Documentation

When edu a pt with demi talk w/ fam

match each scenario to the purposes of nurses' records

• A patient was transferred from the emergency department to a medical-surgical floor. During the handoff, the incoming nurse reviews the patient’s chart.

• A nurse notices a patient has had trouble sleeping and has not been eating much since admission. The nurse updates the care plan accordingly.

• A patient files a complaint claiming they did not receive their prescribed medication, but the nurse had documented the administration on time.

• A hospital is undergoing a quality assurance audit, and the auditors are reviewing nursing documentation for trends in medication errors.

• A lawyer request the records regrading the patient

Communication

Nursing Documentation (Care Plan)

Financial Reimbursement

Auditing / Monitoring

Legal Documentation

What is focus charting and charting by exception?

Focus charting → focus on one problem

Charting by exception → only documenting abnormal or significant findings

What does PIE, and SOAPIE stand for?

PIE → prob, intervention, Eval

SOAPIE→ sub., obj, anazlzyle/assess., planning, intervention, and evaluation

What 3 things does every nurses note need to have?

1. Assessment findings

2. What the interventions tooken by the nurse

3. How did the PT respone to intervention

How do you omit a mistake in writing a nursing note?

one strike through the word. Ex left right arm

When paper charting, should you document the time of the entry or the time the intervention was performed? (Date and time)

time of entry and then when the intervention was performed later in the note

ISBARR stand for

intro-Situation-Background-Assessment-Recommendation- repeat

Patient education is broken down into 3 part, what are those parts and give examples?

Cognitive (knowlege) → “this is why insulin is important“

Psychomotor (skills) → “Let me show you how to take a shot of insulin“

Affective (attiudes) → “I think taking insulin is stupid“

Is the teaching process simliar to the nursing process?

Yes