Documenting Communication with Providers and Unique Events - Documenting and Reporting Flashcards
Used to review the levels of care given to and needed by residents in long-term care facilities.
Documentation
Governmental agencies and provincial and territorial laws are instrumental in determining the standards and policies for d___.
d-ocumentation
Components of Documentation in Long-Term Care
Section 1: The ___ ___ ___
The ___ ___ ___ includes the resident’s name and medical number; date and time of admission; change in resident’s condition; informed consent; note or discharge summary; incident reporting; monthly summary charting; and type of therapy and treatment time.
Section 2: Resident A___ and Related Documents
This section consists of the admission record; preadmission assessment; admission assessment; assessment of risk for falls; skin assessment; bowel and bladder assessment; physical restraint assessment; record of self-administration of medication; nutrition assessment; and activities, recreation, or leisure interests.
Section 3: Other Records
Other records include drug therapy records, medication or treatment records, flow sheets or other graphic records, laboratory and special reports, consent forms, acknowledgements and notices, advance directives, and discharge or transfer records.
Health Care Record / health care record
A-ssessments
Document ___ phone call you make to a healthcare provider. Include ___ the call was made, ___ made it (if you did not make the call), ___ was called, to ___m information was given, ___ information was given, and ___ information was received. An example is as follows: “May 20, 2017 (2030 hrs): Called Dr. Morgan’s office. Spoke with Sam Thomas, RN, who will inform Dr. Morgan that Mr. Wade’s potassium level drawn at 2000 hrs was 5.9 mEq/dL. Informed that Dr. Morgan will call back after he is finished seeing his current patient. Carla Skala, RN.”
every / when / who x2 / who-m / what x2
Occur when a health care provider gives therapeutic orders over the phone to a registered nurse.
Telephone Orders (TO)
Occur when a health care provider gives therapeutic orders to a registered nurse while they are standing in close proximity to each other.
Verbal Orders (VO)
These two orders usually occur at night or during emergencies; they should be used only when absolutely necessary and not for the sake of convenience.
Telephone Orders or Verbal Orders
In some situations, it is prudent to have a second person listen to t___o ___.
t-elephone o-rders
Guidelines for Telephone Orders and Verbal Orders
- Clearly determine the patient’s n___, r___ number, and diagnosis
- Repeat any prescribed orders b___ to the physician or healthcare provider
- Use clarification questions to avoid misunderstandings
- Write telephone order (“TO”) or verbal order (“VO”), including ___ and ___, ___ of patient, and the co___ order; ___ the names of the physician or other healthcare provider and nurse.
- Follow agency policies; some institutions require telephone (and verbal) orders to be reviewed and signed by ___ nurses.
- The physician must co-sign the order within the time frame required by the institution (usually ___ hours)
n-ame / r-oom
b-ack
date / time / name / co-mplete / sign
two
24
The nurse receiving a TO or VO enters the complete order into the computer using the computerized provider order entry (CPOE) software or writes it out on a physician’s order sheet for entry in the computer as soon as possible. After taking the order, the nurse reads it back using the “___-___” process and ___ that he or she did this, to provide evidence that the information received (such as call-back instructions and/or therapeutic orders) was verified with the provider. An example follows: “March 4, 2017 (0815 hrs) Change IV fluid to Lactated Ringer’s with potassium 20 mEq per litre to run at 125 mL/hour. TO: Dr. Knight/J. Woods, RN, read back.” The healthcare provider later verifies the TO or VO legally by signing it within a set time (e.g., 24 hours) as set by hospital policy.
read / back / documents
Nurses give a change-of-shift report o___ in person, by audiotape recording, by writing information on a summary report sheet, or by standing at the patient’s bedside.
o-rally
An advantage of o___ reports is that they allow staff members to ask questions or clarify explanations. The nurses can see the patient together to perform needed assessments, evaluate progress, and discuss the interventions best suited to the patient’s needs.
o-ral
An au___ report is given by the nurse who has completed care for the patient; this type of report is left for the nurse on the next shift to review. However, it is essential to schedule an opportunity for the incoming nurses to ask questions for clarification after they listen to the taped report.
au-diotape
Human factors such as stress, distraction, and communication problems make change-of-shift reports more prone to error. Several Canadian hospitals have implemented standardized bedside safe patient handoffs using t___ of a___ (TOA) practice guidelines developed by their institution.
t-ransfer / a-ccountability
The process provides an opportunity for the outgoing night nurse and the incoming day nurse to engage in a verbal report and to complete a patient safety checklist at the bedside.
Transfer of accountability
An effective ___-of -___ report describes patients’ health status and tells staff on the next shift exactly what kind of care the patients require.
change / shift
Should not simply be a reading of documented information. Instead, significant facts about patients are reviewed (e.g., condition of wounds, episodes of chest pain) to provide a baseline for comparison during the next shift. Data about patients need to be objective, current, and concise.
Change-of-shift reports
An organized ___-of-___ report follows a logical sequence. The following is an example of a change-of-shift report:
B___ information: Cy Tolan in bed 4, a 32-year-old patient of Dr. Lang, is scheduled for a colon resection this morning at 0800 hrs. He has had ulcerative colitis for 2 years with recent bouts of frank bleeding in his stools. He was admitted at 0600 hrs this morning with slight abdominal discomfort. This is his first experience with surgery. He knows he may require a colostomy. He has been NPO (had nothing by mouth) since midnight at home.
A___: Mr. Tolan mentioned that he was unable to sleep last night. He had many questions about surgery on admission this morning.
Nursing d___: His chief nursing care problems are anxiety related to inexperience with surgery and risk for body image disturbance.
T-eaching plan: I talked to him about postoperative routines and answered all his questions. He attended the preoperative admission clinic 2 weeks ago, but he did not have as many concerns at that time. He stated that he felt less anxious now that he knows what to expect.
Tr___: I started an intravenous infusion of normal saline in his left arm at 0645 hrs and it is running at 125 mL/hr.
F___ information: His wife came with him this morning and will wait in the surgical waiting room till his surgery is complete.
D___ plan: Mr. Tolan is a very active person and participates in strenuous sports such as swimming. Mrs. Tolan is concerned about how he might react to a colostomy. I suggest making a referral to the enterostomal therapist early, if the colostomy is performed.
P___ needs: Right now, Mr. Tolan is relaxing in his room. All preoperative procedures have been completed except for his preoperative antibiotic, due on call to the operating room.
change / shift
B-ackgorund
A-ssessment
d-iagnosis
T-eaching
Tr-eatments
F-amily
D-ischarge
P-riority
A professional demeanour is essential when giving a report about patients or family members. It is often necessary to describe the interactions among patients, nurses, and family members in behavioural terms. Nurses must avoid using judgemental language such as uncooperative, diff___, or bad when describing such behaviours.
diff-icult
Patients may transfer from one unit to another to receive different levels of care. For example, patients transfer from a Critical Care Unit or the recovery room to general nursing units when they no longer require intense monitoring. To promote continuity of care, the nurse may give transfer ___ by phone or in person.
report x2
When giving a t___ ___, the nurse needs to include the following information:
- Patient’s name, age, name of primary physician, and medical diagnosis
- Summary of progress up to the time of transfer
- Patient’s current health status (physical and psychosocial)
- Patient’s allergies
- Patient’s emergency code status
- Patient’s family support (e.g., spouse or partner, children, parents)
- Patient’s current nursing diagnoses or problem and care plan
- Any critical assessments or interventions to be completed shortly after transfer (helps receiving nurse to establish priorities of care)
- Need for any special equipment, such as isolation equipment, suction equipment, or traction
t-ransfer / report
Any v___ report must be timely, accurate, and relevant. Many Canadian hospitals use the situation–background–assessment–recommendation (SBAR) technique or i___–situation–background–assessment–recommendation–r___ ___ (I-SBAR-R) technique to share important patient information in an effective and efficient way and to help standardize communication.
v-erbal / i-dentification / r-ead / back
This technique is a situational briefing system that fosters a culture of patient safety. This technique can be incorporated into a variety of ways of reporting (e.g., a nurse’s report to a physician about a critically ill patient, change-of-shift reports about individual patients) and can be adapted for use with or by other healthcare providers.
SBAR/I-SBAR-R
When calling the physician, follow the I-SBAR-R process as follows:
I___: Who is calling and who are you calling about?
• Identify yourself and your role
• Identify the unit, the patient, and the room number
S___: What is the situation you are calling about?
• Briefly state the problem: What it is, when it started, and the severity
B___: Provide background information as necessary related to the situation, including the following:
• The admitting diagnosis, date of admission, and pertinent medical history
• List of current medications, allergies, intravenous fluids, and laboratory tests
• Laboratory results (date and time each test was performed and results of previous tests for comparison)
• Other clinical information
• Code status
A___: What is your assessment of the situation?
Examples include the following:
- Most recent vital signs
- Changes in vital signs or assessment from previous assessments
R___: What is your recommendation, or what do you think needs to be done?
Examples include the following:
- Patient to be admitted or transferred
- New medication or further tests
- Patient to be seen now
- Orders to be changed
R___ ___:
- Repeat back orders that have been given
- Clarify any questions
I-dentification
S-ituation
B-ackground
A-ssessment
R-eccommendation
R-epeat / back
An ___ or occurrence is any event that is not consistent with the routine, expected care of a patient or the standard procedures in place on a health care unit. Examples include patient falls, needle-stick injuries, a visit by someone who has symptoms of illness, medication administration errors, accidental omission of ordered therapies, and circumstances that led to injury or risk for patient injury.
incident
An ___ ___ (or occurrence or safety learning report) is completed whenever an incident occurs. They are an important part of the quality improvement program of a unit.
incident report
An event that could have resulted in unwanted consequences, but did not because either by chance or through timely intervention the event did not reach the patient.
Near miss (close call)
When an incident occurs, as the nurse, document an o___ description of what happened; what you observed; and the follow-up actions taken, including notification of the patient’s healthcare provider in the patient’s medical record. Remember to evaluate and document the patient’s response to the incident.
objective
Incident or occurrence reports contain c___ information; distribution of the report is limited to those responsible for reviewing the forms.
c-onfidential
It is important to follow agency policy when making an ___ report and file the report with the risk-management department of your agency.
incident
Analysis of ___ reports helps identify trends in an organization that provide justification for changes in policies and procedures or for in-service programs.
incident
Do not include any reference to an incident in the m___ record. A notation about an incident report in a patient’s m___ record makes it easier for a lawyer to argue that the reference makes the incident report part of the m___ record and therefore subject to attorney review.
m-edical x3
