Communication and Documentation

Question 1

What is the only way to ensure understanding?

Answer 1

acknowledgement of receipt of the info is the only way to know that communication has taken place

Question 2

What is the best kind of communication?

Answer 2

face to face communication

Question 3

What should be hard wired into every discussion involving patient care?

Answer 3

the opportunity to ask questions

Question 4

When is asking questions particularly important?

Answer 4

1. hand offs
2. time outs
3. patient education
4. verbal orders

Question 5

What should we do to help prevent the misunderstanding that typically precedes a patient error?

Answer 5

clarifying that information

Question 6

the joint commission has identified what as a critical patient safety issue?

Answer 6

effective communication

Question 7

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?

Answer 7

the stressful, high-paced perioperative environment

Question 8

What prevent the observation of visual and nonverbal cues?

Answer 8

masks

Question 9

What can discourage staff from asking questions or speaking up about a potentially unsafe practice?

Answer 9

the hierarchical structure of the operating room, with its top-down method of info delivery

Question 10

Are monitors, equipment, radios, and alarms an issue?

Answer 10

yes they add to the ambient noise level

Question 11

What are 11 possible squelae to ineffective communication?

Answer 11

1. adverse events
2. preventable errors
3. avoidable readmissions
4. procedural delays
5. inappropriate treatments
6. increased costs
7. increased length of hospital stay
8. inefficiencies
9. omissions in care
10. wasted resource s
11. stressful work environments
12. other negative patient experiences

Question 12

What are 4 ways that RN’s can share pertinent information accurately and efficiently with other members of the interdisciplinary team?

Answer 12

1. tools
2. hand offs
3. safe verbal order practices
4. debriefs

Question 13

The use of standardized tools for communicating pertinent infromation on the status of the patient improves what?

Answer 13

the transmission and quality of the information being communicated, thus affecting patient outcomes

Question 14

What can tools be used as a guide for?

Answer 14

a guide to communicate important information to incorporate in the design and implementation of safe and effective patient care

Question 15

What are 4 frequently used tools in the perioperative setting?

Answer 15

1. SBAR
2. I PASS THE BATON
3. SWITCH
4. SURPASS

Question 16

What does SBAR stand for?

Answer 16

Situation, Background, Assessment, Recommendation

Question 17

What does I PASS the BATON stand for?

Answer 17

Introduction, Patient, Assessment, Situation, Safety Concerns, (the) Background, Actions, Timing, Ownership, Next

Question 18

What does SWITCH stand for?

Answer 18

Surgical procedure, Wet, Instruments, Tissue, Counts, Have you any questions

Question 19

What does SURPASS stand for?

Answer 19

Surgical Patient Safety System

Question 20

As the patient travels through the phases of the surgical experience, what are used?

Answer 20

hand offs

Question 21

What do handoffs do?

Answer 21

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

Question 22

What does the quality of handoffs do?

Answer 22

has a direct effect on patient safety and optimal patient outcomes

Question 23

When should hand offs occur?

Answer 23

always occur at a change of shift or during relief of personnel

Question 24

What is one of the most important communication tools available to protect the patient from surgery on wrong site or side?

Answer 24

the Joint Commissions’s Universal Protocol

Question 25

When is the Joint Commissions’s Universal Protocol initiated?

Answer 25

during the preoperative prep phase

Question 26

When does the the Joint Commissions’s Universal Protocol continue?

Answer 26

when the RN circulator conducts a preprocedural verification process

Question 27

What is the final part of the universal protocol?

Answer 27

the time out conducted when the patient enters the operative or invasive procedure area

Question 28

the time out provides what?

Answer 28

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

Question 29

What is the purpose of the timeout process?

Answer 29

to address any missing information or discrepancies before starting the procedure

Question 30

What is the RN’s role in the timeout?

Answer 30

verifies the correct patient using 2 patient identifiers

Question 31

What is the team’s role in the time out process? (2 things)

Answer 31

1. 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
2. each team member describes how he or she is prepared to prevent or address that risk

Question 32

What should be known by the end of the timeout and before the initial incision?

Answer 32

all the known elements that place the patient at risk should have been discussed and resolved

Question 33

What should be done when an RN receives a verbal order?

Answer 33

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

Question 34

all verbal orders must be included where?

Answer 34

in the patient’s medical record, dated, timed, and authenticated by the persons issuing and receiving the orders

Question 35

What is especially important when an unexpected adverse incident (i.e. procedures involving trauma, death in the OR) occurs?

Answer 35

providing a debriefing opportunity

Question 36

What is the debrief an opportunity for?

Answer 36

an opportunity to identify successes and opportunities for improvement

Question 37

A simple debriefing tool answers what 3 questions?

Answer 37

1. What went well?
2. What could be improved for next time (systems, supplies, staffing, communciation, safety)?
3. How can these issues be resolved and prevented?

Question 38

What should be included in all applicable team member communciations that could affect the surgical experience?

Answer 38

1. critical lab values
2. allergies
3. implants
4. comorbidities
5. medications

Question 39

What is another word for critical lab values?

Answer 39

panic values

Question 40

define critical lab values?

Answer 40

defined as results that are outside established norms and considered life threatening

Question 41

In the perioperative setting, who should be notified when there is a critical lab value?

Answer 41

surgeon, anesthesia care provder, or other health care providers involved with the patient’s care

Question 42

What should documentation of a critical lab value include?

Answer 42

time, date, and persons to whom this information was transmitted

Question 43

team members working in a culture of patient safety are encourage to do what?

Answer 43

speak up whenever there is an opportunity to prevent an error

Question 44

What reactions should people pay special attention to?

Answer 44

special attention should be patid to patient reports of difficulty breathing or swallowing, hives, and swelling of the face, lips, or tongue

Question 45

In addition to documentation on the patient’s medical record, facilities use a what to signify an allergy?

Answer 45

a color-coded bracelet

Question 46

When should allergies be communicated?

Answer 46

during the time out and all patient hand-offs

Question 47

Where is the presence of allergies initially verified?

Answer 47

during the preoperative preparation of the patient

Question 48

For patients with an existing implant, what should be documented and communicated to the surgical team?

Answer 48

the type of device and its location

Question 49

What is important to discuss and implenet into the plan of care?

Answer 49

special care related to the implant’s function during the procedure

Question 50

For devices implanted during surgery, the US Food and Drug Admin is responsible for what?

Answer 50

tracking medical devices

Question 51

Manufacturers of implants are required to do what 3 things?

Answer 51

1. track devices whose failure would be reasonable likely to have serious adverse health consequences
2. that are intented to be implanted in the human body for more than 1 year
3. or that are life-sustaining or life-supporting

Question 52

At minimum, documentation for any implanted device should include what?

Answer 52

1. the lot, batch, and serial numbers of the implanted device
2. the manufacture and expiration dates of the implanted device
3. the patient’s name and contact info
4. the facility where the device was implanted
5. the name and contact info of the surgeon implanting the device

Question 53

What the Joint Comission continue to list as one of its National Patient Safety Goals?

Answer 53

medication safety

Question 54

What is the purpose of medication reconciliation?

Answer 54

the decrease the number of med errors related to discrepancies between home and facility-ordered medications

Question 55

medications should be reviewed at every transition in care to ensure what?

Answer 55

there are no omissions, duplications, contraindications, or unclear information between the current and proposed medications

Question 56

When does medication review start first?

Answer 56

beginning with the preoperative assessment

Question 57

With the increase in same-day surgeries, the patient’s home can be considered what?

Answer 57

an extension of PACU

Question 58

What does the patient’s home being an extension of PACU require?

Answer 58

necessitates postoperative instructions and patient education that can be understood and adhered to by nonmedical persons

Question 59

when does a transfer of care occur?

Answer 59

as the patient undergoing an operative or other invasive procedure transitions through the pre-, intra-, and postoperative phases of care

Question 60

what is transfer of care communication like? why?

Answer 60

telephone; the risk of inaccurate or forgotten info increases during each transfer of care from one team member to another

Question 61

What are the 4 transfers of care during the perioperative continuum of care?

Answer 61

1. preoperative care provider to preoperative nurse
2. preoperative nurse to intraoperative nurse
3. intraoperative nurse to postoperative nurse
4. 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

Question 62

the 4 transfers of care have specific what?

Answer 62

transfer of care criteria

Question 63

what is transfer of care criteria based on?

Answer 63

the perioperative phases of care

Question 64

What does use of a standardized hand-over tool do?

Answer 64

1. reduces errors and omissions of important information
2. helps promote a seamless transition betweeen the phases of the perioperative experience

Question 65

Ideally, when should a patient be evaluated? but no more than when?

Answer 65

approximately 2 weeks; but no more than 30 days

Question 66

At the preoperative care provider apppointment what is done?

Answer 66

1. performs a complete head-to-toe physical assessment that includes all body systems
2. 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.

Question 67

What does the preop care provider use the preoperative assessment for?

Answer 67

as a risk factor assessment to determine whether additional preoperative testing is required

Question 68

When may a preoperative nurse at a surgery center perform a preop evaluation?

Answer 68

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

Question 69

In the surgery center situation much of the preop interview is conducted by how?

Answer 69

phone; including providing preoperative education

Question 70

When does the preop telephonic interview normally occur?

Answer 70

a day or 2 before surgery

Question 71

What may a preop nurse note on their day of surgery assessment of the patient?

Answer 71

any unusual or abnormal findings that may affect patient outcomes (altered skin integrity, neuro status)

Question 72

What does the preop nurse use to begin formulating the individualized perioperative plan of care?

Answer 72

1. the findings from the preoperative evaluation
2. the results of any testing
3. the current patient status to begin to formulate an individualized preoperative plan of care

Question 73

What increases when there is a change in personnel in the OR?

Answer 73

1. the chance of errors
2. miscommunication
3. lack of communication

Question 74

What is best as far as transfer of care?

Answer 74

less of them

Question 75

What is good when intraoperative nurse is giving handoff to postoperative nurse?

Answer 75

providing advanced notice allows the receiving nurse the opportunity to prepare for the patient’s arrival

Question 76

During the final minutes of the procedure and at a point when intraop care will not be compromised, what should the RN do?

Answer 76

provides a report to the nurse from the receiving unit

Question 77

What are the phases for transfers of care?

Answer 77

1. preoperative phase
2. intraoperative phase
3. immediate postoperative phase in the… PACU, ICU, or another anxillary department such as radiology
4. home, inpatient nursing unit, skilled nursing unit

Question 78

What 3 things does the type of postoperative care depend on?

Answer 78

1. depends on the procedure
2. unique needs of the patient
3. and type of anesthetic the patient received

Question 79

What does the American Society of PeriAnesthesia nurses define phase I as?

Answer 79

as the level of care typically provided in a PACU or ICU

Question 80

What do patients in phase I require?

Answer 80

1. close monitoring - including airway and ventillatory support, assessment of hemodynamic status, pain management, fluid management, and other acute aspects of patient care

Question 81

After meeting criteria for discharge from Phase I, the patient transitions to what?

Answer 81

Phase II level of care

Question 82

Based on the facility, phase I and phase II may occur where?

Answer 82

in the same room

Question 83

In Phase II, what happens?

Answer 83

care and assistance to the patient care are provided before discharge to home or an extended care environment

Question 84

How does a patient move from one phase to another?

Answer 84

by meeting criteria established by regulatory and accreditation requirements and facility policies and procedures

Question 85

What scoring system do some facilities use to determine whether.a patient has met defined discharge criteria?

Answer 85

aldrete system or postanesthesia scoring system

Question 86

What has happened with the increase in the number of same day surgery patients?

Answer 86

criteria have been established specifically to meet the needs for the safe transition to home for the ambulatory surgery patient

Question 87

What does the Post Anesthetic Discharge Scoring System include?

Answer 87

safe parameters for vital signs, ambulation, nausea and vomiting, pain, bleeding, and voiding

Question 88

What must patients score a minimum of what on the Post Anesthetic Discharge Scoring System in order to go home?

Answer 88

9

Question 89

Ideally when does discharge planning start?

Answer 89

when the decision for surgery is made

Question 90

at minimum, the interdisciplinary services discharge team consists of what?

Answer 90

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

Question 91

What should discharge planning include?

Answer 91

1. a review of the reconciled med list
2. a review of dates and contact info for follow-up appointments
3. a description of any home care or resources needed
4. patient education with the use of teach back
5. an overview of wound care
6. an overview of warning signs and symptoms of possible complications and information to who to call
7. an overview of restrictions on diet, mobility

Question 92

What should the patient’s responsible party sign after the nurse has completed the postoperative patient education?

Answer 92

a printed patient discharge instruction sheet

Question 93

What is included on a discharge sheet?

Answer 93

1. follow up provider appointments
2. follow up lab or radiological tests
3. postoperative restrictions
4. wound care

Question 94

What numbers should be on the discharge sheeet

Answer 94

telephone numbers for the patient’s physician or answering service and when to call 911 are noted

Question 95

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

Answer 95

true

Question 96

What is the process of giving the final medication reconciliation sheet intended to reduce?

Answer 96

the number of adverse drug events that may lead to an emergency department visit or readmission

Question 97

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?

Answer 97

48 to 72 hours

Question 98

What can a follow up phone call identify?

Answer 98

identify and treat any potential complications from the surgical experience before a problem escalates and readmission is required

Question 99

What helps to reduce discharge errors?

Answer 99

discharge checklist

Question 100

A discharge checklist helps the nurse ensure what?

Answer 100

that all components of the discharge process are completed according tor egulatory guidelines

Question 101

a discharge checklist is especially helpful when multiple discharge team members are coordinating what?

Answer 101

the patient’s discharge follow up

Question 102

A checklist serves as a useful what?

Answer 102

a useful tool for internal chart audits for demonstrating compliance with chart audits as required by regulatory agencies

Question 103

What are the 4 goals of discharge planning?

Answer 103

1. ensure that patients are discharged in a timely manner
2. decrease the incidence of postoperative complications
3. lessen the likelihood of hospital readmissions
4. increase patient satisfaction

Question 104

All hospitals that receive medicare and medicaid funding must include what?

Answer 104

an evaluation conducted by an RN or other qualified personnel

Question 105

What should the evaluation include?

Answer 105

1. a discharge plan for high-risk patients
2. an individualized plan of care that includes patient preferences when possible
3. documentation of the plan in the patient’s record

Question 106

what happens with facilities that fail to meet national standards for readmission rates?

Answer 106

financial penalties

Question 107

What should be part of the development of an individualized plan of care?

Answer 107

RNs should identify patient at increased risk for readmission or postoperative complications and include nursing interventions to address those risks

Question 108

What are risk factors for post op complications?

Answer 108

1. increased age
2. comorbidities and/or chronic illnesses
3. extensive or lengthy surgical procedures
4. polypharmacy
5. social and economic factors affecting home care

Question 109

Why is a well-coordinated discharge process essential?

Answer 109

it is essential for preventing unplanned readmissions that will trigger financial disincentives from third-party payers and dissatisfaction from patients and their families

Question 110

What does the joint commission evaluate during discharge planning?

Answer 110

evaluates the effectiveness of discharge planning as one of their requirements for hospital accreditation

Question 111

When does the discharge planning process start?

Answer 111

traced from the point the patient is admitted until after discharge

Question 112

What does information from the tracer survey include?

Answer 112

1. who is involved with discharge planning and when
2. types of patient education
3. communication practices that help ensure patient and caregiver understanding
4. methods for transferring info to other providers of care

Question 113

What is also done in regards to personnel during discharge planning?

Answer 113

the competency of the personnel involved in patient discharge is evaluated through a review of personnel records and files

Question 114

proper perioperative documentation is the what?

Answer 114

the collection of data related to whether patient goals have been met and patient outcomes have been achieved

Question 115

perioperative documentation should include what?

Answer 115

1. patient information
2. physical and psychosocial assessments
3. nursing diagnoses
4. nursing interventions
5. patient goals
6. patient oucomes
7. patient education
8. discharge planning

Question 116

why should documentation be comprehensvie?

Answer 116

as it serves as a means of communication to multiple health care members as the patient progresses through the perioperative experience

Question 117

What is the goal of an effective patient education plan?

Answer 117

to inform the patient and his or her family about what to expect during the preoperative, intraoperative, and postoperative phases

Question 118

What is part of the success of the surgical procedure?

Answer 118

education provided to the patient and family

Question 119

When does patient education begin?

Answer 119

the moment the patient agrees to undergo the operative or invasive procedure

Question 120

Does patient education continue throughout the perioperative experience?

Answer 120

yes

Question 121

What does providing instruction preoperatively do?

Answer 121

1. decreases patient anxiety and length of stay
2. assists with pain management
3. reduces the incidence and severity of complications
4. increases compliance with postoperative instructions
5. improves patient, staff, and employer satisfaction

Question 122

What are 5 tips for streamlining patient education?

Answer 122

1. give the most important info first
2. limit the number of messages by concentrating on what the patient has to know
3. provide the rationale for any actions; answer the question “what’s in it for me?” from the patient’s perspective
4. use examples that are familiar to your audience
5. emphasize small steps that are achievable

Question 123

What should intraoperative instructions focus on?

Answer 123

sights, sounds, and sensations the patient will encounter in the operative or invasive procedure room

Question 124

Who is responsible for education postoperatively?

Answer 124

education must be provided at the level of understanding of the person responsible for providing care after discharge

Question 125

What 2 formats should education be provided in?

Answer 125

oral and and written formats

Question 126

Postoperative complications may be traced to what?

Answer 126

lack of or inadequate patient education

Question 127

What must the RN assure the patient and home caregiver can do before discharging?

Answer 127

are able to independently demonstrate any necessary skills required during recovery

Question 128

Part of serving as a patient advocate for perioperative patient education is being what?

Answer 128

knowledgeable of the available resources for patient and family education, including community and institutional resources

Question 129

What are 8 tips for maximizing the patient education experience?

Answer 129

1. arrange for a quiet and private teaching environment
2. avoid using medical terminology and jargon
3. break down the instructions into manageable steps
4. arrange material in a logical sequence
5. provide reasons and benefits for activities
6. make instructions relevant to the situation
7. do not provide too much info at one time
8. repeat, repeat, repeat

Question 130

define health literacy

Answer 130

the patient’s ability to understand and process health-related information

Question 131

When should health literacy be establisheD?

Answer 131

at the beginning of the relationship

Question 132

Health literacy is not dependent on what?

Answer 132

on the patient’s education level, age, or socioeconomic status

Question 133

What is a significant barrier to families and patients?

Answer 133

medical jargon

Question 134

The centers for disease control and prevention estimate what?

Answer 134

that 9 out of 10 people in the US may lack the skills to manage their health

Question 135

What helps the patient and caregiver retain key information and prepare them for a seamless transition to the next level of care?

Answer 135

repetition and reinforcement

Question 136

what is the downside of close-ended questions?

Answer 136

may not provide the detail required to develop an accurate plan of care

Question 137

What can illicit more information than close-ended questions?

Answer 137

open-ended inquiry in a neutral manner

Question 138

What is an example of open-ended inquiry?

Answer 138

Tell me everything you have had to eat or drink, including water and candy, since midnight

Question 139

What can be helpful in addition to what is said?

Answer 139

nonverbal behaviors

Question 140

An interaction with a patient should end with what?

Answer 140

the ability of the patient to ask questions

Question 141

What can help determine the need for additional reinforcement of content with interviews?

Answer 141

the type and quality of patient education

Question 142

What is the most effective way to determine a patient’s understanding of instructions?

Answer 142

to have the patient or caregiver repeat back the instructions in their own words OR perform a return demonstration of the skill being taught

Question 143

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?

Answer 143

the teach-back method OR show-me method

Question 144

The teach-back or show me method is not meant to what, but rather to do what?

Answer 144

not meant to test the patient’s recall but to determine how well the info was relayed and understood

Question 145

Using the teach-back method can help with what?

Answer 145

help the nurse identify and correct any mistakes that the patient may have made and reinforce correct behaviors

Question 146

When developing a teaching plan the RN should consider what?

Answer 146

1. patient’s culture
2. language preference
3. ethnicity
4. religious background

Question 147

Who should not serve as interpreters between patients and health care team members?

Answer 147

family members

Question 148

If a family member is asked to interpret sensitive info what could be compromised?

Answer 148

patient confidentiality

Question 149

The Joint Commission requires that hospitals communicated information related to what 3 things in a way that meets the patient’s communication needs?

Answer 149

1. provision of care
2. services
3. treatments

Question 150

What is a key characteristic of infants and toddlers younger than 2 years of age?

Answer 150

they have limited verbal ability and depend on others to meet their physical and emotional needs

Question 151

How should education be directed in infants and toddlers younger than 2?

Answer 151

patient education and consent should be directed to and obtained from the primary caregiver

Question 152

What is the principal stressor in infants and toddlers younger than 2? What should be done about this?

Answer 152

separation from the primary caregiver; limit the amount of the time patient and caregiver are separated?

Question 153

If a caregiver accompanies an infants and toddlers younger than 2 to the OR what should the RN do?

Answer 153

provide basic instructions on the principles of perioperative safety and a brief overview of what to expect.

Question 154

What must RNs incorporate into plan of care for children in the OR?

Answer 154

the short attention span and limited vocabulary

Question 155

What are effective strategies to address children’s magical thinking?

Answer 155

stories, videos, play activities, and a tour of the OR a day before the scheduled procedure

Question 156

RN’s should limit the amount of info provided to children younger than what age?

Answer 156

7

Question 157

Of all age groups, who experiences the most rapid cognitive growth?

Answer 157

adolescents

Question 158

What are 4 characteristics of adolescents?

Answer 158

1. egocentric
2. have a need to establish their own identity and independence
3. are extremely reliant on peer support
4. place high importance on physical appearance

Question 159

What 2 things should RN’s do when developing the plan of care for adolescents?

Answer 159

provide for privacy and plenty of opportunities to ask questions

Question 160

Who should be included in patient education and are responsible for informed consent until the patient has reached legal age or is emancipated?

Answer 160

parents

Question 161

Even though a parent is responsible for being their patient education and informed consent, what should the RN allow for with adolescents?

Answer 161

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

Question 162

A safe environment should be provided to adolescents when…

Answer 162

when inquiring about sexual activity and drug use

Question 163

Education for adults should be based on what 3 things?

Answer 163

1. what they need to know
2. their readiness to learn
3. what they already know

Question 164

With adults, RN’s should supplement verbal instructions with what whenever possible?

Answer 164

written instructions

Question 165

What might the issue be with patients who are highly anxious or in pain?

Answer 165

they may not understand verbal instructions

Question 166

Nurses should ensure that educational materials, to accomodate most reading and comprehension levels, are written at what level?

Answer 166

third to fifth grade level

Question 167

Aging affects the ability and speed of what?

Answer 167

processing information

Question 168

What may challenge communication in geriatric patients?

Answer 168

sensory and cognitive deficits and functional limitations

Question 169

To include a geriatric patient in the education plan, the RN’s should leave the patient’s what on?

Answer 169

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

Question 170

How should nurses speak as much as possible with geriatrics?

Answer 170

slowly, clearly, and reduce background noise

Question 171

What font should written material for geriatric patients be written in?

Answer 171

LARGE FONT

Question 172

If the patient agrees, nurses should include who in patient education sessions and allow them to remain with the patient as much as possible?

Answer 172

family members or other caregivers in patient education sessions

Question 173

Information that needed to be recorded with education must include what… (6 things)

Answer 173

1. patient and family’s learning needs
2. what was taught to address those needs
3. the educational resources used
4. the overall response to the interaction
5. any future educational needs or follow up
6. persons involved

Question 174

The purpose of education is what?

Answer 174

to provide an accurate, retrievable, and coherent record of the care provided to a patient

Question 175

From the RN’s viewpoint, documentation does what?

Answer 175

captures each component of the nursing process

Question 176

From a legal standpoint, the patient record is what?

Answer 176

admissable as evidence in a court of law

Question 177

From a regulatory standpoint, nursing documentation must what?

Answer 177

meet quality performance indicators for reimbursement

Question 178

Health care facilities use what to store at least some PHI in an electronic format?

Answer 178

information technology

Question 179

What are the 2 electronic formats for storing PHI?

Answer 179

electronic medical record (EMR) or electronic health record (EHR)

Question 180

What is an EMR

Answer 180

it is like a traditional patient paper chart and is used to track sets of patient info and document patient responses to interventions

Question 181

What are drawbacks to the EMR?

Answer 181

typically site-specific, making it difficult to transfer info from one health care setting to another

Question 182

Why was the EHR designed?

Answer 182

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

Question 183

What does the EHR do?

Answer 183

chronicles patient’s medical info throughout the person’s lifetime, rather than capturing a patient care experience at one point

Question 184

EMR and EHR increase the quality of services and treatments provided by doing what 3 things?

Answer 184

1. facilitating communication among providers
2. decreasing errors associated with handwritten orders
3. reducing health care costs by… improving patient outcomes AND avoiding duplication of costly treatments and tests

Question 185

Because of the perceived benefits of electronic formats, hospitals participating in medicare and Medicaid programs are provided with what?

Answer 185

financial incentives to move PHI to electronic formats

Question 186

What is the downside to electronic record?

Answer 186

managing patient info transfers during disruptions to network services

Question 187

What should RNs have access to during both planned and unexpected computer downtime?

Answer 187

backup processes that will allow uninterrupted patient care processes

Question 188

EMR or EHR requires maintaining what?

Answer 188

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

Question 189

What does title II of HIPPA give patients the right to?

Answer 189

access their own medical records, correct errors, and be informed of who accesses their PHI and how that info is used

Question 190

What 2 HIPPA privacy regulations should perioperative nurses be aware of when communciating patient care activities?

Answer 190

1. 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
2. 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

Question 191

Who is allowed to hear, read, or discuss a patient’s info?

Answer 191

only those health care team members directly involved in patient’s care

Question 192

What is included in patient info that is protected?

Answer 192

1. patient education materials
2. take-home medication instructions
3. discharge instructions

Question 193

Who else is allowed to receive any verbal instructions or written take-home materials?

Answer 193

only family members or other caregivers who have been granted permission by the patient or who have been granted access through legal measures

Question 194

What should RN’s do with their computers to maintain HIPPA?

Answer 194

not share their computer passwords or leave open computer screens unattended

Question 195

RNs should be familiar with what when electronic documentation platforms are disrupted by technology failures or routine updates? Why?

Answer 195

back up plans; to avoid loss of data and interruptions in patient care

Question 196

HIPPA privacy rules require that employess and volunteers are provided with training on what 3 things?

Answer 196

1. the organization’s policies and procedures regarding patient privacy and confidentiality
2. reporting standards for infractions
3. consequences for employees who violate organizational or HIPPA privacy rules

Question 197

Perioperative documentation should include what?

Answer 197

1. all components of the nursing process (ADPIE)
2. clinical problems and changes in clinical status
3. communication with other health care providers
4. patient education
5. medical records
6. order acknowledgement
7. perioperative-specific nursing interventions (positioing, patient skin antisepsis, safety precautions, type of anesthesia. specimen and tissue management

Question 198

It is the responsibility of the perioperative nurse to maintain what?

Answer 198

initial and continuing competency to ensure that documentation and transfer of PHI meet federal and organizational standards

Question 199

RNs have what kind of obligation to protect their patients’ privacy, including protecting the confidentiality of PHI?

Answer 199

ethical oblication

Question 200

Persons who knowingly obtain or disclose identifiable patient info face fines of what?

Answer 200

$50,000 to $250,000 and up to 10 years of imprisonmnet based on the severity of the wrongful conduct

Question 201

When should documentation take place, even despite shorter procedures?

Answer 201

shortly following the event

Question 202

correcting inaccurate entries exposes what?

Answer 202

the institution to potential litigation for falsifying patient care info

Question 203

What is documented at the end of the case to accurately capture any breaks in aseptic technique or deviations between pre- and postoperative diagnoses?

Answer 203

wound classification

Question 204

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?

Answer 204

C-section, hysterectomy, and ovarian surgery wounds

Question 205

according to the CDC, wounds associated with what kind of procedures can never be documented as class I?

Answer 205

appendectomy, cholecystectomy, bile duct, liver, pancreatic, or bowel surgery, rectal procedures, vaginal hysterectomy