Communication) – Questions With Accurate
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- at night
When can verbal orders
- in emergency situations
be accepted from a
- only when absolutely necessary
doctor?
- not for the sake of convenience
What kind of orders are TO - telephone order (over phone)
there for a doctor to VO - verbal order (standing close to nurse)
give?
- use read-back process
- document that you did this
ex. "March 4, 2017 (0815hrs) Change IV fluid to
What does the nurse do
lactated ringers with potassium 20 mEq per litre to
after receiving a TO or
run ar 125 mL/ hour. TO: Dr Doctor/K. Woods, LPN,
VO?
read back"
- verify the order by signing within 24 hrs
- physician must sign within 24hrs
What do you do when draw a single line and sign and write error
you make a mistake in
documenting?
Are you allowed to skip NO and use a line to the end if writing does not fill
lines in documenting? up line
, A legal record that can be used as evidence of
events that occurred or treatments given. Show the
use of the nursing process. It contains observations
by the nurses about the client's condition, care, and
Why do nurses treatment delivered.
document? - Provides data for quality assurance studies and
shows progress toward expected outcomes.
- Legallity
- Research
- EVB
objective (assessment data or descriptions of
What info are nurse
behaviour, what you can see and observe)
supposed to document?
subjective (client description "i am in pain") feelings
Can you quote a doctor? yes write their name
What is a phrase you "patient complains"....instead "patient stated or
should not document...? reports"
When focus charting in Time
column write late entry and
the time the skill was done,
How do you document a - or in time column write time
late entry? of entry and then in focus
column write late entry and in
notes write the time the skill
was completed
Nurses complete a safety event report (sometimes
How and where would a
called an incident report) following an event such
nurse document a med
as a medication error or a fall. The safety event
error?
report is not part of the client record.
Do nurses inform the Nurses inform the client about any care before it is
client before providing provided, even if a client has been deemed
care if they are incapable incapable of consenting.
of providing concent?
Consent may be given verbally, in writing, or
How can conscent be
through an alternative communication system (e.g.,
given?
computer assisted).