Health Care Information

Question 1

Goals of documentation?

Answer 1

Support Perioperative nurse workflow
Facilitating data
Eliminating redundancies
Reflecting patient focused care
Contain all important info for ongoing and transitional care

Question 2

6 steps of nursing process?

Answer 2

Assessment
Nursing dx
Outcome identification 
Planning 
Implementation 
Evaluation

Question 3

How must info be documented?

Answer 3

Systematically and consistently

Question 4

Issues that arise with data?

Answer 4

Access
Security
Privacy

Question 5

Responsibilities is nursing process?

Answer 5

Safety 
Education - pt & fam
Planning - continuity 
Communication 
Appropriate care - culturally, ethically, age appropriate

Question 6

Documentation considerations?

Answer 6

Document throughout entire nursing process
Incorporate standardized clinical terminology
Accurate data to measure and evaluate pt outcomes
Storage and extraction

Question 7

Documentation vocab?

Answer 7

PNDS - standardized nursing language

Question 8

Electronic health records?

Answer 8

Real time
Pt centered
Info available instantly and securely

Question 9

Benefits of EHR?

Answer 9

Improve pt care
Increase pt participation 
Improve care coordination
Improve diagnostic and pt outcomes 
Cost saving

Question 10

Downtime for EHR?

Answer 10

Ensure pt care is not interrupted

Alternate data entry
Back up protocols

Question 11

How to document?

Answer 11

State info clearly
Individualized per pt
Will understand in future
- able to explain what care was provided, supportive

Question 12

When can you have verbal orders?

Answer 12

Only when clinically indicated

Question 13

How to document verbal orders?

Answer 13

Enter in ASAP
Read back 
Record names and roles
No abbreviations 
No trailing zeros 
Standardized names and terms
Follow P&P for standing orders

Question 14

When should you make corrections?

Answer 14

Should only be done to present accurate description of care or protect or interest

Question 15

How to decrease malpractice lawsuit with documentation?

Answer 15

Documentation should be..
F - factual 
A - accurate 
C - complete 
T - timely

Question 16

What causes lawsuit?

Answer 16

Failure to:
Communicate 
Document
Assess/ monitor
Follow standards of care
Act as pt advocate 
Use equipment in reasonable manner

Question 17

Whose risk reductions should you follow?

Answer 17

Standards of Perioperative nursing
- define and enumerate responsibilities

AORN guidelines for Perioperative practice
- recommendations for Perioperative pt care

Question 18

Informed consent

Answer 18

Ethical and legal right to act autonomously

• procedure
• research interventions
• pt wishes

Question 19

Who gathers consent?

Answer 19

Surgeon, anesthesiologist and/or other licensed practitioners

Nurse - can witness consent, review consent forms

Question 20

HIPPA? And nurses role?

Answer 20

Privacy

Protect bodies from more exposure than required
Never comment in and outside of pt care areas

Question 21

How does HIPPA affect health care facilities?

Answer 21

Pt consent - how info will be used
Privacy and security - limit use or disclosure of info
Administrative procedures - protect privacy and confidentiality
Perioperative protocols - P&P

Question 22

Documentation about dressings?

Answer 22

Appliances
Packing descriptions
Ointments

Question 23

Documentation about tourniquet?

Answer 23

Cuff pressure
Times of inflation and deflation
Reactions to ischemia and reperfusion

Question 24

Documentation about lasers?

Answer 24

Total energy used
Eye protection
Wavelength

Question 25

Documentation about positioning?

Answer 25

Type and location
Additional padding
Actions to prevent injury
Type and location of safety restraints

Question 26

What is evaluated right before sending pt to PACU?

Answer 26

Airway status

• type and presence of an airway
• oxygen flow rate

Mental status