Foundation chapter 3 Flashcards
What is incident report and when should it be filed?
Asap no later than 24hrs, internal, helps with Q
What would require completing incident report, give example?
needle stick, injury, med errors, anything out of ordinary
Should the note be written that incident report has been completed in the
patient’s chart?
NO
What is nurse’s priority if incident occurred involving a patient, what is a priority action?
Assess the patient
What is the purpose of nursing notes?
Communication, care was provided reimbursement
When is the best time to document care?
As soon as care is provided
The patient’s medical record is a legal document, therefore what
considerations must be taken?
How to correct mistakes? Don’t white out,
initial, draw line though and initial,
Can abbreviations be used? If yes what kind?
Avoid abbreviations, check your facility list
What format is used for charting by exemption
Chart things that are not routine, new findings, addition treatments/withheld, changes
How frequently password needs to be changed?
Every 6months
When providing care what needs to be documented?
What you did?
Assessment, how you did? Result?, how pt tolerated it? Reveval
According to HIPPA who is entitled to information about the patient?
pt, POA, clinical reason/need to know
What is nursing process?
Systematic, framework, scientific
How to ensure the security of EHR
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
What implementations need doctor’s order?
Nursing driven
Physician driven
Collaborative
