Describe guidelines for effective nursing documentation (Box 20-1 on page 521)
Give this one a try later!
Should be complete, accurate, concise, current, factual, and organized. It
should be communicated in a timely manner to facilitate care coordination
and serve as a legal document. Avoid generalizations, slang, etc. Note
problems as they occur and the interventions taken with the patient's
response to them. Update/delete problems as appropriate. Document all
, orders written and verbal with date, time, provider info, etc. Don't
document something before it is done.
What documentation record is an organization that provides services to enable the
electronic sharing of health-related information.
Give this one a try later!
Health information exchange (HIE)
What is AIDET acronym
Give this one a try later!
Acknowledge
Introduce
Duration
Explanation
Thank
What assessment screening is used to determine extent and severity of a patient to
then recommend appropriate follow ups
Give this one a try later!
Triage
, What MUST you do first before a patient transfer?
Give this one a try later!
1. Assess patients muscle strength of legs and upper arms and therefore
assist
2. Assess their levels of motivation (for them to assist us)
3. Assess level of understanding
4. Know where all your tubes are
5. Be sure that brakes are in locked position (bed, wheelchair, stretcher)
What initiation type is orders carriesd out by a nurse from other providers like a
pharmacist, respiratory therapist, PA, etc.
Give this one a try later!
Collaborative initiation
What type of diagnosis is a clinical judgement concerning the vulnerability of an
individual for developing an adverse response to a health condition
Give this one a try later!
Risk diagnosis
What is the Benner Theory?
Give this one a try later!
Should be complete, accurate, concise, current, factual, and organized. It
should be communicated in a timely manner to facilitate care coordination
and serve as a legal document. Avoid generalizations, slang, etc. Note
problems as they occur and the interventions taken with the patient's
response to them. Update/delete problems as appropriate. Document all
, orders written and verbal with date, time, provider info, etc. Don't
document something before it is done.
What documentation record is an organization that provides services to enable the
electronic sharing of health-related information.
Give this one a try later!
Health information exchange (HIE)
What is AIDET acronym
Give this one a try later!
Acknowledge
Introduce
Duration
Explanation
Thank
What assessment screening is used to determine extent and severity of a patient to
then recommend appropriate follow ups
Give this one a try later!
Triage
, What MUST you do first before a patient transfer?
Give this one a try later!
1. Assess patients muscle strength of legs and upper arms and therefore
assist
2. Assess their levels of motivation (for them to assist us)
3. Assess level of understanding
4. Know where all your tubes are
5. Be sure that brakes are in locked position (bed, wheelchair, stretcher)
What initiation type is orders carriesd out by a nurse from other providers like a
pharmacist, respiratory therapist, PA, etc.
Give this one a try later!
Collaborative initiation
What type of diagnosis is a clinical judgement concerning the vulnerability of an
individual for developing an adverse response to a health condition
Give this one a try later!
Risk diagnosis
What is the Benner Theory?
