Summary ATI RN COMPREHENSIVE PREDICTOR 2016 REMEDIATION.

ATI RN COMPREHENSIVE PREDICTOR 2016 REMEDIATION Management of Care – (9) Advance Directives/Self-Determination/Life Planning – (1) ▪ Professional Responsibilities: Client Teaching About Do-Not-Resuscitate Orders (Active Learning Template – Basic Concept, RM Leadership 7.0 Chp. 3) • Unless a do not resuscitate (DNR) or allow natural death (AND) prescription is written, the nurse should initiate CPR when a client has no pulse or respirations. The written prescription for a DNR or AND must be placed in the client’s medical record. The provider consults the client and the family prior to administering a DNR or AND. Client Rights – (1) ▪ Coordinating Client Care: Appropriate Action When a Client Leaves Against Medical Advice (Active Learning Template – Basic Concept, RM Leadership 7.0 Chp. 2) • A client who leaves a facility without a prescription for discharge from the provider is considered leaving against medical advice (AMA). A client who is legally competent has the legal right to leave the facility at any time. The nurse should immediately notify the provider. If the client is at risk for harm, it is imperative that the nurse explain the risk involved in leaving the facility. The individual should sign a form relinquishing responsibility for any complications that arise from discontinuing prescribed care. The nurse should document all communication, as well as the specific advice that was provided for the client. A nurse who tries to prevent the client from leaving the facility can face legal charges of assault, battery, and false imprisonment. Collaboration with Interdisciplinary Team – (1) ▪ Coordinating Client Care: Information to Report to Occupational Therapist (Active Learning Template – Basic Concept, RM Leadership 7.0 Chp. 2) • Patient’s condition and current status; any medications the patient is on; patient’s tolerance level for pain; any assistive devices the patient uses Confidentiality/Information Security – (1) ▪ Professional Responsibilities: Protecting Confidential Client Information (Active Learning Template – Basic Concept, RM Leadership 7.0 Chp. 3) • It is essential for nurses to be aware of the rights of clients in regard to privacy and confidentiality. Facility policies and procedures are established in order to ensure compliance with HIPAA regulations. It is essential that nurses know and adhere to the policies and procedures. HIPAA regulations also provide for penalties in the event of noncompliance with the regulations. Continuity of Care – (1) ▪ Information Technology: Preparing a Change-of-Shift Report (Active Learning Template – Basic Concept, RM FUND 9.0 Ch 5) • Nurses give this report at the conclusion of each shift to the nurse assuming responsibility for the clients. Formats include face to face, audiotaping, or presentation during walking rounds in each client’s room (unless the client has a roommate or visitors are present). An effective report should: include significant objective information about the client’s health problems; proceed in a logical sequence; include no gossip or personal opinion; relate recent changes in medications, treatments, procedures, and the discharge plan Legal Rights and Responsibilities – (1) ▪ Professional Responsibilities: Understanding Regulations for Nursing Scope of Practice (Active Learning Template – Basic Concept, RM Leadership 7.0 Chp. 3) • Standards of care guide, define, and direct the level of care that should be given by practicing nurses. They also are used in malpractice lawsuits to determine if that level was maintained. Nurses should refuse to practice beyond the legal scope of practice and/or outside of their areas of competence regardless of reason (staffing shortage, lack of appropriate personnel). Nurses should use the formal chain of command to verbalize concerns related to assignment in light of current legal scope of practice, job description, and area of competence. Performance Improvement (Quality Improvement) – (1)