Week Three Flashcards
Purposes of the client medical record
communication, planning client care, auditing health agencies, research, education, reimbursement, legal documentation, health care analysis (evidence based practice)
Admission sheet
client’s demographic, billing, allergies, MD info
Nursing care plan must be initiated how many hours within admission?
24 hours
Client discharge plan
upon admission, includes discharge plans and referral data
1000 mcg (mg)
1
60mg (gr)
1 gr
1gm (mg)
1000mg
5cc (tsp)
1 tsp
1kg (lb)
2.2 lb
1 ml (cc)
1cc
1oz (ml)
30 mL
1 qt
1 liter or 1000 mL
DSSP
two tsps
MCC documentation error policy
1 line strike through initials, date, and error
Kardex
system of cards or computer generated forms designed to state concisely the care for each client. name, age, room #, medical diagnoses, admission date, MD/PCP’s name
Source-Oriented Record
each department has their own section of the chart to record under (nursing, PT, RT)
Problem-Oriented Medical Record
data in the record is arranged according to identified client problems. Progress notes are then recorded under each of the identified problems by all disciplines involved in care
Four basic components of POMR
database, problem list, plan of care, progress notes
SOAP
subjective data, objective data, assessment, plan
narrative charting
chronological order, example of source-oriented record
PIE charting
problems identified, interventions performed, evaluation of care/interventions
Charting by exception
significant findings or exceptions to norms are recorded.
Three key elements of charting by exception
flowsheets, standards of nursing care, bedside access to chart forms
Who updates kardexes?
all nurses assigned to providing care to that client
Acceptance
receiving the client’s honest feelings/actions without judgement
Commitment
a pledge or contract to fulfill an obligation or agreement
Communication
any means of exchanging information or feelings between two or more people
Concreteness
being specific and clear when communicating
Confrontation
RN points out discrepancies between thoughts, feelings, and actions that inhibit the client’s self-understanding or exploration of specific areas
Empathy
the ability the discriminate what the other person’s world is like and to communicate to the other this understanding in a way that shows that the helper understand the client’s feelings and the behavior and experience underlying these feelings
Genuineness
statement that is helpful is solidifying the rapport between the RN and the client
Respect
attitude that considers the client’s point of view
self-disclosure
same as boundaries which are limits in which a person may act or refrain from acting within a designated time or place
therapeutic communication
promotes understanding and can help establish a constructive relationship between the RN and the client
therapeutic relationship
also known as a helping relationship that is made up of four phases (pre interaction, introductory, working, termination)
trust
reliance on someone without doubt or question
Communication Process
Message —> Receiver —> Decode —> Encode —> Message (Response) —> Decode —> Encode –> Sender
Public Space
12-15 feet
Intimate Space
touching to 1.5 feet
PErsonal Space
1.5-4 feet
Social Space
4-12 feet
Three major barriers to communication
failure to listen, improper decoding of client’s message, placing one’s needs over the other’s
Attentive Listening
listening actively, using all the senses as opposed to listening passively with just the ear
Use of Silence
accepting pauses or silences that may extend for several seconds or minutes without any verbal response
Providing General Leads
using statements or questions that encourage verbalization, a topic choice, and facilitate continued verbalization
Using Open-ended questions
asking broad questions that lead or invite the client to explore thoughts or feelings
Using Touch
Proving appropriate forms of touch to reinforce caring feeling. Must be sensitive to the differences and practices of clients and self
Paraphrasing
repeating client’s basic message in similar words
Seeking Clarification
a method of making a client’s broad overall meaning of the message more understandable. used when paraphrasing is difficult or when the communication is rambling or garbled
Consensual validation
similar to clarifying - verifies the meaning of specific words rather than the overall meaning
Offering self
suggesting one’s presence, interest, or wish to understand client without making any demands or attaching conditions that the client must comply with the receive attention
Giving Information
providing simple, factual info the client may or may not request
Focusing
helping the client expand on and develop a topic of importance
Reflection
directing thoughts, feelings, questions content back at client for further exploration
Summarizing
stating the main points of a discussion to clarify the relevant points discussed
Agreeing/Disagreeing
akin to judgmental responses, agreeing and disagreeing imply tha tthe client is either right or wrong and that the nurse is in a position to judge this. these responses deter clients from thinking through their position and may cause a client to become defensive
Being defensive
protection from admitting weaknesses “you have no right to complain”
Challenging
giving a response that makes clients prove their statement or point of view. these responses indicate that the nurse is failing to consider the client’s feelings, making the client feel it is necessary to defend a position
Changing Subject
directing the communication into areas of self-interest rather than considering client’s concerns is often a self-protective response to a topic that causes anxiety. these responses imply that what the nurse considers important will be discussed and that the clients should not discuss certain topics
Giving common advice
telling client what to do “if I were you, I’d go to a nursing home”
Passing judgment
giving opinions and approving or disapproving responses, moralizing or implying one’s own values. these responses imply that the client must think as the nurse thinks, fostering client dependence
Probing
asking for information chiefly out of curiosity rather than with the intent to assist the client. these responses are considered probing and violate the client’s privacy. asking why is often probing and places the client in a defensive position
Rejecting
refusing to discuss certain topics
stereotyping
offering generalized and oversimplified beliefs about groups of people that are based on experiences too limited to be valid. these responses categorize clients and negate their uniqueness as individuals
Unwarranted reassurance
“don’t worry” “I’m sure everything will be okay”
