Nurs 371 Midterm Exam 2025

Documentation is - -The written or electronic legal record of all pertinent interactions with the patient assessing diagnosing planning implementing and evaluating Characteristic of effective documentation - -Consistent with professional and agency Standerds, complete , accurate, concise, factual, organized and timely, legally prudent, confidential What is confidential? - -All information about patients written on paper spoken aloud saved on commuter (Name, address, phone, fax social security, reason the person is sick, assessments and treatments patient receives, information about past health conditions) A nurse who fails to log off a commuter after documenting patient care has breached patient confidentiallity true or false - -True A patient has the right to obtain review and revise the patient information in his or her health record True or false - -False Records included: - -client identification and demogrphic data, informed consent for treatment and procedures, admission nursing history, nursing diagnoses or problems, nursing or multidiscriplinary care plan includes respiratory disease, records of nursing care treatment and evaluation, medical history, medical diagnosis, therapy orders, medical and health discipline progress notes, reports of physical examinations, reports of diagnostic studies, summary of operative procedures, discharge plan and summary Purpose of patient records - -Communication with other healthcare professionals, records of diagnostic and therapeutic orders, care plannning, quality process and performance improvement, research, decision analysis, education, credentialing regulation and legislation, legal and historical documentation, reimbursement, facilitate patient care, serve as a financial and legal record, help in clinical research, support decision analysis Guidelines for receiving verbal orders in an emergency - -record the orders in patients medical records, read back the order to verify accuracy, date and not the time orders were issued in emergency, record VO, the name of the physician or nurse practitioner followed by nurses name and title, the registered professional nurse nurse must see that the orders are transcribed according to procedure Terminology used: - -Medical terminology used to facilitate communication, breakdown medical terminology into the three parts prefix root suffix Nurs 371 Nurs 371 Terminology Abbreviation notes - -Keep to standard abbreviation different areas or specialties vary, know approved abbreviation for specific agency Documentation Essentials Legal document: What you need: - -Black ink, contain facts and be accurate, legible, brief/concise, exact time (may be military time), logical by time and content, Errors/Omissions, no blank spaces, signature Good assessors are usuallly good charters why? - -Assessing from head to toe paining a good picture should chart what you did and saw Charting: - -Takes time and practice, practice, proactive, you will always be perfecting the skill When to chart? - -Admission, assuming care, transferring a patient, discharging a patient Types of entries: - -Newly admitted patient, opening notes for shift, interval notes(when something has changed), anything abnormal, any change, test, lab, doctor visit, dietitian show orders carried out, transfer discharge Documentation essentials: - -Patient teaching, entries should be objective avoid good, bad, seems like, do symptom analysis on complaints/pain, Entries must reflect patient needs if you find something wrong you must chart what you did and how your patient responded, dressing should not location attachments drainage not skin condition if removed, tubes state type placement infusion site condition drainage suction, Mar available for routine meds PRN are entered in narrative notes with assessment intervention and response note meds not given (when patient complains of pain state nurse notified , Psychosocial-LOC and safety, ADL-flow sheet/transfer needs, Jewelry- describe (gold-yellow) where sent and who recieved, spiritual care- not expression of grief/anger symbols/rituals, sins of distress sources of hope, safety:side rails ambulation call light restraints teaching about safety incident form is fall, elderly:ADL mobility safety mental status affective behavior Methods of documentation: source oriented - -Separate division for each discipline, may be narrative Methods of documentation problem oriented - -data base, problem list, plans, progress Documentation formats-problem oriented: - -SOAP: subjective data, objective data, assessment, plan APIE: assessment, problems, interventions, evaluations Focus:Data, action, response charting by exception case management model collaborative pathways occurrence charting Nurs 371 Nurs 371 computerized records Documentation formats: - -24 hour assessment -note abnormal findings in narrative kardex plan of care/needs list pathways progress notes flow sheets (graphics, I&O, MAR) -Follow trends -organized -consistent -needs date/time./initials Fix this charting: c/o burning pain on urination, fowl, smelling, yellow, cloudy urine...........J.Doe, RN - -C/o burning pain on urination, foul, smelling, cloudy yellow urine...........J.Doe, RN Fix this charting: stool well-formed, polls then larger pieces, medium brown in color....J.Jones, RN - -stool well-formed, large formed medium brown stool....J.Jones, RN Fix this charting: Denies pain, o2 on at 2L/min per nasal cannula. IV of D5W patent at 21 gets/min.c 300cc TBA, awake, alert, urine clear yellow, lungs clear, oriented x3........ K.Smith, RN - -Denies pain. awake,alert, oriented x3..lungs clear, o2 on at 2L/min per nasal cannula. IV of D5W patent at 21 gets/min.c 300 cc TBA, the sit is without redness or swelling, urine clear yellow...........K.Smilth, RN fix this charting: Ambulated down hall and back. BP 112/78 p ambulation----tolerated s problems....B.Roberts - -Ambulated down hall and back with assistance tolerated. BP 110/70 before ambulating. After ambulation BP 112/78........B.Roberts fix this charting: C/o pain in abdomen....C.Blake, RN. - -Rates pain 7/10. C/o pain in lower right quadrant of abdomen. Does not radiate. Started a week before admission. Was at home watching the oschers when it started. Nothing makes it feel better. Nothing makes it feel worse. the pain is consistent. Fix this charting: Condition worsening. C/o pain in abdomen, constant , sharp, carrying & requesting pain med. and. Distended s bowel sounds. Transferred to ICU....J. Mean, RN - -Condition worsened pt is confused, Bp has dropped form 115/70 to 85/70. C/o pain in right lower quadrant. Rates pain 7/10. Pain started an hour ago. Abd distended s bowel sounds. Nothing makes it better. Nothing makes it worse. constant, sharp, carrying and requesting pain med.......J.Mean, RN Transferred to ICU report given to C. Bagley, SLUSN at 0800...........J. Mean, RN Nurs 371 Nurs 371 Fix this charting: Dietitian visited, passed gas, ate meal.......D. Nurse, RN - -Dietitian visited, pt ate 50% of meal and 250ml of fluids, after consumption pt passed gas without N/V/D.....D.Nurse, RN Do not duplicate this documentation - -if the flow sheet or history form has the information do not rewrite it in narrative Potential risk: Found lying on floor with IV disconnected from arm Oriented and alert, stated "I tried to make it back to bed alone... S.Smith, RN Assisted back to bed, side rails up x2. C. Supervisor, Rn notified....S.Smith, RN - Found lying on the floor with IV disconnected from arm. Oriented x3, stated "I tried to make it back to bed alone".....S.Smith, RN Assisted back to bed, side rails up x2. Call light at bedside. No physical injuries. C.Supervisor , RN notified.....S. Smith, RN Attitudinal Bias: Yelling obscene words at the nurses aid, pushed wife out of room.... P.Black, RN Nurse supervisor notified of his irrational, inappropriate behavior and difficulty in caring for him. Acting immature and childish....S. Nurse, RN - -Yelling obscene words at the nurses aid, pushed wife out of room......P.Balck, RN Nurse supervisor notified of his behavior and difficulty in caring for him........S. Nurse, RN Reporting care: - -Change of shift or hand off reports telephone/telemedicine report change of care transfer/discharge family and significant other reports Change of shift/hand off reports - -basic identifying information about each patient current appraisal of each pt health status -changes in pt status and pt response to therapy -pertinent monitoring lab and or radiology data -abnormal findings in your assessment -where pt stands in relation to identified dignosises and goals -pain level and management needs current orders (nurse and physician) abnormal occurrences during the shift unfilled orders that will continue onto the next shift report on pt transferred or discharged Methods of reporting: - -face to face meeting telephone conversation Nurs 371 Nurs 371 messengers written messages audio taped messages computer messages conferring about care: - -consultations and referrals nursing and interdisciplinary team care conferences nursing care rounds Documentation of errors: - -incident report narrative Legislation and control: Federal law - -Government controls on drug sales and distribution Violation of the Controlled Substances Act are punishable by fines, imprisonment, and loss of nurse licensure Legislation and control: Health care institution - -Example - Limit # day on med order - like antibiotics Track adverse reactions Legislation and control: nursing - -State practice act sets and defines nurses scope of practice Set limits of practice, define professional functions and responsibilities You are being prepared to be a safe and competent practitioner Physicians role - -Writes orders - Types of Orders Standing - carried out until cancelled by another order PRN - as needed STAT - carried out immediately Prescriptions Transfers to another floor or facility & surgery cancels all previous orders. New orders must be written. Pharmacist role - -Prepares & Distributes Distribution Systems Stock supply Unit dose (individual supply) Medication cart Computer controlled Bar coded medication cart Nursing Role - -Administration Monitoring Nurs 371 Nurs 371 Teaching Nurses can question an order or choose not to give for a legitimate reason, however, document why and who notified Nursing responsibility - -Understanding a drug's action Side effects Administering correctly Monitoring the patients response Helping the patient self-administer drugs correctly and knowledgeably Delegation - -The registered nurse may not delegate the following nursing functions relative to intravenous medication and fluids Administration of investigational drugs, med by IV push, blood & blood products, TPN solutions Unless defined by health agency protocol for emergency situations RN must know cause & effect of each drug she administers personally or by delegation She must ascertain competency of personnel administering meds under her direction. Nurse Practice Act - -"Has demonstrated actual or potential inability to practice nursing with reasonable skill and safety to individuals because of use of alcohol or drugs; or has demonstrated inability to practice nursing with reasonable skill and safety to individuals because of illness or as a result of any mental or physical condition." Limited Prescriptive Authority - -dvanced Nurse Practitioner for one year Successful completion of 45 hrs. education in adva