FUN Test #2

ch. 5,6,12,14,15,22

Charting by exception

A method of documentation where only significant or abnormal findings are recorded. Normal findings are assumed unless otherwise noted.

Confidentiality

The ethical and legal duty to protect a patient’s private health information from being shared without their consent.

Documentation

The written or electronic recording of all aspects of patient care, including assessments, interventions, and outcomes, to ensure continuity and legal accountability.

Purpose of Documentation

1. Legal record of care – Protects patients and healthcare providers in case of legal disputes by providing proof of care given.

2. Communication – Helps healthcare team members stay informed about the patient's condition, treatments, and responses.

3. Continuity of care – Ensures that care is consistent and seamless between shifts, departments, or facilities.

4. Quality improvement – Used to evaluate and improve patient care practices through audits and reviews.

5. Billing and reimbursement – Accurate documentation supports insurance claims and ensures proper billing for services provided.

6. Research and education – Provides data for clinical studies, case reviews, and training future healthcare professionals.

7. Accountability – Tracks the actions, decisions, and responsibilities of healthcare providers.

Electronic health record (EHR)

A digital version of a patient’s paper chart that provides real-time, patient-centered records accessible to authorized healthcare providers.

EHR allowed where

required in hospitals, but not in LTC facilities.

Focus charting

A method of charting that centers around a specific patient problem or concern, using the format: Data, Action, and Response.

DAR

Data, Action, and Response.

Kardex

A paper or electronic system used to quickly summarize important patient information such as medications, treatments, and care plans; often used for quick reference by nursing staff.

Narrative charting

A detailed, chronological account of patient care and responses written in paragraph form.

PIE charting

A type of documentation focusing on: Problem, Intervention, and Evaluation, promoting a structured and problem-oriented approach.

SOAPIER charting

A comprehensive documentation method that includes:

• Subjective data

• Objective data

• Assessment

• Plan

• Intervention

• Evaluation

• Revision

Confidentiality of Patient Records

• Patient records must be protected under laws like HIPAA (Health Insurance Portability and Accountability Act).

• Only authorized personnel should access patient information.

• Do not discuss patient information in public areas.

• Use passwords and secure systems for electronic records.

• Always log out of electronic systems when not in use.

Admission forms

Document initial assessments and patient history.

Flow sheets

Record frequent observations (e.g., vital signs).

Progress notes

Track the patient’s condition and responses to care.

MAR (Medication Administration Record)

Tracks medications given.

Care plans

Outline goals, interventions, and expected outcomes

Incident reports

Record unusual events; not part of the patient chart

Guidelines for Electronic Documentation

• Use correct login credentials; never share passwords.

• Double-check entries before submitting.

• Avoid using copy/paste unless updated and appropriate.

• Log out after use.

• Do not chart for someone else.

• Report system errors or security concerns immediately.

Source-orientated

Source of information (e.g., nursing, physician, lab). Each discipline documents independently

Problem-orientated

Patient problems. All disciplines chart around shared problems

Common Sections of a Source-Oriented Documentation System

• Admission record

• Physician’s orders

• Progress notes

• Nursing notes

• Lab reports

• Radiology reports

• MAR (Medication Administration Record)

Use and Importance of Electronic Health Records (EHRs)

• Provide real-time, up-to-date access to patient info.

• Enhance communication among the care team.

• Improve accuracy and legibility.

• Help with alerts/reminders (e.g., allergies, interactions).

• Enable data tracking for quality improvement.

Documentation in LTC

• Charting often done weekly unless there is a change in condition.

• Focuses on resident-centered goals, ADLs, and social well-being.

• MDS (Minimum Data Set) assessments required for Medicare.

Documentation of Home health

• Includes patient’s home environment, caregiver availability, and compliance.

• Must document every visit in detail for insurance.

• Often tied to Medicare guidelines with strict documentation rules.

Five Documentation Mistakes That Increase Risk of Legal Action

1. Failing to document care that was provided

2. Incomplete or vague charting (e.g., “patient doing fine”)

3. Charting ahead of time

4. Not documenting patient response to interventions

5. Altering a record (even correcting without proper procedure)

Reporting and Handoff

The process of providing verbal reports (e.g., shift change reports) and ensuring key information is transferred effectively.

Vital Signs and Assessments

Recording baseline data and changes in condition.

The Chain of Infection

• Infectious Agent: The pathogen (e.g., bacteria, virus, fungi).

• Reservoir: Where the pathogen lives and multiplies (e.g., humans, animals, environment).

• Portal of Exit: How the pathogen leaves the reservoir (e.g., respiratory tract, blood, skin).

• Mode of Transmission: How the pathogen is spread (e.g., contact, droplet, airborne).

• Portal of Entry: How the pathogen enters a new host.

• Susceptible Host: An individual who is vulnerable to the infection.

Standard Precautions key practices

The importance of consistent hand hygiene, appropriate use of personal protective equipment (PPE) (gloves, gowns, masks, eye protection), and safe injection practices.

Standard Precautions (fluid and secretions)

Recognizing that standard precautions apply to contact with blood, body fluids, nonintact skin, and mucous membranes.

Standard Precautions (Universal Application)

• Understanding that standard precautions (also known as universal precautions) apply to the care of all patients, regardless of their diagnosis or presumed infection status.

Transmission-Based Precautions

DROPLET

Used for infections spread by large droplets expelled during coughing or sneezing (e.g., influenza, meningitis). Requires a surgical mask.

🛡 PPE for Droplet Precautions:

• Surgical mask (worn within 3 feet of the patient)

• Gloves and gown if risk of contact

• Private room or cohort with same illness

• Eye protection if splashing is likely

Examples of droplet-transmitted diseases SPIDERMAN

Disease	Details
S – Sepsis	Especially from Neisseria meningitidis
P – Pertussis	Whooping cough; highly contagious
I – Influenza	Seasonal flu and avian flu
D – Diphtheria	Respiratory form (not skin type)
E – Epiglottitis	Often caused by Haemophilus influenzae type B (Hib)
R – Rubella	German measles; not the same as measles
M – Mumps	Swollen salivary glands; viral
A – Adenovirus	Causes cold-like symptoms, pink eye, sore throat
N – Meningitis	Droplet type: Neisseria meningitidis (bacterial)

💡 Memory Trick for Droplet Diseases

"Stop flu and MMR with a mask!"
(S - Sepsis/Strep, T - Tdap [pertussis, diphtheria], O - Other viruses like RSV, P - Parvovirus / plague)

Transmission-based prec.

Airborne Precautions

Used for infections spread by small droplet nuclei suspended in the air (e.g., tuberculosis, measles, varicella). Requires a negative-pressure room and an N95 respirator mask.

🛡 PPE for Airborne Precautions

• N95 respirator (or higher, like a PAPR)

• Negative pressure room (air flows in, not out)

• Gown and gloves if risk of contact

• Keep door closed at all times

🦠 Examples of Airborne-Transmitted Diseases

Disease	Details
M – Measles (Rubeola)	Very contagious; causes cough, coryza, conjunctivitis, Koplik spots
C – Chickenpox (Varicella)	Also contact precautions; pustular rash that crusts over
H – Herpes Zoster (Shingles)	Disseminated (widespread) or immunocompromised patients only
T – Tuberculosis (TB)	Pulmonary TB only is airborne; needs airborne isolation

💡 Memory Trick for Airborne Diseases

“My Chicken Hez TB”

• Measles

• Chickenpox

• Herpes Zoster (disseminated)

• TB

(Only disseminated shingles is airborne. Localized shingles = contact.)

Transmission-based prec.

CONTACT

Used for infections spread through direct or indirect contact (e.g., MRSA, C. difficile). Requires gloves and gown.

🛡 PPE for Contact Precautions:

• Gloves

• Gown

• Private room or cohort with same infection

• Dedicated equipment (BP cuff, stethoscope, etc.)

• Hand hygiene before & after patient contact

🦠 Examples of Contact-Transmitted Diseases

Disease	Details
M – Multidrug-resistant organisms (MDROs)	Like MRSA, VRE, CRE
R – Respiratory infections (e.g., RSV)	RSV is both contact and droplet; highly contagious in infants
S – Skin infections	Includes scabies, impetigo, lice, herpes simplex, shingles (localized)
W – Wound infections (uncontained)	Especially if drainage is not controlled
E – Enteric infections	C. difficile (C. diff), norovirus, rotavirus – handwashing required
E – Eye infections	Like conjunctivitis (pink eye)

💡 Memory Trick for Contact Diseases

“MRS. WEE loves sticky stuff”
(MRSA, RSV, Skin, Wound, Enteric, Eye — all spread through touch or messy secretions)

Medical Asepsis definition

Practices that reduce the number and transfer of pathogens (e.g., handwashing, cleaning surfaces).

Medical Asepsis uses what type of technique

clean technique

Surgical Asepsis uses what type of technique

sterile technique

Surgical Asepsis definition

Practices that eliminate all microorganisms, including spores, from an area (e.g., sterile field preparation, surgical procedures).

Autoclaving

A method of sterilization that uses saturated steam under pressure to kill all microorganisms and spores. It is the most common and effective method for sterilizing heat-resistant medical equipment.

Boiling

A method of disinfection that involves immersing items in boiling water for a specified period. While it kills most pathogens, it is generally considered a form of disinfection rather than sterilization, as it may not eliminate all spores.

Chemical disinfection

The use of chemical agents (disinfectants) to destroy or inhibit the growth of most microorganisms on inanimate objects or surfaces. This process does not typically kill bacterial spores.

Circulating nurse

A registered nurse in the operating room (OR) who is not sterile. This nurse manages the overall surgical environment, coordinates the activities of the team, ensures patient safety, and documents the procedure.

Contamination

The process by which an object, surface, or area becomes impure or unclean due to the presence of microorganisms, potentially leading to infection.

Disinfection

A process that eliminates most pathogens, but not necessarily bacterial spores, from inanimate objects.

Gaseous disinfection (

A method of sterilization or high-level disinfection using gaseous agents (such as ethylene oxide) to kill microorganisms. It is often used for heat-sensitive instruments and equipment.

Ionizing radiation

A sterilization method (such as gamma rays or electron beams) used to destroy microorganisms on medical devices and supplies, particularly those sensitive to heat.

Scrub nurse

A registered nurse (or surgical technologist) in the operating room who is sterile and works directly with the surgeon. This individual assists by handling sterile instruments, drapes, and supplies.

Sterile field

A defined area that is considered free of all microorganisms. This area is established to maintain surgical asepsis during procedures and is only handled using sterile technique.

Sterile technique

The use of specific practices and procedures to ensure that an object or area is completely free of all microorganisms. This is also referred to as surgical asepsis.

Sterilization

The process by which all microorganisms, including bacterial spores, are completely destroyed or removed from an object or surface.

Surgical conscience

The ethical responsibility and professional obligation of a healthcare worker to recognize and immediately correct any breach in sterile technique, even if the contamination is not observed by others.

Medical Asepsis (Clean Technique) examples

Hand hygiene, using clean gloves, standard precautions, cleaning patient environment.

Surgical Asepsis (Sterile Technique) examples

Preparing a surgical site, inserting a urinary catheter, changing a surgical dressing.

How to Tell if Supplies Are Sterile

• Packaging Integrity: Ensure the packaging is intact, dry, and free of tears, holes, or moisture.

• Expiration Date: Check the expiration date on the packaging.

• Sterilization Indicators: Look for chemical indicators on the packaging (e.g., tape that changes color) or internal indicators within the package that confirm the item has gone through the sterilization process.

Restricted Settings in the Hospital Where Aseptic Surroundings Are Maintained

• Operating Rooms (ORs)

• Surgical Suites

• Labor and Delivery Suites (for C-sections and sterile deliveries)

• Cardiac Catheterization Laboratories

• Some intensive care units (ICUs) when performing invasive, sterile procedures (e.g., central line insertion).

• Sterile compounding pharmacies.

Safety Issues Related to Surgical Asepsis

Failure to maintain surgical asepsis can lead to severe safety issues for the patient, primarily healthcare-associated infections (HAIs), such as:

• Surgical site infections (SSIs).

• Central line-associated bloodstream infections (CLABSIs).

• Catheter-associated urinary tract infections (CAUTIs).

SSI: Surgical Site Infection

an infection that occurs in the part of the body where a surgery took place.

CLABSI: Central Line-Associated Bloodstream Infection

a serious bloodstream infection that occurs when bacteria or other germs enter the patient's bloodstream through a central venous catheter, commonly known as a central line.

CAUTI: Catheter-Associated Urinary Tract Infection

develops in a patient whose urinary bladder is currently catheterized or was catheterized within the past 48 hours. CAUTIs are among the most common HAIs and occur when bacteria enter the urinary tract through the urinary catheter.

Active listening

A communication technique that involves fully concentrating on what is being said, understanding the content and feelings of the message, and responding appropriately.

Aphasia

A condition that affects a person's ability to communicate, often resulting from brain injury (such as a stroke). It can impact speaking, understanding language, reading, and writing.

Body language

A form of nonverbal communication that involves the use of physical behavior, expressions, and posture to convey information or emotions.

Communication process

The exchange of information, ideas, and feelings between a sender and a receiver. It typically includes encoding the message, transmitting it through a channel, and receiving feedback.

Congruent

When a person’s verbal message matches their nonverbal communication, resulting in a clear and consistent message.

Connotative meaning

The emotional or cultural associations and implications of a word, which can differ from person to person based on their experiences.

Denotative meaning

The literal, dictionary definition of a word.

Feedback

The response from the receiver to the sender's message, which indicates whether the message was received and understood.

Incivility

Behavior that shows a lack of respect for others, often characterized by rudeness, disrespect, or discourtesy in the workplace or professional settings.

Nonverbal communication

The transmission of messages without the use of spoken or written words. This includes gestures, facial expressions, tone of voice, and body movements.

Proxemics

The study of how people use space and distance (personal boundaries) in communication, and how it affects interactions.

Shared meaning

A mutual understanding of the message between the sender and the receiver, ensuring that the intended meaning is conveyed and understood.

Therapeutic communication

A goal-directed form of communication used by nurses to build a trusting relationship with a patient, facilitate understanding, and promote the patient's well-being and health goals.

Verbal communication

The use of spoken or written words to exchange information.

Factors that Influence Communication

• Culture and Language: Different cultural norms regarding communication style, eye contact, and expression of emotion.

• Gender: Differences in communication patterns between genders.

• Age and Developmental Level: Communication tailored to the patient's age and cognitive ability.

• Physical and Emotional State: A patient's pain, anxiety, or fatigue can impede communication.

• Environment: Noise, lack of privacy, and interruptions can act as barriers.

• Education and Literacy: The patient's ability to understand health information.

Assertive

Expressing thoughts and needs clearly and respectfully, while advocating for oneself and the patient. This is the preferred style in nursing

Communication Barriers: Actions that impede effective communication:

• Giving advice

• Offering false reassurance ("Everything will be fine")

• Changing the subject

• Expressing approval or disapproval

• Asking "Why" questions (can sound accusatory)

The DESC Method of Communication

• Describe the situation objectively.

• Express your feelings or concerns about the situation.

• Specify the desired change or action.

• Consequence (or outcome) of the action.

The Nurse-Patient Relationship

trust and empathy

ISBARR

• (Introduction, Situation, Background, Assessment, Recommendation, Read back): A standardized format for handoff communication between healthcare professionals, ensuring all critical information is conveyed clearly and concisely.

Communication for Patients with Specific Sensory Needs

Hearing Impairment:

Face the patient, speak slowly and clearly, use low-pitched tones, reduce background noise, use visual aids, and verify understanding.

Communication for Patients with Specific Sensory Needs

Vision Impairment

Identify yourself and others in the room; orient the patient to the surroundings; explain procedures before performing them; use touch with permission.

Communication for Patients with Specific Sensory Needs

Aphasia (Language Impairment)

Use short, simple sentences; allow the patient sufficient time to respond; use visual aids or gestures; ask yes/no questions; be patient and non-judgmental

Hand-off or end-of-shift reporting is an area of communication vulnerable to ineffective communication that increases

the chances of medical errors.

Health promotion

The process of enabling people to increase control over, and to improve, their health. This involves lifestyle changes, education, and supportive environments.

Interpreter

A professional who translates spoken language between a patient and a healthcare provider, ensuring accurate communication, particularly for patients with limited English proficiency.

Kinesthetic learning

A learning style in which an individual learns best through physical activity, hands-on experiences, movement, and practical application.

Reinforce

To strengthen or support a learning behavior or understanding through repetition, practice, or positive feedback.

Teachable moments

Optimal times for education when a patient or learner is most receptive to new information, often occurring when the person has a perceived need or a sudden realization.

Wellness strategies

Actions, behaviors, or plans designed to improve and maintain overall health, well-being, and quality of life.