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Level II Midyear Class - NCM 107: Care of Mother, Child and Adolescent with Normal Physiologic Processes > Skills Lab JBD: Sande - Documentations, Medication Cards and Charting > Flashcards

Skills Lab JBD: Sande - Documentations, Medication Cards and Charting Flashcards

1
Q

What is documentation?

A

Anything written or electronically generated that describes the status of a client or the care or services given to that client that is obtained through the nursing process.

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2
Q

How documentation obtained?

A

This is obtained through the nursing process.

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3
Q

What are the principles of documentation?

A 
Factual
Accurate
Complete
Current (Timely)
Organized
Compliant with standards
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4
Q

What is confidentiality?

A

Clients have a right to protection of their privacy

  1. Access
  2. Storage
  3. Retrieval
  4. Transmittal of records
  5. Receive a copy of their health records for a reasonable fee.
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5
Q

What are the six purpose of charting or documentation?

A

6 Purpose of Documentation

  1. Communication and continuity of care
  2. Quality Improvement/Assurance and Risk Management
  3. Establishes professional accountability
  4. Legal reasons
  5. Funding and resource management
  6. Expanding the science of nursing
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6
Q

What are the five guidelines in making documentation?

A

5 Guidelines in making Documentation

  1. Clear, concise, unbiased and accurate
  2. Legibility and spelling
  3. No blank (white) space
  4. Abbreviation, symbols and acronyms
  5. Mistaken entry/errors and changes and additions.
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7
Q

Is white blank spaces allowed in documentation? Why or why not?

A

It is not allowed.

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8
Q

If there is a white blank space in the documentation , what should the nurse do?

A

An accepted practice is to draw a single line completely through the white space, including before and after your signature

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9
Q

What are the things that a nurse should remember in using abbreviations, symbols and acronyms?

A

Meaning should be well understood by everyone
Use only those abbreviations, symbols and acronyms that are on a current agency-approved list or an agency approved reference text

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10
Q

What can you do for the mistaken entries, errors, changes/additions?

A

Inaccuracies in documentation can result in inappropriate care decisions and client injury
Errors must be corrected according to agency policy

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11
Q

What can a nurse do if there is an error in paper-based documentation?

A
  1. Do not make entries between lines.
  2. Do not remove anything (e.g., monitor strips, lab reports, requisitions, checklists).
  3. Do not erase or use correction products, stickers or felt pens to hide or obliterate an error .
  4. Under no circumstance should chart pages or entries be recopied because of a documentation error.
  5. If information is difficult to read, add pertinent information in a ‘note to chart’ or ‘note to file’.
  6. Failing to correct an error appropriately (according to agency policy) or correcting or modifying another’s documentation may be interpreted as falsification of a record.
  7. Falsifying records is considered professional misconduct.
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12
Q

What are the exact actions that must be done to correct the mistaken entries on the documentation?

A

A generally accepted practice to correct an error in a paper-based system is to cross through the word(s) with a single line, above the line write “mistaken entry” and insert your initials, along with the date and time the correction was made and enter the correct information.

Example:

July 13, 2021
10:30 am > patient vomited 3x, previously taken food
Mistaken entry ٧
in moderate amount in large amount

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13
Q

Why is not changing pens while writing important?

A

This may cause suspicion that the data has been tampered and could be investigated for falsification of records.

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14
Q

Erasing or tampering the mistaken entry could result to?

A

Suspicion for falsification of record or the nurse may face misconduct.

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15
Q

What can you do if there are lack of space in the already written record

A

Write please refer to addendum at the bottom.

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16
Q

True or false: You should not write something or change someone’s written record if his or her notes has errors and he or she is absent.

A

Never correct the mistaken entry of the others. Call that person’s attention and inform her. The involved person must come back to the hospital and change it by himself or herself.

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17
Q

What is admission?

A

Admitting or receiving the patient for admission. Nurse’s courtesy, confidence, and efficiency are needed.

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18
Q

What are the steps in admitting a patient?

A

Steps in admitting a patient

  1. Prepare the patient’s unit as soon as notified by admitting clerk
  2. Receive patient
  3. Observe for signs and symptoms
  4. Orient patient
  5. Take date and chart - TBR and BP
  6. Inform attending or resident physician
  7. Carry orders as given by physician
  8. Notify kitchen
  9. Plan an individualized nursing care based on the patient’s need.
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19
Q

Wh17. What are the things that you should acquire after admitting the patient?

A

VS and TBR as well as other objective and subjective data

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20
Q

What is a medication card?

A

A medication card is a card that contains the medications of a patient as ordered by the doctor.

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21
Q

What is the shape of an oral medication card?

A

A box.

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22
Q

What is the shape of an parenteral medication card?

A

Ribbon-like tail.

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23
Q

What is the shape of an treatment medication card?

A

Tip of the sword.

24
Q

What is the color of medication card for 3x a day?

A

TID - White.

25
Q

What is the color of medication card for 2x a day?

A

BID - Blue

26
Q

What is the color of medication card for STAT or at once/immediately?

A

Red

27
Q

What is the color of medication card for round the clock medication?

A

RTC - Yellow

28
Q

What is the color of medication card for once a day?

A

OD - Orange

29
Q

What is the color of medication card for 4x a day?

A

QID - Green

30
Q

What are the information that a medication card contains?

A

Date of ordered, ward and bed number.
Medications and dosage as well as route
and other instructions of the physician. It also contains the standard time depending on the doctor’s order. The nurse should also write his or her initials and name at the back of the card.

31
Q

When are verbal and telephone orders are deemed acceptable?

A

a. Urgent or emergency situations (impractical for a prescriber to interrupt client care and write the medication order)
b. When a prescriber is not present and direction is urgently required by a registered nurse to provide appropriate client care

32
Q

What are the information needed to obtain verbal/telephone orders completely?

A
  1. Client’s name
  2. Medication name
  3. Dosage form
  4. Route of administration
  5. Exact strength of concentration
  6. Dose
  7. Frequency of administration
  8. Quantity and duration
  9. Purpose or indication for the medication
  10. Prescriber’s name and designation
33
Q

What are the guidelines in taking a verbal/telephone order?

A
  1. Write down the time and date on the physicians’ order sheet
  2. Write down the order exactly as given by the physician
  3. Read the order back to the physician to ensure it is accurately recorded
  4. Record the physician’s name on the order sheet, state “telephone order”
  5. Print your name and sign the entry, along with your designation (e.g.,“RN”)
34
Q

Who will be the one to transcribe the doctor’s order?

A

The nurse that admitted the patient.

35
Q

Why do you need to put an arrow in the blank spaces in medication card?

A

This is to ensure that other nurses from other shifts who will administer the medications will not be confused and placed their entries in the proper places.

36
Q

What does double slanting lines mean?

A

It means “discontinued”/discontinue medication.

37
Q

Why does an upward or downward arrow could be beside the double slanting lines?

A

There has been some changes in the in medication administration (dosage, route, etc.) and is indicative of a medication increasing or decreasing their dosage or change in form of medicine.

38
Q

True or false: Transcribe the doctor’s order in the new space in medication form despite having the same name.

A

True as the doctor could have change the route, dosage as well as changes in time of administration depending on the order.

39
Q

True or false: The nurse could discontinue the medication without the doctor’s order.

A

False: Don’t stop the medication without the doctor’s order.

40
Q

What exemption wherein the nurse could discontinue the medications?

A

The patient displays allergic reaction to the medication as observed by the nurse. Immediately notify the doctor.

41
Q

True or false: Write the discontinued medications along with the new medications that the physician ordered.

A

False. The nurse should only write the medications that has been currently ordered and administered.

42
Q

Determine the requirement needed for a discharge?

A

Requires the written order of the physician or by patient’s request.

43
Q

What can the nurse do for the patient during a discharge?

A

Assist patient:

  1. Self-care needed at home (dressings, medication, diet)
  2. Refer to other departments for instructions
  3. Let the relatives make the financial arrangements notify the kitchen about the discharge of the patient
44
Q

Determine the process of discharge.

A
  1. Check if order of discharge has been given in written form
  2. Prepare patient for discharge
  3. Inform head nurse of patient’s going home
  4. Return all extra medications
  5. Complete patient’s chart, chart time, condition and signature
  6. Escort patient by wheelchair to hospital’s main entrance
  7. Leave patient’s chart at information pay or charity
  8. Return dirty linens. Clean room
  9. Remove all medicine and treatment cards
  10. Remove name of patient from DIRECTORY
  11. Notify kitchen on discharge
45
Q

What is HAMA?

A

Home against medical advice

46
Q

What is DAMA?

A

Discharge against medical advice

47
Q

What steps should the nurse take if the patient requests for HAMA or DAMA?

A

Telephone the attending physician first and explain the reasons why the patient must remain in the hospital.

48
Q

What steps should the nurse take if the patient insist on HAMA or DAMA despite the nurse’s or doctor’s explanation?

A

Let the patient write his or her wish and sign if of legal age, if not let a relative write and sign the form and have it witnessed.

49
Q

Determine the requirement when the patient wants or needs to transfer in another hospital?

A

Ask for the attending physician’s transfer order and ask the family to make the arrangements for the transfer.

50
Q

Define the focus charting.

A

This is a systematic approach to documentation and is a method of organizing health information in an individual record which is intended to make the client and client concerns and strengths the focus of care.

51
Q

What are the focus of the focus chart?

A
  1. Skin integrity
  2. Fluid and Hydration
  3. Pain management
  4. Education
  5. Patient safety
  6. Nutrition management
  7. Discharge management
  8. Emotional support
  9. Respiratory management
  10. Mobility
  11. Neuromuscular management
  12. Cardiovascular management
52
Q

What are the parts of focus chart?

A

Data
Action
Response

53
Q

Define data pertinent to focus charting.

A

This is similar to the assessment phase in the nursing process which both subjective and objective data.

Assessment cues like: vital signs, behaviors, and other observations noticed from the patient.

54
Q

Define action pertinent to focus charting.

A

Reflects the planning and implementation phase of the nursing process and includes immediate and future nursing actions and any changes to the plan of care.

Written in past form.

55
Q

Define response pertinent to focus charting.

A

Reflects the evaluation phase of the nursing process and describes the client’s response to any nursing and medical care.

56
Q

How does a nurse close a focus chart?

A

Writing the nurse’s initials as an indication that he or she has finished writing in the chart.

Level II Midyear Class - NCM 107: Care of Mother, Child and Adolescent with Normal Physiologic Processes (6 decks)

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