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Involves education about every aspect of the care being provided and
alternatives.
Choose an answer
1 Implied Consent 2 Informed Refusal
3 Truth And Reconciliation 4 Informed Consent
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Terms in this set (124)
Accepted at night, in emergency situations, only
Verbal orders
when absolutely necessary, not for the sake of
acceptance
convenience.
Types of orders from a TO - telephone order (over phone), VO - verbal
doctor order (standing close to nurse).
, Use read-back process, document the order, verify
Actions after receiving a
the order by signing within 24 hrs, physician must
TO or VO
sign within 24 hrs.
Mistake in documenting Draw a single line, sign, and write 'error'.
Skipping lines in Not allowed; use a line to the end if writing does
documenting not fill up the line.
A legal record that can be used as evidence of
events that occurred or treatments given, shows the
Purpose of nursing
use of the nursing process, contains observations
documentation
about the client's condition, care, and treatment
delivered.
Objective (assessment data or descriptions of
Information to document behavior, what you can see and observe) and
subjective (client description, e.g., 'I am in pain').
Quoting a doctor Yes, write their name.
Phrase to avoid in 'Patient complains'; instead use 'patient stated or
documentation reports'.
In Time column write 'late entry' and the time the
skill was done, or write time of entry and then in
Documenting a late entry
focus column write 'late entry' and in notes write the
time the skill was completed.
Complete a safety event report (incident report)
Documenting a med
following an event such as a medication error or a
error
fall; the report is not part of the client record.
Nurses inform the client about any care before it is
Informing clients about
provided, even if a client has been deemed
care
incapable of consenting.
Consent may be given verbally, in writing, or
Consent methods through an alternative communication system (e.g.,
computer assisted).
A child who is a mature minor (19 years old or
younger assessed by a health care provider) may
Children's consent
make their own health care decisions independent
of their parents' or guardians' wishes.