Documentation, Report Communication & Medication Administration Flashcards
With regards to documentation, entry level registered nurses are expected to ___
Documents and reports clearly, concisely, accurately, and in a timely manner
What are the 6 documentation guidelines?
Factual
Accurate
Complete
Current
Organized
Compliant with standards
What is the traditional method of documentation?
Narrative documentation
What type of documentation involves database, problem list, care plan & progress notes?
Problem-oriented health care record
What is a source record?
Each discipline records in a separate section
What is charting by exception?
Progress notes are only written when the standardized statement is not met
What type of documentation eliminates the need for nurses’ notes, flow sheets and nursing care plans?
Critical pathways or care maps
What does SOAP stand for?
Subjective
Objective
Assessment
Plan
What does SOAPIE(R) stand for?
Subjective
Objective
Assessment
Plan
Intervention
Evaluation
Revision of plan
What does PIE stand for?
Problem
Intervention
Evaluation
What does DAR stand for?
Data
Action
Response
What is required for documentation to be used as evidence?
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
What is reporting?
When nurses report information about an assigned patient to another nurse who is going to assume responsibility for the patient’s care
What does SBAR stand for?
Situation
Background
Assessment
Recommendation
What does ISBARR stand for?
Identification
Situation
Background
Assessment
Recommendations
Repeat back
What are the 3 principles that outline the expectations related to medication practices that promote public protection?
Authority
Competence
Safety
When do RNs and RPNs require an order for a medication practice?
A controlled act is involved
Administering a prescribed medication
It is required by legislation that applies to a practice setting
What does AC, ac mean?
Before meals
What does PC, pc mean?
After meals
What does hs mean?
At bedtime
What does prn mean?
As needed
What does STAT mean?
Give immediately
What does qh mean?
Every hour
What does q2h mean?
Every 2 hours
What does q6h mean?
Every 6 hours
What does BID, bid mean?
Two times/day
What does TID, tid mean?
Three times/day
What does QID, qid mean?
Four times/day
Medication administration is the collective responsablity of ___
Prescriber, pharmacist, and nurse
What are “now orders”?
Meds to be given once, quickly but not immediately (within 90 mins)
What are the 10 rights of medication administration?
- medication 6. documentation
- dose 7. reason
- patient 8. right to refuse
- route 9. patient education
- time and frequency 10. evaluation
When do medication errors often occur?
When a patient is transferred to a different unit or around shift change
What are 4 common medication errors?
Omission
Improper dose
Wrong time
Wring patient
What does the CNO Jurisprudence exam assess?
An applicant’s knowledge and understanding of the laws, regulations, by-laws and practice standards and guidelines that govern the nursing profession in Ontario
