NUR 501 WEEK 1-8 REFLECTIONS ON NURSING PRACTICE AND ETHICS | 2026
UPDATE WITH COMPLETE SOLUTION
HIPAA - -Federal law protecting all patient-identifiable health information in written, verbal,
or electronic form.
--Confidential Patient Information - -Name, address, phone, SSN, diagnosis, treatments, and
any identifying medical data.
--HIPAA Patient Rights - -Right to view, copy, update records; request restrictions; obtain
disclosure lists; choose how information is received.
--Pain (0-10 Scale) - -Subjective patient-reported pain intensity from 0 (no pain) to 10 (worst
pain).
--Nursing Documentation - -Legal written/electronic record of all patient care and
interactions.
--ADPIE - -Assessment, Diagnosis, Planning, Implementation, Evaluation.
--Timely Documentation - -Record using date and military time during admission, transfer,
discharge, procedures, post-op, changes in condition, critical provider calls.
--"If it wasn't documented, it wasn't done." - -Legal rule meaning undocumented care is
considered not performed.
--Electronic Health Record (EHR) - -Digital patient chart improving accuracy, efficiency, and
coordination.
--Source-Oriented Record - -Documentation organized by discipline (nursing, provider, PT,
etc.).
--Problem-Oriented Record - -Documentation organized around patient problems.
--Nursing Care Plan - -Document listing patient problems, goals, and nursing interventions.
--Critical Pathway - -Standardized multidisciplinary care plan for specific diagnoses.
--Kardex / Patient Care Summary - -Quick patient overview including diagnosis, meds,
treatments.
--Flow Sheets - -Structured forms for routine charting (vitals, I/O, assessments).
--Narrative Note - -Chronological, story-style documentation.
--SOAP Note - -Subjective, Objective, Assessment, Plan.
, --PIE Note - -Problem, Intervention, Evaluation.
--Focus Charting (DAR) - -Data, Action, Response.
--Charting by Exception - -Only abnormal findings are documented.
--Interpreting Orders - -Orders may be written, typed, verbal, or telephone.
--Verbal/Telephone Orders - -Used only in emergencies; must be read back and later signed.
--Patient Handoff - -Transfer of essential information to next caregiver for safety and
continuity.
--ISBAR - -Identify, Situation, Background, Assessment, Recommendation.
--Continuity of Care - -Consistent, coordinated care across shifts and departments.
--Confidentiality Breach - -Unauthorized viewing, discussing, or sharing patient info.
--Preventing Confidentiality Breaches - -Lock screens, avoid public discussions, verify
recipients, no social media, secure paperwork.
--Patient Record - -Legal, permanent documentation of all care—nurse's strongest legal
defense.
--Patient Teaching (Oxygenation) - -Teach meds, breathing techniques, positioning, infection
prevention, vaccinations.
--Tripod Position - -Leaning forward to improve chest expansion.
--Semi-Fowler's Position - -HOB 30-45° to enhance oxygenation.
--High Fowler's Position - -HOB 60-90° for maximum lung expansion.
--Hypoxia - -Low oxygen at the cellular level.
--Hypoxemia - -Low oxygen level in the blood.
--Incentive Spirometer - -Device encouraging deep breathing to expand alveoli and lung
volume.
--Nasal Cannula (Low Flow) - -1-6 L/min.
--Nasal Cannula (High Flow) - -10-15 L/min.
--Simple Mask - -5-8 L/min.
UPDATE WITH COMPLETE SOLUTION
HIPAA - -Federal law protecting all patient-identifiable health information in written, verbal,
or electronic form.
--Confidential Patient Information - -Name, address, phone, SSN, diagnosis, treatments, and
any identifying medical data.
--HIPAA Patient Rights - -Right to view, copy, update records; request restrictions; obtain
disclosure lists; choose how information is received.
--Pain (0-10 Scale) - -Subjective patient-reported pain intensity from 0 (no pain) to 10 (worst
pain).
--Nursing Documentation - -Legal written/electronic record of all patient care and
interactions.
--ADPIE - -Assessment, Diagnosis, Planning, Implementation, Evaluation.
--Timely Documentation - -Record using date and military time during admission, transfer,
discharge, procedures, post-op, changes in condition, critical provider calls.
--"If it wasn't documented, it wasn't done." - -Legal rule meaning undocumented care is
considered not performed.
--Electronic Health Record (EHR) - -Digital patient chart improving accuracy, efficiency, and
coordination.
--Source-Oriented Record - -Documentation organized by discipline (nursing, provider, PT,
etc.).
--Problem-Oriented Record - -Documentation organized around patient problems.
--Nursing Care Plan - -Document listing patient problems, goals, and nursing interventions.
--Critical Pathway - -Standardized multidisciplinary care plan for specific diagnoses.
--Kardex / Patient Care Summary - -Quick patient overview including diagnosis, meds,
treatments.
--Flow Sheets - -Structured forms for routine charting (vitals, I/O, assessments).
--Narrative Note - -Chronological, story-style documentation.
--SOAP Note - -Subjective, Objective, Assessment, Plan.
, --PIE Note - -Problem, Intervention, Evaluation.
--Focus Charting (DAR) - -Data, Action, Response.
--Charting by Exception - -Only abnormal findings are documented.
--Interpreting Orders - -Orders may be written, typed, verbal, or telephone.
--Verbal/Telephone Orders - -Used only in emergencies; must be read back and later signed.
--Patient Handoff - -Transfer of essential information to next caregiver for safety and
continuity.
--ISBAR - -Identify, Situation, Background, Assessment, Recommendation.
--Continuity of Care - -Consistent, coordinated care across shifts and departments.
--Confidentiality Breach - -Unauthorized viewing, discussing, or sharing patient info.
--Preventing Confidentiality Breaches - -Lock screens, avoid public discussions, verify
recipients, no social media, secure paperwork.
--Patient Record - -Legal, permanent documentation of all care—nurse's strongest legal
defense.
--Patient Teaching (Oxygenation) - -Teach meds, breathing techniques, positioning, infection
prevention, vaccinations.
--Tripod Position - -Leaning forward to improve chest expansion.
--Semi-Fowler's Position - -HOB 30-45° to enhance oxygenation.
--High Fowler's Position - -HOB 60-90° for maximum lung expansion.
--Hypoxia - -Low oxygen at the cellular level.
--Hypoxemia - -Low oxygen level in the blood.
--Incentive Spirometer - -Device encouraging deep breathing to expand alveoli and lung
volume.
--Nasal Cannula (Low Flow) - -1-6 L/min.
--Nasal Cannula (High Flow) - -10-15 L/min.
--Simple Mask - -5-8 L/min.
