Communication and Documentation Flashcards
What is the only way to ensure understanding?
acknowledgement of receipt of the info is the only way to know that communication has taken place
What is the best kind of communication?
face to face communication
What should be hard wired into every discussion involving patient care?
the opportunity to ask questions
When is asking questions particularly important?
- hand offs
- time outs
- patient education
- verbal orders
What should we do to help prevent the misunderstanding that typically precedes a patient error?
clarifying that information
the joint commission has identified what as a critical patient safety issue?
effective communication
What about the perioperative environment can influence the accurate intake of info and discourage dialogue to clarify unfamiliar terms, which can cause errors in the delivery, receipt, acknowledgement, or documentation of patient care?
the stressful, high-paced perioperative environment
What prevent the observation of visual and nonverbal cues?
masks
What can discourage staff from asking questions or speaking up about a potentially unsafe practice?
the hierarchical structure of the operating room, with its top-down method of info delivery
Are monitors, equipment, radios, and alarms an issue?
yes they add to the ambient noise level
What are 11 possible squelae to ineffective communication?
- adverse events
- preventable errors
- avoidable readmissions
- procedural delays
- inappropriate treatments
- increased costs
- increased length of hospital stay
- inefficiencies
- omissions in care
- wasted resource s
- stressful work environments
- other negative patient experiences
What are 4 ways that RN’s can share pertinent information accurately and efficiently with other members of the interdisciplinary team?
- tools
- hand offs
- safe verbal order practices
- debriefs
The use of standardized tools for communicating pertinent infromation on the status of the patient improves what?
the transmission and quality of the information being communicated, thus affecting patient outcomes
What can tools be used as a guide for?
a guide to communicate important information to incorporate in the design and implementation of safe and effective patient care
What are 4 frequently used tools in the perioperative setting?
- SBAR
- I PASS THE BATON
- SWITCH
- SURPASS
What does SBAR stand for?
Situation, Background, Assessment, Recommendation
What does I PASS the BATON stand for?
Introduction, Patient, Assessment, Situation, Safety Concerns, (the) Background, Actions, Timing, Ownership, Next
What does SWITCH stand for?
Surgical procedure, Wet, Instruments, Tissue, Counts, Have you any questions
What does SURPASS stand for?
Surgical Patient Safety System
As the patient travels through the phases of the surgical experience, what are used?
hand offs
What do handoffs do?
they are used to communicate information from a health care provider in one setting to a provider in another setting or to a home caregiver to ensure the continuity and safety of the patient’s care
What does the quality of handoffs do?
has a direct effect on patient safety and optimal patient outcomes
When should hand offs occur?
always occur at a change of shift or during relief of personnel
What is one of the most important communication tools available to protect the patient from surgery on wrong site or side?
the Joint Commissions’s Universal Protocol
When is the Joint Commissions’s Universal Protocol initiated?
during the preoperative prep phase
When does the the Joint Commissions’s Universal Protocol continue?
when the RN circulator conducts a preprocedural verification process
What is the final part of the universal protocol?
the time out conducted when the patient enters the operative or invasive procedure area
the time out provides what?
provides a multidisciplinary approach in which each member of the team is introduced and participates actively in the final verification of correct patient, site, and surgery
What is the purpose of the timeout process?
to address any missing information or discrepancies before starting the procedure
What is the RN’s role in the timeout?
verifies the correct patient using 2 patient identifiers
What is the team’s role in the time out process? (2 things)
- the team validates that they are about to perform the correct procedure on the correct patient, on the correct side, and at the correct level
- each team member describes how he or she is prepared to prevent or address that risk
What should be known by the end of the timeout and before the initial incision?
all the known elements that place the patient at risk should have been discussed and resolved
What should be done when an RN receives a verbal order?
reading back (repeating the order) and entering the order in the patient record as close as possible to the time the order was given help to maintain the accuracy of the message
all verbal orders must be included where?
in the patient’s medical record, dated, timed, and authenticated by the persons issuing and receiving the orders
What is especially important when an unexpected adverse incident (i.e. procedures involving trauma, death in the OR) occurs?
providing a debriefing opportunity
What is the debrief an opportunity for?
an opportunity to identify successes and opportunities for improvement
A simple debriefing tool answers what 3 questions?
- What went well?
- What could be improved for next time (systems, supplies, staffing, communciation, safety)?
- How can these issues be resolved and prevented?
What should be included in all applicable team member communciations that could affect the surgical experience?
- critical lab values
- allergies
- implants
- comorbidities
- medications
What is another word for critical lab values?
panic values
define critical lab values?
defined as results that are outside established norms and considered life threatening
In the perioperative setting, who should be notified when there is a critical lab value?
surgeon, anesthesia care provder, or other health care providers involved with the patient’s care
What should documentation of a critical lab value include?
time, date, and persons to whom this information was transmitted
team members working in a culture of patient safety are encourage to do what?
speak up whenever there is an opportunity to prevent an error
What reactions should people pay special attention to?
special attention should be patid to patient reports of difficulty breathing or swallowing, hives, and swelling of the face, lips, or tongue
In addition to documentation on the patient’s medical record, facilities use a what to signify an allergy?
a color-coded bracelet
When should allergies be communicated?
during the time out and all patient hand-offs
Where is the presence of allergies initially verified?
during the preoperative preparation of the patient
For patients with an existing implant, what should be documented and communicated to the surgical team?
the type of device and its location
What is important to discuss and implenet into the plan of care?
special care related to the implant’s function during the procedure
For devices implanted during surgery, the US Food and Drug Admin is responsible for what?
tracking medical devices
Manufacturers of implants are required to do what 3 things?
- track devices whose failure would be reasonable likely to have serious adverse health consequences
- that are intented to be implanted in the human body for more than 1 year
- or that are life-sustaining or life-supporting
At minimum, documentation for any implanted device should include what?
- the lot, batch, and serial numbers of the implanted device
- the manufacture and expiration dates of the implanted device
- the patient’s name and contact info
- the facility where the device was implanted
- the name and contact info of the surgeon implanting the device
What the Joint Comission continue to list as one of its National Patient Safety Goals?
medication safety
What is the purpose of medication reconciliation?
the decrease the number of med errors related to discrepancies between home and facility-ordered medications
medications should be reviewed at every transition in care to ensure what?
there are no omissions, duplications, contraindications, or unclear information between the current and proposed medications
When does medication review start first?
beginning with the preoperative assessment
With the increase in same-day surgeries, the patient’s home can be considered what?
an extension of PACU
What does the patient’s home being an extension of PACU require?
necessitates postoperative instructions and patient education that can be understood and adhered to by nonmedical persons
when does a transfer of care occur?
as the patient undergoing an operative or other invasive procedure transitions through the pre-, intra-, and postoperative phases of care
what is transfer of care communication like? why?
telephone; the risk of inaccurate or forgotten info increases during each transfer of care from one team member to another
What are the 4 transfers of care during the perioperative continuum of care?
- preoperative care provider to preoperative nurse
- preoperative nurse to intraoperative nurse
- intraoperative nurse to postoperative nurse
- postoperative nurse to patient and his or her family member, other health care (i.e. home care nurse, visiting nurse, other community resource) or next level of in-hospital care
the 4 transfers of care have specific what?
transfer of care criteria
what is transfer of care criteria based on?
the perioperative phases of care
What does use of a standardized hand-over tool do?
- reduces errors and omissions of important information
- helps promote a seamless transition betweeen the phases of the perioperative experience
Ideally, when should a patient be evaluated? but no more than when?
approximately 2 weeks; but no more than 30 days
At the preoperative care provider apppointment what is done?
- performs a complete head-to-toe physical assessment that includes all body systems
- obtains and documents the patient’s patient’s past and current history of medical conditions, any previous surgical procedures, and significant medical and surgical histories of family members.
What does the preop care provider use the preoperative assessment for?
as a risk factor assessment to determine whether additional preoperative testing is required
When may a preoperative nurse at a surgery center perform a preop evaluation?
may perform components of the evaluation (except for the actual physical examination and ordering of additional preoperative tests) before or on the day of the surgery
In the surgery center situation much of the preop interview is conducted by how?
phone; including providing preoperative education
When does the preop telephonic interview normally occur?
a day or 2 before surgery
What may a preop nurse note on their day of surgery assessment of the patient?
any unusual or abnormal findings that may affect patient outcomes (altered skin integrity, neuro status)
What does the preop nurse use to begin formulating the individualized perioperative plan of care?
- the findings from the preoperative evaluation
- the results of any testing
- the current patient status to begin to formulate an individualized preoperative plan of care
What increases when there is a change in personnel in the OR?
- the chance of errors
- miscommunication
- lack of communication
What is best as far as transfer of care?
less of them
What is good when intraoperative nurse is giving handoff to postoperative nurse?
providing advanced notice allows the receiving nurse the opportunity to prepare for the patient’s arrival
During the final minutes of the procedure and at a point when intraop care will not be compromised, what should the RN do?
provides a report to the nurse from the receiving unit
What are the phases for transfers of care?
- preoperative phase
- intraoperative phase
- immediate postoperative phase in the… PACU, ICU, or another anxillary department such as radiology
- home, inpatient nursing unit, skilled nursing unit
What 3 things does the type of postoperative care depend on?
- depends on the procedure
- unique needs of the patient
- and type of anesthetic the patient received
What does the American Society of PeriAnesthesia nurses define phase I as?
as the level of care typically provided in a PACU or ICU
What do patients in phase I require?
- close monitoring - including airway and ventillatory support, assessment of hemodynamic status, pain management, fluid management, and other acute aspects of patient care
After meeting criteria for discharge from Phase I, the patient transitions to what?
Phase II level of care
Based on the facility, phase I and phase II may occur where?
in the same room
In Phase II, what happens?
care and assistance to the patient care are provided before discharge to home or an extended care environment
How does a patient move from one phase to another?
by meeting criteria established by regulatory and accreditation requirements and facility policies and procedures
What scoring system do some facilities use to determine whether.a patient has met defined discharge criteria?
aldrete system or postanesthesia scoring system
What has happened with the increase in the number of same day surgery patients?
criteria have been established specifically to meet the needs for the safe transition to home for the ambulatory surgery patient
What does the Post Anesthetic Discharge Scoring System include?
safe parameters for vital signs, ambulation, nausea and vomiting, pain, bleeding, and voiding
What must patients score a minimum of what on the Post Anesthetic Discharge Scoring System in order to go home?
9
Ideally when does discharge planning start?
when the decision for surgery is made
at minimum, the interdisciplinary services discharge team consists of what?
patient, a family member or significant other to provide home care for at least the first 24 hours, the surgeon, and nurses from all phases of the surgical experience
What should discharge planning include?
- a review of the reconciled med list
- a review of dates and contact info for follow-up appointments
- a description of any home care or resources needed
- patient education with the use of teach back
- an overview of wound care
- an overview of warning signs and symptoms of possible complications and information to who to call
- an overview of restrictions on diet, mobility
What should the patient’s responsible party sign after the nurse has completed the postoperative patient education?
a printed patient discharge instruction sheet
What is included on a discharge sheet?
- follow up provider appointments
- follow up lab or radiological tests
- postoperative restrictions
- wound care
What numbers should be on the discharge sheeet
telephone numbers for the patient’s physician or answering service and when to call 911 are noted
true or false; a copy of the patient’s final medication reconciliation sheet should be provided to the patient or responsible adult after reviewing it for medication dosages, administration times, side effects, or drug drug interactions
true
What is the process of giving the final medication reconciliation sheet intended to reduce?
the number of adverse drug events that may lead to an emergency department visit or readmission
a follow up phone call within what time frame of the patient’s discharge can identify and address any questions or problems that paitent may have encountered in the first few postoperative days?
48 to 72 hours
What can a follow up phone call identify?
identify and treat any potential complications from the surgical experience before a problem escalates and readmission is required
What helps to reduce discharge errors?
discharge checklist
A discharge checklist helps the nurse ensure what?
that all components of the discharge process are completed according tor egulatory guidelines
a discharge checklist is especially helpful when multiple discharge team members are coordinating what?
the patient’s discharge follow up
A checklist serves as a useful what?
a useful tool for internal chart audits for demonstrating compliance with chart audits as required by regulatory agencies
What are the 4 goals of discharge planning?
- ensure that patients are discharged in a timely manner
- decrease the incidence of postoperative complications
- lessen the likelihood of hospital readmissions
- increase patient satisfaction
All hospitals that receive medicare and medicaid funding must include what?
an evaluation conducted by an RN or other qualified personnel
What should the evaluation include?
- a discharge plan for high-risk patients
- an individualized plan of care that includes patient preferences when possible
- documentation of the plan in the patient’s record
what happens with facilities that fail to meet national standards for readmission rates?
financial penalties
What should be part of the development of an individualized plan of care?
RNs should identify patient at increased risk for readmission or postoperative complications and include nursing interventions to address those risks
What are risk factors for post op complications?
- increased age
- comorbidities and/or chronic illnesses
- extensive or lengthy surgical procedures
- polypharmacy
- social and economic factors affecting home care
Why is a well-coordinated discharge process essential?
it is essential for preventing unplanned readmissions that will trigger financial disincentives from third-party payers and dissatisfaction from patients and their families
What does the joint commission evaluate during discharge planning?
evaluates the effectiveness of discharge planning as one of their requirements for hospital accreditation
When does the discharge planning process start?
traced from the point the patient is admitted until after discharge
What does information from the tracer survey include?
- who is involved with discharge planning and when
- types of patient education
- communication practices that help ensure patient and caregiver understanding
- methods for transferring info to other providers of care
What is also done in regards to personnel during discharge planning?
the competency of the personnel involved in patient discharge is evaluated through a review of personnel records and files
proper perioperative documentation is the what?
the collection of data related to whether patient goals have been met and patient outcomes have been achieved
perioperative documentation should include what?
- patient information
- physical and psychosocial assessments
- nursing diagnoses
- nursing interventions
- patient goals
- patient oucomes
- patient education
- discharge planning
why should documentation be comprehensvie?
as it serves as a means of communication to multiple health care members as the patient progresses through the perioperative experience
What is the goal of an effective patient education plan?
to inform the patient and his or her family about what to expect during the preoperative, intraoperative, and postoperative phases
What is part of the success of the surgical procedure?
education provided to the patient and family
When does patient education begin?
the moment the patient agrees to undergo the operative or invasive procedure
Does patient education continue throughout the perioperative experience?
yes
What does providing instruction preoperatively do?
- decreases patient anxiety and length of stay
- assists with pain management
- reduces the incidence and severity of complications
- increases compliance with postoperative instructions
- improves patient, staff, and employer satisfaction
What are 5 tips for streamlining patient education?
- give the most important info first
- limit the number of messages by concentrating on what the patient has to know
- provide the rationale for any actions; answer the question “what’s in it for me?” from the patient’s perspective
- use examples that are familiar to your audience
- emphasize small steps that are achievable
What should intraoperative instructions focus on?
sights, sounds, and sensations the patient will encounter in the operative or invasive procedure room
Who is responsible for education postoperatively?
education must be provided at the level of understanding of the person responsible for providing care after discharge
What 2 formats should education be provided in?
oral and and written formats
Postoperative complications may be traced to what?
lack of or inadequate patient education
What must the RN assure the patient and home caregiver can do before discharging?
are able to independently demonstrate any necessary skills required during recovery
Part of serving as a patient advocate for perioperative patient education is being what?
knowledgeable of the available resources for patient and family education, including community and institutional resources
What are 8 tips for maximizing the patient education experience?
- arrange for a quiet and private teaching environment
- avoid using medical terminology and jargon
- break down the instructions into manageable steps
- arrange material in a logical sequence
- provide reasons and benefits for activities
- make instructions relevant to the situation
- do not provide too much info at one time
- repeat, repeat, repeat
define health literacy
the patient’s ability to understand and process health-related information
When should health literacy be establisheD?
at the beginning of the relationship
Health literacy is not dependent on what?
on the patient’s education level, age, or socioeconomic status
What is a significant barrier to families and patients?
medical jargon
The centers for disease control and prevention estimate what?
that 9 out of 10 people in the US may lack the skills to manage their health
What helps the patient and caregiver retain key information and prepare them for a seamless transition to the next level of care?
repetition and reinforcement
what is the downside of close-ended questions?
may not provide the detail required to develop an accurate plan of care
What can illicit more information than close-ended questions?
open-ended inquiry in a neutral manner
What is an example of open-ended inquiry?
Tell me everything you have had to eat or drink, including water and candy, since midnight
What can be helpful in addition to what is said?
nonverbal behaviors
An interaction with a patient should end with what?
the ability of the patient to ask questions
What can help determine the need for additional reinforcement of content with interviews?
the type and quality of patient education
What is the most effective way to determine a patient’s understanding of instructions?
to have the patient or caregiver repeat back the instructions in their own words OR perform a return demonstration of the skill being taught
What is it when the patient or caregiver repeat back the instructions in their own words OR perform a return demonstration of the skill being taught?
the teach-back method OR show-me method
The teach-back or show me method is not meant to what, but rather to do what?
not meant to test the patient’s recall but to determine how well the info was relayed and understood
Using the teach-back method can help with what?
help the nurse identify and correct any mistakes that the patient may have made and reinforce correct behaviors
When developing a teaching plan the RN should consider what?
- patient’s culture
- language preference
- ethnicity
- religious background
Who should not serve as interpreters between patients and health care team members?
family members
If a family member is asked to interpret sensitive info what could be compromised?
patient confidentiality
The Joint Commission requires that hospitals communicated information related to what 3 things in a way that meets the patient’s communication needs?
- provision of care
- services
- treatments
What is a key characteristic of infants and toddlers younger than 2 years of age?
they have limited verbal ability and depend on others to meet their physical and emotional needs
How should education be directed in infants and toddlers younger than 2?
patient education and consent should be directed to and obtained from the primary caregiver
What is the principal stressor in infants and toddlers younger than 2? What should be done about this?
separation from the primary caregiver; limit the amount of the time patient and caregiver are separated?
If a caregiver accompanies an infants and toddlers younger than 2 to the OR what should the RN do?
provide basic instructions on the principles of perioperative safety and a brief overview of what to expect.
What must RNs incorporate into plan of care for children in the OR?
the short attention span and limited vocabulary
What are effective strategies to address children’s magical thinking?
stories, videos, play activities, and a tour of the OR a day before the scheduled procedure
RN’s should limit the amount of info provided to children younger than what age?
7
Of all age groups, who experiences the most rapid cognitive growth?
adolescents
What are 4 characteristics of adolescents?
- egocentric
- have a need to establish their own identity and independence
- are extremely reliant on peer support
- place high importance on physical appearance
What 2 things should RN’s do when developing the plan of care for adolescents?
provide for privacy and plenty of opportunities to ask questions
Who should be included in patient education and are responsible for informed consent until the patient has reached legal age or is emancipated?
parents
Even though a parent is responsible for being their patient education and informed consent, what should the RN allow for with adolescents?
they should be included in the decision-making process as much as possible and ideally should be allowed to give consent for the procedure if at all possible
A safe environment should be provided to adolescents when…
when inquiring about sexual activity and drug use
Education for adults should be based on what 3 things?
- what they need to know
- their readiness to learn
- what they already know
With adults, RN’s should supplement verbal instructions with what whenever possible?
written instructions
What might the issue be with patients who are highly anxious or in pain?
they may not understand verbal instructions
Nurses should ensure that educational materials, to accomodate most reading and comprehension levels, are written at what level?
third to fifth grade level
Aging affects the ability and speed of what?
processing information
What may challenge communication in geriatric patients?
sensory and cognitive deficits and functional limitations
To include a geriatric patient in the education plan, the RN’s should leave the patient’s what on?
the patient’s hearing and vision aids in place for as long as possible and return them to the patient early in the postoperative period
How should nurses speak as much as possible with geriatrics?
slowly, clearly, and reduce background noise
What font should written material for geriatric patients be written in?
LARGE FONT
If the patient agrees, nurses should include who in patient education sessions and allow them to remain with the patient as much as possible?
family members or other caregivers in patient education sessions
Information that needed to be recorded with education must include what… (6 things)
- patient and family’s learning needs
- what was taught to address those needs
- the educational resources used
- the overall response to the interaction
- any future educational needs or follow up
- persons involved
The purpose of education is what?
to provide an accurate, retrievable, and coherent record of the care provided to a patient
From the RN’s viewpoint, documentation does what?
captures each component of the nursing process
From a legal standpoint, the patient record is what?
admissable as evidence in a court of law
From a regulatory standpoint, nursing documentation must what?
meet quality performance indicators for reimbursement
Health care facilities use what to store at least some PHI in an electronic format?
information technology
What are the 2 electronic formats for storing PHI?
electronic medical record (EMR) or electronic health record (EHR)
What is an EMR
it is like a traditional patient paper chart and is used to track sets of patient info and document patient responses to interventions
What are drawbacks to the EMR?
typically site-specific, making it difficult to transfer info from one health care setting to another
Why was the EHR designed?
to address the limitations of the EMR, so it was designed to share info among health care providers in a variety of settings and between providers and patients
What does the EHR do?
chronicles patient’s medical info throughout the person’s lifetime, rather than capturing a patient care experience at one point
EMR and EHR increase the quality of services and treatments provided by doing what 3 things?
- facilitating communication among providers
- decreasing errors associated with handwritten orders
- reducing health care costs by… improving patient outcomes AND avoiding duplication of costly treatments and tests
Because of the perceived benefits of electronic formats, hospitals participating in medicare and Medicaid programs are provided with what?
financial incentives to move PHI to electronic formats
What is the downside to electronic record?
managing patient info transfers during disruptions to network services
What should RNs have access to during both planned and unexpected computer downtime?
backup processes that will allow uninterrupted patient care processes
EMR or EHR requires maintaining what?
the privacy and security of info in accordance with the HIPPA while allowing health care providers and insurance companies access to patient helath care info
What does title II of HIPPA give patients the right to?
access their own medical records, correct errors, and be informed of who accesses their PHI and how that info is used
What 2 HIPPA privacy regulations should perioperative nurses be aware of when communciating patient care activities?
- If PHI can identify a patient (name, DOB, SSN, telephone numbers, drivers licence number, postal or email addresses, health insurance identification numbers, MRN’s, full face photographs), it should never be sent to a non-secure source that could be distributed and viewed by multiple people. –> including any form of media, including electronic-paper-or verbal
- Perioperative nurses should ensure that PHI is shared only with authorized persons. Except in certain circumstances, patients have the right to determine who receives their PHI. This has implications for the perioperative nurse who proivdes updates on the progress of a surgical procedure to family members or significant others
Who is allowed to hear, read, or discuss a patient’s info?
only those health care team members directly involved in patient’s care
What is included in patient info that is protected?
- patient education materials
- take-home medication instructions
- discharge instructions
Who else is allowed to receive any verbal instructions or written take-home materials?
only family members or other caregivers who have been granted permission by the patient or who have been granted access through legal measures
What should RN’s do with their computers to maintain HIPPA?
not share their computer passwords or leave open computer screens unattended
RNs should be familiar with what when electronic documentation platforms are disrupted by technology failures or routine updates? Why?
back up plans; to avoid loss of data and interruptions in patient care
HIPPA privacy rules require that employess and volunteers are provided with training on what 3 things?
- the organization’s policies and procedures regarding patient privacy and confidentiality
- reporting standards for infractions
- consequences for employees who violate organizational or HIPPA privacy rules
Perioperative documentation should include what?
- all components of the nursing process (ADPIE)
- clinical problems and changes in clinical status
- communication with other health care providers
- patient education
- medical records
- order acknowledgement
- perioperative-specific nursing interventions (positioing, patient skin antisepsis, safety precautions, type of anesthesia. specimen and tissue management
It is the responsibility of the perioperative nurse to maintain what?
initial and continuing competency to ensure that documentation and transfer of PHI meet federal and organizational standards
RNs have what kind of obligation to protect their patients’ privacy, including protecting the confidentiality of PHI?
ethical oblication
Persons who knowingly obtain or disclose identifiable patient info face fines of what?
$50,000 to $250,000 and up to 10 years of imprisonmnet based on the severity of the wrongful conduct
When should documentation take place, even despite shorter procedures?
shortly following the event
correcting inaccurate entries exposes what?
the institution to potential litigation for falsifying patient care info
What is documented at the end of the case to accurately capture any breaks in aseptic technique or deviations between pre- and postoperative diagnoses?
wound classification
Based on 2020 Guidelines for Perioperative Practice, what 3 procedures can be class I/clean if certain criteria are met at the end of the procedure?
C-section, hysterectomy, and ovarian surgery wounds
according to the CDC, wounds associated with what kind of procedures can never be documented as class I?
appendectomy, cholecystectomy, bile duct, liver, pancreatic, or bowel surgery, rectal procedures, vaginal hysterectomy
