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NSG 2113 > Documentation, Report Communication & Medication Administration > Flashcards

Documentation, Report Communication & Medication Administration Flashcards

1
Q

With regards to documentation, entry level registered nurses are expected to ___

A

Documents and reports clearly, concisely, accurately, and in a timely manner

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2
Q

What are the 6 documentation guidelines?

A

Factual
Accurate
Complete
Current
Organized
Compliant with standards

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3
Q

What is the traditional method of documentation?

A

Narrative documentation

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4
Q

What type of documentation involves database, problem list, care plan & progress notes?

A

Problem-oriented health care record

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5
Q

What is a source record?

A

Each discipline records in a separate section

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6
Q

What is charting by exception?

A

Progress notes are only written when the standardized statement is not met

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7
Q

What type of documentation eliminates the need for nurses’ notes, flow sheets and nursing care plans?

A

Critical pathways or care maps

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8
Q

What does SOAP stand for?

A

Subjective
Objective
Assessment
Plan

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9
Q

What does SOAPIE(R) stand for?

A

Subjective
Objective
Assessment
Plan
Intervention
Evaluation
Revision of plan

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10
Q

What does PIE stand for?

A

Problem
Intervention
Evaluation

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11
Q

What does DAR stand for?

A

Data
Action
Response

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12
Q

What is required for documentation to be used as evidence?

A

Notes were made by the person testifying
It was part of the nurse’s duty to make notes
The notes were made contemporaneously with the event
There have been no alterations, additions, or deletions to the notes

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13
Q

What is reporting?

A

When nurses report information about an assigned patient to another nurse who is going to assume responsibility for the patient’s care

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14
Q

What does SBAR stand for?

A

Situation
Background
Assessment
Recommendation

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15
Q

What does ISBARR stand for?

A

Identification
Situation
Background
Assessment
Recommendations
Repeat back

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16
Q

What are the 3 principles that outline the expectations related to medication practices that promote public protection?

A

Authority
Competence
Safety

17
Q

When do RNs and RPNs require an order for a medication practice?

A

A controlled act is involved
Administering a prescribed medication
It is required by legislation that applies to a practice setting

18
Q

What does AC, ac mean?

A

Before meals

19
Q

What does PC, pc mean?

A

After meals

20
Q

What does hs mean?

A

At bedtime

21
Q

What does prn mean?

A

As needed

22
Q

What does STAT mean?

A

Give immediately

23
Q

What does qh mean?

A

Every hour

24
Q

What does q2h mean?

A

Every 2 hours

25
Q

What does q6h mean?

A

Every 6 hours

26
Q

What does BID, bid mean?

A

Two times/day

27
Q

What does TID, tid mean?

A

Three times/day

28
Q

What does QID, qid mean?

A

Four times/day

29
Q

Medication administration is the collective responsablity of ___

A

Prescriber, pharmacist, and nurse

30
Q

What are “now orders”?

A

Meds to be given once, quickly but not immediately (within 90 mins)

31
Q

What are the 10 rights of medication administration?

A
  1. medication 6. documentation
  2. dose 7. reason
  3. patient 8. right to refuse
  4. route 9. patient education
  5. time and frequency 10. evaluation
32
Q

When do medication errors often occur?

A

When a patient is transferred to a different unit or around shift change

33
Q

What are 4 common medication errors?

A

Omission
Improper dose
Wrong time
Wring patient

34
Q

What does the CNO Jurisprudence exam assess?

A

An applicant’s knowledge and understanding of the laws, regulations, by-laws and practice standards and guidelines that govern the nursing profession in Ontario

NSG 2113 (7 decks)

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