fogging
- remove rugs
- hand rails
- lights on steps
- light switch placement
- non slipfloor in tubs
- toilet risers
- clear all pathways
What are the two types of restraints?
chemical and physical
What are some purposes that restraints are used for?
- Reduce risk of injury from falls
- Preven interuption of therapy: ivs, catheter
- Prevent confused or agitated pt from removing life support
- reduce risk of injury to others by agitated client
What is required in order for a restraint to be used?
A written order is required
When are restraint orders updated?
every 24 hrs
Can you put restraints on a patient before an order?
Yes, pt safety comes first. Just be sure to get an order asap.
When is it ok to use restraints?
When all other methods have been exhausted
How often should patients in restraints be checked on?
Every 15 min
What needs to be done when checking on a pt in restraints?
- Assess and document condition of pt: skin and circulation
- Reposition the pt
- Assist with toileting and offer fluids
- Reassess need for restraints
What could you do to prevent the use of restraints?
- Orient pt
- encourage family/friends to stay with pt
- keep confused pts near nursing station
- use diversionary activities
- familiarize environment
- maintain frequent toileting routine
- reposition and ambulate frequently
- evaluate meds
- use relaxation techniques
What should you do in the even of pt poisoning?
- Treat the pt first and then the poison.
What are some common S&S of accidental poisoning?
- change in appearance/behavior
- burns, blisters, suspicious odor in mouth
- longer naps than usual
What are the secondary steps in poison control?
- Identify the poison
- time and amount ingested
- save any vomitus
- call poison control center
What are the tests used in diagnostics?
- Urine and serum analysis
- CAT scan, EEG
- Liver enzymes
What is the guideline to follow in disaster planning?
Do the greatest good for the greatest number of people
Which pts have the most priority in diaster planning?
resources should be used for pts with the strongest possibility of survival
What is included in disaster planning?
- notification and communication of disaster
- all available staff required to report
- use of diagnostic procedures limited
- use of hospital resources determined by designated med officer
- areas of hospital used as needed for treatment
- person designated to deal with media and traffic control
What are the nurse's responsibilities in diasaster planning?
- assess nursing unit for resources
- assess current clients for discharge
- activate staff recall plan
- communicate with hospital disaster control center
What are the levels are triage in disaster planning?
- red: unstable, need immediate care to save
- yellow: stable, can wait 30-60 min
- green: stable, can wait longer
- black: unstable and probably fatal
- doa: dead on admission
What are the interventions in disaster planning?
- render first aid
- care standardized to standing orders (dont need phys order)
- specialistsbecome generalists
- expanded nursing responsibilities
- emotional and spiritual care to pts and families
Evaluation of diaster planning includes what?
- have clients been cared for in orderly fashion?
- have client's physical needs been met?