CORRECT Answers
, HIPAA & Confidentiality Protect patient privacy at all times.
Key principles Only access chart information necessary for care (minimum necessary rule).
Do not discuss patient information in public areas (hallways, elevators, cafeteria).
Verify identity before giving information over the phone.
No sharing of passwords or EHR log-ins.
Patients have the right to access their own medical records.
Documentation Accurate, objective, timely, and complete.
General rules Use factual descriptions (avoid "seems" or assumptions).
Document ASAP after care is provided.
Use correct spelling, approved abbreviations.
If it wasn't documented, it wasn't done.
NEVER alter or delete entries.
Late entry must be labeled.
SBAR S – Situation: What is happening now?
Structured communication tool B – Background: Relevant history, diagnosis, medications.
A – Assessment: Current findings (VS, pain, lab values).
R – Recommendation: What you want (orders, tests, evaluation).
Therapeutic Communication DO's Open-ended questions
Empathy ("That sounds very difficult")
Silence
Clarification
Restating/paraphrasing
Focus on feelings
Therapeutic Communication DONT's Giving advice
Asking "why?"
False reassurance
Minimizing
Redirecting away from feelings
Nursing Process (ADPIE) Assessment – collect subjective & objective data.
Diagnosis – NANDA: problem related to cause as evidenced by signs.
Planning – set SMART goals.
Implementation – perform interventions.
Evaluation – determine if goals are met or need revision.
Delegation: RN cannot delegate Assessments
Teaching
Nursing judgment
Unstable patients
Delegation: LPN may do Stable patients
Medication administration (not IV push in many areas)
Wound care
Foley insertion
Delegation: UAP may do: ADLs
Vital signs (stable)
Positioning, bathing, feeding (non-aspiration risk)