Unit VI (Communication & Delegation) Flashcards
Who states that “The nurse has the duty to maintain the confidentiality for all patient information?
ANA Code of Ethics (2001)
What does HIPAA stand for?
Health Insurance Portability and Accountability Act
What are the three characteristics of nursing documentation?
Formal
Legal
Confidential
What characteristic of nursing documentation provide evidence or care provided? (Formal, Legal, or Confidential)
Legal
The nursing student understands that accurate and proper documentation prevents the nurse from:
being liable.
The nursing student understands that accurate and proper documentation protects the nurse from:
the error of another.
What contributes to a successful lawsuit?
Poor documentation
State the purposes of documentation (8 of them)
Communication with other providers Planning Care Legal Recording of care provided Reimbursement Reviews and Audits Education Research Healthcare Analysis
The Ohio Nurse Practice Act states that documentation is to be _______ _______ and _______.
complete, accurate, timely.
The Joint Commission requires documentation to be complete, accurate, timely, __________, and _______ to client.
confidential, specific
Name the four types of documentation.
Narrative
Focus Charting
Charting by Exception (CBE)
Computerized (EMR)
The nurse documents: “Patient was assisted to bathroom with assistance of UAP. Gait slow and steady.” What type of documentation is this?
Narrative
What type of documentation records routine care, normal findings, patient problems, and is written in chronological order?
Narrative
What is the disadvantage of narrative charting?
Tendency for repetitious information
Time consuming
Need to sort through to find desired data.
What type of charting makes the patient concerns and and stregths the focus of care?
Focused Charting
Focused charting focuses on _________ & ________ data.
subjective & objective
What type of charting is written with the nursing process?
Focused Charting
What type of charting only documents abnormal or significant findings?
Charting by Exception (CBE)
What is the primary advantge of Charting by Exception?
Makes changes in patient conditions more obvious.
What does charting by exception assume?
Assumes the nurse assessed the patient and determined what responses were normal/abnormal.
The nurse feels the current charting method is not sufficient because “if it wasn’t charted, it wasn’t done”. What type of charting is the nurse using?
Charting by Exception (CBE)
How does the RN sign their documentation?
First Initial. Last Name RN
How does the SCC Nursing Student sign their documentation?
First Initial. Last Name SNS
What must be included in nursing documentation?
Date, Time, Name and Title.
What occurences may happen that the nurse MUST chart?
Refusal of medications
Teaching
Outcomes for interventions
Change in condition, who your reported it to, and what you did about it.
The nurse has made an error in the chart. What can the nurse NOT do? How does the nurse accurately correct the mistake?
NOT:
Erase, black out, white out.
Correct:
Single line through mistake, write error above with initials.
The nurse plans to place an indwelling catheter for the patient, and charts: Foley catheter placed, anchored to left leg. Is this legal?
No, you cannot chart ‘ahead’ (things that have not been performed yet).
The nurse charts: “Pt fell, assissted back to bed. Vital signs: 110/70 (80) R-18, T-98.1. Incident form completed.
What error was made?
Do not indicate that incident or risk form completed.
When calling the physician to obtain a pain medication order for the patient, what role does the nurse assume for the patient?
Patient advocate.
What is required for a medication order?
Name of medication Dose Route Frequency Quantity Duration Indication for Use
How does the nurse indicate a medication order was taken by telephone?
T.O.R.B. Dr Name/Nurse Name RN
How does the nurse indicate a medication order was taken verbally?
V.O.R.B. Dr. Name/ Nurse Name RN
How long does the doctor have to sign the medication order?
24 Hours
What does SBAR stand for?
Situation
Backgroung
Assessment
Recommendation
What does the nurse include in the ‘Situation’ portion of the SBAR?
State your Name, Unit, Patient Name
-Briefly state the problem.
What does the nurse include in the ‘Background’ portion of the SBAR?
State the date of admission and admitting diagnosis.
- Pertinent medical history
- Summary of treatment to date
- Code Status if appropriate
What does the nurse include in the “Assessment” portion of the SBAR?
Vital Signs
Pain Scale
Changes from prior assessments
What does the nurse include in the “Recommendation” portion of the SBAR?
What you would like to see done.
Ask if the provider wants to order labs or meds
Ask if the provider wants to be notified with further changes, or failure to improve.
When is SBAR a good tool to use?
- Calling a physician
- Handing of pt to another nurse
- Transferring pt to another unit of facility.
Who does the RN delegate care to?
Who does the RN direct care to?
Care is delegated to the UAP
Care is directed to the LPN
Who defines delegation as the transfer of responsibility for the performance of an activity from one individual to another while retaining accountability for the outcome?
ANA
Who adds to the ANA’s definition of delegation: …..from a licensed nurse authorized to perform the task to an individual who does not otherwise have the authority to perform the task?
Ohio Nurse Practice Act
Who give the LEGAL authority to delegate?
State Nurse Practice Act
What is the goal of the State Nurse Practice Act in regards to delegation?
Safe patient care and protection of the public.
Who is ultimately responsible for the provision and management of nursing tasks/care?
RN
Who is responsible for the decision to delegate?
RN
The RN has delegated a task. The decision to delegate has increased to RN’s scope of ___________.
liability.
What should the nurse consider when delegating a task?
Job descriptions
Knowledge base
Demonstration of skill.
What things can the RN never delegate?
Assessment (Initial & PAIN) Teaching Any task involving nursing judgement/nursing process: -Interpretation of test results -Identify pt needs -Evaluating success of intervention
In addition to the rules and regulations of the facility, what other governing document must the RN be aware of when considering delegating care?
State Nurse Practice Act
The nurse has failed to delegate a task appropriately and supervise the care. What is this seen as?
Malpractice
The RN has delegated appropriately. However, the UAP has made an error. Does the Ohio Board of Nursing hold the RN accountable?
No, as long as:
RN followed state regualtion (NPA)
RN intervened when they became aware of actual or portential problem.
List the five rights of delegation.
1) Right Task
2) Right Circumstance
3) Right Person
4) Right Direction/Communication
5) Right Supervision/Evaluation
To whom is the UAP assigned? RN or patient?
RN
The nurse identifies the pt has many complex needs, and is at risk to change quickly. What ‘Right of Delegation’ has the nurse assessed?
Right Circumstance
The nurse identifies that bathing can be delegated to the UAP for a stable patient because the task is repetitive, and requires little clinical judgement. What ‘Right of Delegation” has the nurse assessed?
Right Task
The nurse identified the task will require a great deal of personal judgement and decision making. What ‘Right of Delegation’ is the nurse assessing?
Right Task
The nurse provides the UAP with clear direction for the task, and lists signs and symptoms to look for. What ‘Right of Delegation’ is the RN executing?
Right Communication/Direction
The nurse asks the UAP to immediately report if Mr. Smith’s B/P is lower that 120/60. What ‘Right of Delegation’ is the nurse executing?
Right Communication/Direction
The nurse identifies the LPN has the required skills and training required to execute the task. What ‘Right of Delegation’ is the RN executing?
Right Person
The nurse assesses the workload of the UAP when delegating tasks. What ‘Right of Delegation’ is the RN executing?
Right Person
The nurse has identified the patient has serious infections and is at risk to contract further infections. What ‘Right of Delegation’ is the nurse using?
Right Circumstance
The nurse has observed the UAP perform a task, and has provided praise. What ‘Right of Delegation’ is the RN implementing?
Right Supervision/Evaluation
The nurse identifies the UAP needs further training on the delegated task. What ‘Right of Delegation’ is the RN implementing?
Right Supervision/Evaluation
The nurse asks the UAP to repeat the steps of the process to verify understanding. What ‘Right of Delegation’ is the RN implementing?
Right Direction/Communication
What does JCAHO require that the nurse can use to identify delegatable tasks?
Documentation of Staff Competencies.
What causes subordinate resistance?
- Overwhelmed
- Fear
- Resistance to authority
- Tasks delegated in terms of specificity
- Cultural Differences
