Week 8 - Patient Records and Confidentiality

Question 1

What are the key aspects of keeping patient records?

Answer 1

Accuracy, completeness, timeliness.
Legal documentation of care provided.
Confidentiality measures (secure storage, limited access).

Question 2

What forms are used in patient records?

Answer 2

Admission assessments.
Care plans.
Progress notes.
Discharge summaries.

Question 3

What are the legal requirements for nursing documentation?

Answer 3

Accuracy, legibility, timeliness.
Reflects nursing process and adheres to legal standards.

Question 4

What are the components of the SOAPIER framework?

Answer 4

S: Subjective data (what the patient reports about their condition).
O: Objective data (what is observed or measured during assessment).
A: Assessment (nursing diagnosis based on the collected data).
P: Plan (what will be done to address the patient’s needs).
I: Intervention (specific actions taken to implement the plan).
E: Evaluation (patient response to interventions and progress towards goals).
R: Revision (modifications to the care plan based on evaluation).

Question 5

What is the ISBAR/ISOBAR framework for clinical handover?

Answer 5

I: Identify (yourself and the patient, including relevant identifiers).
S: Situation (current status of the patient, including any immediate concerns).
B: Background (relevant medical history and context for the current situation).
A: Assessment (current clinical findings and any changes in condition).
R: Recommendation (what needs to be done next, including any requests for further action).