Communication and Digital Health

Question 1

What are the four main goals of a medical record?

Answer 1

To communicate, document, plan and evaluate patient progress

Question 2

What’s an EMR?

Answer 2

Electronic Medical Record. A digital version of traditional paper based medical record mostly used in hospital setting

Question 3

What’s a PCEHR?

Answer 3

Personally Controlled Electronic Health Record. A health record made collaboratively with patient and health provider. Allows patient to plan and manage their healthcare with information about medications and referrals

Question 4

What are the components of an ISBAR handover?

Answer 4

Identify
Situation
Background
Assessment
Requests

Question 5

Identify

Answer 5

Identify yourself, including your name position and location. Identify the patient and their UR number

Question 6

Situation

Answer 6

Explain the purpose of the interaction. Ensure that all parties are on the same page

Question 7

Background

Answer 7

Provide relevant information about the patient’s history. Include relevant examinations performed as well as details around investigation and management of the patient

Question 8

Assessment

Answer 8

Where you state what you believe is going on with the patient, your interpretation of the situation that should be made explicitly clear.

Question 9

Requests or Recommendations

Answer 9

Where you tell the receiver what it is you want from them. What further assessments and recommendations are required by who and when

Question 10

What are the four ways of administering injectable medications (parenteral)

Answer 10

Subcut
Intramuscular
Intravenous
Intradermal

Question 11

At what angles should the different non-IV injection types be administered?

Answer 11

Subcut: 45
Intramuscular: 90
Intradermal: 15

Question 12

Where should subcut and intramuscular injections be administered?

Answer 12

Subcut: Into loose connective tissue under dermis. Injection sites on belly, thighs, small of back and upper back, outer upper arm.

Intramuscular: Into the muscle. Location sites on upper arm, thigh muscle and into the hip muscles

Question 13

What should always be included in progress notes?

Answer 13

Date and time of every entry
Print your surname, designation and signature countersigned by buddy nurse.
Have a patient ID on front and back with UR number and surname

Question 14

What systems and categories can be included in progress notes in correct order?
(Depending on institution)

Answer 14

Summary
CNS
CVS
Resp
Renal
GIT
Metabolic
MSK
Integ
Other
Care plan
Discharge plan