Documentation

be clear, accurate, concise, and accessible, should provide a clear understanding of the client

What is PIE?

Problem, Intervention, Evaluation

What is SOAP?

Subjective

Objective

Assessment

Plan

What is subjective?

symptoms the client is describing / telling you

What is Objective?

what the provider observes -smells, hears, sees, measures, touches

What is Assessment?

combines subjective and objective information to arrive at a nursing diagnosis

What is Plan?

Steps to treat clients and suggests need for consultation or additional testing to address client needs

Source Oriented?

the traditional format for documenting. divided into history and physical, progress notes, nurse notes lab reports, and diagnostic testing

Focus Charting

Focus charting centers on specific health care problems, changes in condition, client events, and concerns.

three components that must be documented in focus charting

Data - information related to a patient's condition or situation

Action - interventions by healthcare providers in response to data

Response - patients' response to intervention or treatment provided

What does FACT stand for in documentation?

Factual

Accurate

Complete

Timely

What is the correct way to correct documentation errors?

Keep the original document.

• • Draw a single line through the entry and write “error” along with your initials.
  • Record the date and time when the correction was made.
  • Document the correct information without obscuring the original entry.

What guidelines should be followed when making a late entry in charting?

• Identify the entry as a "late entry."
• Specify which event the late entry is for.
• Ensure all new entries are signed and dated.
• Reference the event or previous note the new note is addressing.
• Avoid leaving blank lines.

What is the purpose of Electronic Health Records (EHRs)

provide a systemic, digitized documentation system that improves client care. They provide comprehensive records of a person’s health history and serve as a communication tool for all healthcare providers involved in the client’s care. They are also used for billing and can be used in court.

What is the role of the Institute for Safe Medication Practices (ISMP)?

The ISMP is devoted to preventing errors that occur within health care facilities and compiles a list of abbreviations appropriate for documentation.

What is priority setting in nursing?

Priority setting is the delivery of nursing care based on the urgency or importance of client needs. It involves organizing client care so that the most critical intervention or action is completed first.

What are the five levels of Maslow's Hierarchy of Needs, and which level must typically be met first?

The five levels are:

1. Physiological Needs
2. Safety Needs
3. Love and Belonging
4. Esteem
5. Self-Actualization

What does the ABCDE method in priority setting stand for?

<ul> <li>A: Airway</li> <li>B: Breathing</li> <li>C: Circulation</li> <li>D: Disability</li> <li>E: Exposure</li> </ul> <br>

What does the CURE acronym stand for in nursing priority setting?

• Critical, Urgent, Routine, Extras.

What is the difference between prioritization and triage in nursing?

- Prioritization involves ranking potential nursing actions in order of importance. Triage, on the other hand, assigns priority based on a quick initial assessment followed by assigning an acuity level, indicating how long a client can safely wait for screening and treatment.

What is the 5-level triage system, and what does it indicate?

• The 5-level triage system categorizes patients based on urgency, with Level 1 being the most urgent (life-threatening conditions) and Level 5 being the least urgent (stable, nonemergency conditions). Common systems include the Emergency Severity Index (ESI) and the Canadian Triage Acuity Scale (CTAS).

What is resource allocation in the context of nursing care?

Resource allocation is the process of assigning portions of services or resources in caring for clients. Priority setting often involves deciding how to distribute these resources effectively based on client needs.

What are the steps of the Nursing Process for a Registered Nurse

• 1. Assessment: Gather objective and subjective data.
  2. Analysis: Determine the client's problems.
  3. Planning: Create a plan to address the problems.
  4. Implementation: Provide care as outlined in the plan.
  5. Evaluation: Assess the effectiveness of interventions and document the response.

• What are the steps of the Nursing Process for a Licensed Practical Nurse (LPN)?

• 1. Data Collection: Collect and report subjective and objective data.
  2. Planning: Create a plan under the RN's supervision.
  3. Implementation: Collaborate with the RN to take action as planned.
  4. Evaluation: Evaluate interventions within the LPN's scope and under RN supervision.

• What is critical thinking in the context of nursing?

Critical thinking is the skill of analyzing and interpreting data to solve a problem and achieve a desired outcome. It includes questioning, analysis, synthesis, interpretation, inference, inductive and deductive reasoning, intuition, application, and creativity.

What is clinical reasoning in nursing?

Clinical reasoning is the mental process of analyzing all data in a clinical situation to make informed decisions. It involves assessing data, selecting relevant information, and making decisions based on nursing knowledge while applying critical thinking in the practice setting.

What is clinical judgment in nursing?

Clinical judgment is the outcome of critical thinking and decision-making that considers nursing knowledge, client situations, prioritization of problems, and evidence-based practice. It develops over time and improves with practice.