Fundamentals 7, 8, 10 Flashcards
Documentation that tracks variances from the clinical pathway
Case management system charting
Documentation of the nursing process, treatment, and associated care
charting
Documentation that focuses on deviations from predefined norms, using preset protocols and standards of care
charting by exception
Documentation in which data are input via the computer
computer-assisted charting
The entering of provider orders into the medical record via computer
Computerized provider order entry (CPOE)
Health record entered into a computer’s software program that is updated via the computer
electronic health record (EHR)
Documentation that centers on the patient from a positive perspective; this form of documentation has three components: data, action, and response
focus charting
Paper or electronic record that contains all orders, tests, treatments, and care that occurred during the time a person was under the care of a health care provider
medical record
method of documentation in which “P” means problem identification, “I” means interventions, and “E” means evaluation
PIE charting
Documentation that focuses on patient status, emphasizes the problem-solving approach to patient care, and provides a method for communication what, when, and how things are to be done to meet the patient’s needs
Problem-oriented medical record (POMR) charting
Documentation that is organized by the “source” or author of the documentation
Source–oriented (narrative) charting
Difficulty expressing or understanding language
aphasia
Technique for communication between members of the health care team; the acronym stands for Introduction, Situation, Background, Assessment, Recommendation, and Readback
ISBAR-R
Recognizing the patient as the source of control and full partner in providing compassionate and coordinated care based on respect for the patient’s values, needs, and preferences
patient-centered care
Communication that promotes understanding between the sender and the receiver
Therapeutic communication
Leadership style of tight control and unlimited power
autocratic
Leadership style practicing social equality or majority rule
democratic
Leadership style that is based on noninterference with what others desire
Laissez-faire
Encourages patient to continue or elaborate
General leads
Encourages patient to elaborate rather than answer in one or two words
Open ended questions or statements
Shows caring, concern, and readiness to help
offering self
Restates received message back to patient. Also encourages further verbalization of feelings. Reflects feelings. Can also be used if the patient is unable to verbalize or if nonverbal information is incongruent with verbal
Reflection
Seeks clarification about the source of the upset feeling. Helps the patient clarify thoughts or ideas
Seeking clarification
Asking a goal-directed question helps the patient focus on key concerns
Focusing
Helps the patient education relevant to specific health care needs or situation
giving information
Helps patients see options and consider alternatives to make their own decisions about health care
looking at alternatives
allows patient time to gather thoughts and sort them out
silence
sums up the important points of an interaction
summarizing
What is the difference between empathy and sympathy?
Empathy is the ability to place oneself in another’s position. With sympathy, concern and perhaps sorrow are felt, indicating that the person is experiencing something difficult
What are the therapeutic techniques with communication? (11)
General Leads. Open ended questions or statements. Offering self. Restatement. Reflection. Seeking clarification. Encouraging elaboration. Giving information. Looking at alternatives. Silence. Summarizing.
Who is responsible for the nursing care of patients during shift
charge nurse
When you are documenting it should show progress towards what
expected outcomes and goals
Charting by exception
Charting by exception is based on the assumption that all standards of practice are carried out and met with a normal or expected response unless otherwise documented. The nurse needs only to document abnormal findings or responses correlated with the nursing diagnoses listed on the nursing care plan. Charting by exception assumes that, unless documented to the contrary, all standards and protocols were followed and assessment values were within accepted limits.
Leadership styles and their descriptions
Laissez-faire leader does not attempt to control the team and offers little if any direction. The authoritarian or autocratic leader tightly controls team members. This leader closely supervises the work of each staff member. The democratic leader consults with staff members and seeks staff participation in decision making. This leader is part of the team, not above it, and accepts responsibility for the team’s actions.
guidelines for documentation
Only record what you have done for the patient, not what you plan to do. Documentation should be accurate, brief, and complete. Verify you are on the correct patient’s computer screen before documenting. Use a 24-hr clock. Documentation is done only by the person who made the observation. Record objective data after completing each task. Follow hospital policy for amending the record. Clearly identify care given by another team member. Record when a patient refuses. Spell medical record entries correctly. If you suspect an order is incorrect seek clarification.
Essential information that needs to be included in documentation
Admission note. Assessment data for all body systems. Body care. Death. Degree of activity. Diagnostic test. Diet and fluids. Discharge from the facility. Dressings and wound care. Intake and output. Intravenous infusions. Medications. Mental state and mood. Mood, concerns, or discomfort. Oxygen in use. Primary care provider’s visits and calls to providers. Postoperative care. Procedures performed. Sleep. Specimens obtained and their disposition. Patient education. Travel from the unit. Tubes and equipment in use. Visitors.
Characteristics of effective communication (5) and (3)
Active listening, interpreting nonverbal messages, obtaining feedback, focusing, adjusting style. Communicating effectively includes taking the time to attend to the person by stopping what you are doing, establishing eye contact, and being polite
Elements of good communication
Good communication requires active listening, timely feedback, and validation of assumptions about nonverbal cues
How do you document behavior and where do you document it
Document behaviors in your nurse’s notes. You must choose which behaviors and observations are noteworthy, or your nurse’s notes will be lengthy and irrelevant. A rule of thumb is that if the behavior or finding is abnormal or is a change from previous behavior or data, document it.
Advantages to source oriented or narrative charting (6)
1 It gives information on the patient’s condition and care in chronological order. #2 It indicates the patient’s baseline condition for each shift. #3 It includes aspects of all steps of the nursing process. #4 It encourages documentation of both normal and abnormal findings, making it difficult to separate pertinent from irrelevant information. #5 It requires extensive documentation time by the staff. #6 It discourages physicians and other health team members from reading all parts of the medical record because of the lengthy descriptive entries in it
What are effective strategies in conflict resolution
Try to remain calm and open and actively listen to the problem. Accept responsibility for any part you played in development of the conflict. Focus on the issue rather than on the feelings of those involved. Mediate by communicating openly. Sort out issues involved by identifying key themes in the discussion. Consider the options and weigh the consequences of each option.
Briefing
often used when there is new information to be shared. The team leader initiates the briefing. Included in a briefing: (a) who is in charge, (b) lines of communication, and © member responsibilities and expected behaviors.
huddle
an impromptu meeting held when the need arises. A huddle is a chance for team members to touch base with each other, evaluate changes in the plan that might be needed, and reorganize the workflow.
debrief
An informal meeting held after a situation or event to discuss the event; usually including what went well, what didn’t work, and how the situation might be handled differently next time.
What does the joint commission expect of you when receiving a telephone order
The nurse is expected to enter the orders in the computer for the prescribing care provider to verify later. Verbal orders can only be taken by licensed nurses, and in some states only by an RN. The provider must authenticate the order by electronically signing the written form of the verbal order as soon as possible.
Delegation to unlicensed assistive personnel and whats appropriate and whats not
basically nothing a tech does, only what the helpers and activities people at wyndridge do (check study guide for full chart)
If you are unclear about an order what do you do
check the drug administration record
How can you limit the liability of a lawsuit against a facility?
By documenting what you need to document. Documentation provides a written record of the history, treatment, care, and response of the patient while under medical and nursing care. Documentation can be used as evidence in the court of law because it shows the use of the nursing process, and provides data for quality-assurance studies.
When you are giving directions what are some characteristics of giving them, how should you give them and in what kind of way
Give clear, concise messages and listen carefully to feedback.
