Perioperative Health Care Information Management Questions And Answers

Perioperative Health Care Information Management Questions And Answers What information does the documentation in the patient's health care record include? ANS current and past health status, nursing diagnoses and interventions, expected patient outcomes, and evaluation of the patient's response. Repeated patient care and electronic documentation can become a nursing cognitive disruption. What are some things you can do to work efficiently and timely in this multi-task process? ANS By simplifying processes, standardizing and organizing data capture. What is PNDS? ANS A controlled, structured, and coded nursing language that describes perioperative nursing's influence in the effectiveness and safety of patient care deliver, and the contributions of perioperative nursing toward patient outcomes. What are the phases of the perioperative patient care continuum? ANS preadmission, preoperative, intraoperative, postoperative As a perioperative nurse, what should you be familiar with about the structured vocabularies in your clinical documentation? ANS The value that structured terminology brings to clinical documentation, the conceptual framework of the PNDS, the contributions of the PNDS to perioperative nursing practice and patient outcomes and how standardized documentation facilities benchmarks, comparative analysis, and efficiency reporting. What are included in the patient care orders in the perioperative documentation? ANS orders for interventions (must be entered as close to the time when the order is communicated), verbal orders, standing orders, orders on surgeon preference cards, and order sets. All must be dated, timed, and authenticated by the ordering health care practitioner. The standards of nursing practice require that documentation is base on which of the following? ANS Patients's condition or need and the relationship of the condition or need to the proposed intervention. What does a properly executed informed consent include? ANS Name of the health care facility providing the surgery, specific name of the intervention, indications of the proposed intervention, name of the responsible health care provider performing the intervention, statement identifying the risks and benefits associated with the proposed intervention and indication that a discussion took place with the patient or patient representative, signature of the patient or patient's representative, date and time the patient or patients representative signed the informed consent document, date and time and signature of the witness signing the informed consent document, signature of the responsible health care provider who discussed the informed consent document with the content or the patient's legal representative. Important guidelines to remember that you make nursing diagnoses and not medical diagnosis or conclusions ANS you are a nurse who has sound nursing judgment but not a physician, your description should be free from bias, when patient makes a statement make a statement do not make it appear as a statement of fact (instead write, "Patient stated that...), use the patients statement to verify your findings but write it accordingly, document significant changes in a timely manner, document any patient education as well as all discharge instructions, be a patient advocate, document any communication with the patient important guidelines a