Foundation chapter 3 Flashcards

1
Q

What is incident report and when should it be filed?

A

Asap no later than 24hrs, internal, helps with Q

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2
Q

What would require completing incident report, give example?

A

needle stick, injury, med errors, anything out of ordinary

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3
Q

Should the note be written that incident report has been completed in the
patient’s chart?

A

NO

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4
Q

What is nurse’s priority if incident occurred involving a patient, what is a priority action?

A

Assess the patient

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5
Q

What is the purpose of nursing notes?

A

Communication, care was provided reimbursement

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6
Q

When is the best time to document care?

A

As soon as care is provided

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7
Q

The patient’s medical record is a legal document, therefore what
considerations must be taken?

A

How to correct mistakes? Don’t white out,

initial, draw line though and initial,

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8
Q

Can abbreviations be used? If yes what kind?

A

Avoid abbreviations, check your facility list

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9
Q

What format is used for charting by exemption

A

Chart things that are not routine, new findings, addition treatments/withheld, changes

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10
Q

How frequently password needs to be changed?

A

Every 6months

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11
Q

When providing care what needs to be documented?

A

What you did?

Assessment, how you did? Result?, how pt tolerated it? Reveval

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12
Q

According to HIPPA who is entitled to information about the patient?

A

pt, POA, clinical reason/need to know

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13
Q

What is nursing process?

A

Systematic, framework, scientific

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14
Q

How to ensure the security of EHR

A

log out, use strong password, change
it frequently, document where other people can’t see
don’t go to Facebook, leave password/share password, do not
document for others

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15
Q

What implementations need doctor’s order?

A

Nursing driven
Physician driven
Collaborative

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