RLE: MIDTERM Flashcards
a report delivered to and by all nurses caring for a patient.
ENDORSEMENT
Gives the indication for admission or medical diagnosis to new clients. Include details on recent and actual changes to the client’s condition.
ENDORSEMENT
a legal document and may be used to provide evidence in court, many factors are considered in recording.
Client’s record
The purpose of endorsing is to communicate specific information to a person or group of people. A report, whether oral or written, should be concise, including pertinent information but no extraneous detail.
Goal of Change-of-Shift Reports
associated with sentinel events that will result in adverse health care outcomes or death
Incomplete handoff communication
I-SBAR
Introduction, Situation, Background, Assessment, Recommendation
PACE:
Patient/Problem, Assessment/Actions, Continuing (treatments)/Changes, Evaluation
Five-P’s:
Patient, Plan, Purpose, Problem, Precautions, Physician
Types of doctor’s order:
written
*verbal
*telephone
*electronic
*email, viber, telegram {social media apps}
communication tool used to convey the client’s current orders as well as upcoming tests or surgery, diet, etc quickly and briefly.
KARDEX
Is a desktop file system that gives a brief overview of each patient and is updated every shift. It is a reference for nurses that is separate from the patient’s chart.
KARDEX
Forms for Recording Data
Flow Sheets
Nurse’s Progress Notes
Discharge Summary
Use only RED BALL PEN
for end-to-end ticking of doctor’s orders. Underline the last phrase to signify the last entry.
as “ An Act Strengthening the Philippine Disaster Risk Reduction and Management System, Providing for the National Disaster Risk Reduction and Management Framework, Institutionalizing the National Disaster Risk Reduction and Management Plan, Appropriating Funds
Republic Act No. 10121
CODE RED
Firke
CODE blue
Adult emergency
Code white
Pediatric Medical Emergency
CODE PINK
Infant Abduction
Rapid Response System
CODE PURPLE
Bomb threat
CODE YELLOW