Ch16 Documentation/Communication

Question 1

Purposes of pt record

Answer 1

Communication 
Assessment 
Care planning
Legal documentation 
Quality assurance 
Reimbursement 
Research 
Education

Question 2

What are the principles of communication?

Answer 2

Confidentiality 
Accuracy 
Conciseness and completeness 
Objective data
Organized &timely

Question 3

Types of nursing process notes

Answer 3

Narrative notes
SOAP -subj data/obj data/ assessment / planning
PIE-planning intervention evaluation
FOCUS(DAR)

Question 4

Nursing entries in pt records

Answer 4

Flow sheets-tables w columns that allow for documentation of routine assessments/ procedures

Plan of care- contains nursing Dx, goals, outcome criteria, interventions, evaluations
ALWAYS INDIVIDUALIZED

Critical pathways-Multidisciplinary tools that ID expected progression of pts toward discharge.
Used for pts requiring complex care, or for frequently encountered situation

Question 5

Pt handoffs

Answer 5

Happens when one provider transfers responsibility and accountability for the care of the pt to another provider
SBAR-
situation -whats happening st the present time?
background-what are the circumstances leading up to the situation?
assessment -what’s the prob?
recommendations- what should be done to correct the problem?

Question 6

TeamSTEPPS

Answer 6

Team Strategies & Tools to Enhance Performance & Pt Safety
Safety curriculum designed to improve pt outcomes by cultivating teamwork among providers
SBAR
Call out
Check back
Hand off
CUS (I’m concerned/I’m uncomfortable/ this is a safety issue)

Question 7

Variance

Answer 7

Occurs when pt does not proceed along the clinical pathway as planned(staying time)