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Legal guidelines for documentation include:
Always start with day and time.
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
General guidlines for documentation include
Important Documentation Rules
No Interpretaiton - Just Facts.
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.
Documentation should reflect:
Evaluations performed by the person signing entry.
Documentation Formats include:
Narrative Documentation Records.
Charting by Exception (CBE)
Use of Flow Charts Records and Shows Trends for:
Blood Glucose Levels.
Frequently Performed Assessments.
Narrative Documentation records:
Information as a sequence of events.
Problem-Orientated Medical Records (POMR) Include:
Forms of Problem-Oriented Medical Records (POMR) Include:
SOAPIE Stands for
Assesment (includes Nursing Dx)
PIE stands for:
DAR stands For
Computerized documentation Advantages Include;
Ease of Acess for Multi users.
Transfer of Client Information.
Access of data from other disciplines
Computerized documentaiton Challenges includes:
Learning new system.
Knowing how to correct errors.
Therapeutic Communication Techniques Include:
*Open Ended Questions
*Looking at Alternatives
The Therapeutic Communicaiton Technique Opening Remarks is the:
Use of general staements based on observations and asesments about the client.
The Therapeutic Communication Technique Focusing is the:
Asking of goal-directed questions to help the client focus on key concerns.
The Therapeutic Communication Technique Reflection is:
Identifying the main emotional themes contained in a communication and directing these back to the client.
Intrapersonal Communication is
Communication that occurs within an individual. "Self-Talk"
Intrapersonal Communication is:
Communication that occurs between two people.
Public Communication is:
Communication that occurs within a large group of people.
Transpersonal Communication is:
Addressing spiritual needs and provides interventions to meet these needs.
Small Group communicaiton is:
Communication within a group of people
Communication Channels are:
method of transmitting and receiving a message (received via sight, hearning, and/or touch.)
Ethics Frameworks include
Utilitarian Framework is:
The proposal that the value of something is determined by its usefulness.
Good of the Community.
Deontology Framework is:
Defind actions as right or wrong
Greater good - w/o regard to consequences.
Morally Obligated to Fulfill.
Principles of Healthcare Ethics include:
Respect fo Autonomy
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.
Do no Harm.
Avoidance of harm or pain as much as possible when giving treatments.
Extention of beneficence
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
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.
Basic Learning Principles include:
Motivation to learn.
Ability to learn.
Domains of Learning include:
Cognitive Learning means:
Refer to rational thought .
Includes all intellectual behaviors
Affective Learning means:
Refers to emotions or feelings.
Deals with expressions of feelings and acceptance of attitiudes, opinions, or values.
Psychomotor learning means:
Learning to perform new physical skills and procedures.
Involves acquiring skills that require integration of mental and muscular activity.
Methods for Evaluating Outcomes of Teaching and Learning Include:
Check off list.
Verbal Methods Of Communication Include:
Change of Shift Reporting
Report to Primary Care Provider
The best way to conduct Verbal Communication is to use which method?
ituations - What is happening at the present time?
ackground - What are the circumstances leading up to this situations?
ssessment- What do I think the problem is?
ecommendations - What should we do to correct the problem?
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.
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.
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.
One professional caregiver gives formal advice about the healthcare of a client to another caregiver.
"Tell me what you recommend."
Request for serices by another provider to determine appropriate client care.
"Could I manage this pt or should you take this one?"
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!
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.
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.
Basic Learning Principles Motivation to learn is:
Addresses the client's desire or willingness to learn.
Basic Learning Principle Ability to Learn Depends on:
Basic Learning Principles of Learning Enviornment is:
Allows a perosn to attend instruction.
4 Domains of Barriers to Learning include:
External Barrier - Enviornmental
External Barrier - Sociocultural
Internal Barrier - Psychological
Internal Barrier - Physiological
External Environmental Barriers to learning are:
Lack of Privacy.
Exteral Sociocultural Barriers to learning are:
Internal Psychological Barriers to learning are:
Inability to Comprehend.
Internal Physicological Barriers to learning are:
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.
To prepare a Teaching plan you must:
Wright learning outcomes.
Select content and time frame.
Select teaching strategies.
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.
Card Set Information
Documentation, Values & Ethics, Pt education, Cultural & Ethnicity, Communication,
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