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Week 12/13
Documentation Guidelines
Factual
Objective Information
Subjective Information from Patient
Objective Supports Subjective
Accurate
Avoid Unnecessary Words and Details
Exact Measurements
Current
Assessments
Document ASAP
Treatment and Response
Change in Status
Admission, Transfer, Discharge or Death
Organized
Document in a Logical Order
Ensure Information Recorded is Complete
4 mins
Tort Law
Tort Law
Tort
Intentional Tort
Assault
False Imprisonment
Battery
Unintentional Tort
Negligence
Malpractice
Legal Issues
Documentation
3 mins
6 Rights of Medication Administration
Right Patient
Right Medication
Right Dose
Right Time
Right Route
Right Documentation
Nursing Considerations
Three Checks
Check for Allergies
Assess the Patient
Education
2 mins
Negligence and Malpractice
Failure to Provide Acceptable Care
Anyone Can be Liable
Did Not Carry Out Duty and Patient Was Injured
Must Be a Professional
Not Following Standard of Care
Failure to Communicate
Failure to Document
Failure to Assess and Monitor Patient
Improper Delegation
3 mins
Reports
Reporting
Shared Communication
ISBAR
ISBAR
Identify
Situation
Background
Assessment
Recommendation
Types of Reports
Change-of-Shift/Handoff Reports
Telephone/Telemedicine Reports
Transfer and Discharge Reports
2 mins
Level of Consciousness: Descriptive guide for Glasgow Coma Scale
Conscious
Confused
Delirious
Somnolent
Obtunded
Stuporous
Comatose
3 mins
Advanced Directives
Advance Care Planning
Process of Planning for Future Care
Living Will
Instructions about Healthcare
Life-Sustaining Treatments
Level of Comfort Care
Artificial Nutrition and Hydration
Durable Power of Attorney for Healthcare
Appointed Person to Make Decisions
Do Not Resuscitate (DNR)
No CPR
Allow Natural Death (AND)
Physician Order for Life-Sustaining Treatment (POLST)
Medical Order
3 mins
Health Insurance Portability and Accountability Act (HIPAA)
Protected Health Information
Confidentiality
HIPAA Patient Rights
See and Copy Health Records
Update and Correct Health Record
Use and Disclosure of Protected Health Information
How to Receive Health Information
Permitted Disclosure of Personal Health Information (PHI) Without Patient Authorization
Public Health Activities
Law Enforcement
Deceased People
3 mins
Suicide Assessment
SAD PERSONS Scale
Verbal Cues
Direct (Overt) Statements
Indirect (Covert) Statements
Behavioral Cues
Giving Away Prized Possessions
Sudden Improvement in Mood
Putting Personal Affairs in Order
Lethality of Plan
Detail of Plan
Availability of Means
Proposed Method
Suicide Precautions
Safe Environment
One-on-One Monitoring
No Suicide Contract
2 mins
Glasgow Coma Scale
LOC Assessment
Score of 3 to 15
8 or Less = Coma
Eye Opening
Verbal Response
Motor Response
1 min
Informed Consent
Key Elements
Names and Qualifications of People Involved
Explanation of the Procedure
Information on Harm that Can Result
Alternative Therapies
Right to Refuse
Nurses and Consent
Nurses May Witness Consent
Student Nurses Do Not Witness Consent
Emergency
Consent from Legally Authorized Person
Life Saving Procedure Without Consent
Special Considerations
Deaf, Illiterate, Speaks a Foreign Language
4 mins
Assessment
Health History
Objective Data
Subjective Data
TEST-TAKING STRATEGY: KEY WORDS
Identify
Determine
Obtain Information
CONSIDERATIONS
Assessment Always Done Before Treatments
3 mins
Implementation
Types of Nursing Interventions
Direct Care Interventions
Indirect Care Interventions
A Community (Public Health) Intervention
Implementing the Care Plan
Partnership with the Patient/Family
Performing the Nursing Action
Documenting Nursing Care
Delegating Nursing Care
TEST-TAKING STRATEGY: KEY WORDS
Intervene
Priority Action
3 mins
Planning
Nursing Care Plan
Tailored to Patient
Short-and-Long-Term Goals
SMART GOALS
Specific
Measurable
Attainable
Realistic
Time-Oriented
2 mins
Diagnosis
A COMPARISON
Medical Diagnosis
Nursing Diagnosis
Collaborative Problem
Data Interpretation and Analysis
Significant Data
Patterns or Clusters
Parts of Nursing Diagnosis Statement
Problem
Etiology
Defining Characteristics
TEST-TAKING STRATEGY: KEY WORDS
Maslow’s Pyramid
Patient’s Concerns
2 mins
How to Write a NANDA Nursing Diagnosis
Nursing Diagnosis
Nursing Diagnosis Components
Problem Statement
Etiology
Defining Characteristics or Risk factors
4 Types of Nursing Diagnoses
Problem-Focused
Risk
Health Promotion
Syndrome
Steps For Writing a Problem-Focused Diagnosis
(Problem-Focused Diagnosis) related to________(Related Factors) as evidenced by _____________ (Defining Characteristics).
Steps For Writing a Risk Diagnosis
Risk for_____as evidenced by_____(Risk Factors).
3 mins
Tuberculosis Skin Mantoux Test (PPD)
Delayed Hypersensitivity (Cell Mediated Response)
Intradermal Injection
Read 48-72 hours
Positive Results
≥ 5 mm Induration
Immunosuppressed
≥ 10 mm Induration
High Risk Patients
≥ 15 mm Induration
Considerations
Chest X-Ray
3 mins
Pyelogram
Indications
Visualizes Urinary Tract
Diagnose Urinary Disorders
Considerations
Bowel Prep (Enema)
IV Contrast Media
X-Ray (Radiopaque)
Increase Fluid Intake
Contraindications
Iodine Allergy
Decreased Renal Function
2 mins
Magnetic Resonance Imaging (MRI)
Procedure
Internal Body Images
Detects Variations of Soft Tissues
Considerations
No Metal Objects
No Pacemakers
Contrast is Non-Iodine
Safe During Pregnancy
Long Procedure
Antianxiety Medications
2 mins
Oral Glucose Tolerance Test (OGTT)
Used for Diabetes Screening
Fasting State
Samples Drawn
Baseline
Normal < 100 mg/dL
30 and 60 Minutes
Normal < 200 mg/dL
120 Minutes
Normal < 140 mg/dL
2 mins
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