Provision of Care, Treatment, and Services Flashcards
What is the plan of care for your patient?
Use the medical record to show documentation to support your plan of care including history, goals, planned interventions, and progress to date.
How are the need of the patient known or identified?
Screening questions are asked regarding their learning needs assessment and any other physical, psychological, social, cultural, or spiritual needs.
What do you do if a patient is suspected of being a victim of abuse?
Contact the social work department ASAP. The social worker or healthcare provider is responsible for reporting the suspected abuse to appropriate agencies.
How is the patient’s pain assessed?
All patients’ pain scores are assessed on initial assessment/admission using the FACES or numerical rating scale. Reassessments are made after procedures, interventions, or any significant change in the patient’s condition.
Where are pain assessments documented?
Within the vitals portion of outpatient notes and with vitals assessments during hospitalizations.
How are patients assessed for fall risk?
Upon admission, patients are assessed by the admitting RN using the fall risk assessment tool.
What interventions are used to reduce a patient’s risk for falls?
Side rails, nonskid slippers, orienting patient to nurse call button, and patient education on opioids if being used
What options are available to prevent the use of restraints in agitated patients?
Providing companionship, diversionary activities, decreasing environmental stimuli, assessing patient for pain, attending to physical needs such as nutrition or hydration, 1-1 care, or verbal redirection.
How long can restraints be used on a patient?
The least possible amount of time. Restraints are always discontinued at the earliest possible opportunity. Only approved restraints can be used. Safety checks are performed/documented every 2 hours (non-behavioral) or 15 minutes (behavioral).
When are the patient and family education needs determined?
Initially at the time of admission or during intake at outpatient clinic appointments.
When his discharge planning initiated?
Upon admission and continues throughout the hospital stay.
How do you assure a patient understood what you taught them?
Through teach-back. The patient demonstrates the required skills and is able to explain the concepts in their own words.
