To ER or not to ER
This Symptom is chest pain with shortness of breath.
What is go to the ER.
This charting type such as the phrase, "patient was being dramatic" should NEVER appear in a professional note.
What is Judgemental Documentation?
The member states " I already took all of my medications prior to coming to the ER" can usually cause concern for this.
What is accidental double dosing?
After the nurse explains the discharge plan three times, a family member typically asks this question immediatley after.
What is "what is the plan"?
This is the first thing any callers say before giving absolutely no identifying information.
What is "I have a question".
148/80 blood pressure reading, no symptoms.
What is do NOT go to the ER.
The Golden Rule of charting says "if it wasn't doucmented...."
What is "you didnt do it".
A confused member suddently says " I think I can walk by myself now", and attempts to get up. This is considered a what?
What is can we take them for a smoke?
A member states angerily " I have been hung up on three times already". What is your first skill you are using?
What is de-escalation?
A diabetic member says that thier blood sugar is 42 and they are confused and sweating.
What is GO to the ER.
This major issue can come from copying yesterday's assesment fowards without verifying anything on it?
A member uses Dr. Google and decides they have a rate tropical disease instead of seasonal allergies. This is reffered to as what.
What is Cyberchondria or Self-Diagnosis from the internet?
A family member arrives to a pre-op patient with Mcdonalds and a chocolate shake asking why they can not eat. You as the nurse inform them that eating this would be what.
What is an aspiration risk?
A member reports to you that they stop taking thier medication because "it looks different". What education should you provide?
What is medicaiton education.
A member reports facial droop, slurred speech, and arm weakness that started 20 mins ago.
What is go to the ER.
Charting on the wrong patient can cause this type of event and may require an incident report?
What is a documentation error?
A member has a documented allergy to "cillins", and is prescribed Amoxicillin. What can this cause?
What is an allergic reaction or Anaphylaxis?
A family member reports that they "watched a you-tube video" and adjusted thier mom's insulin and have been dosing her over her ordered units for the last three days. What is this member at risk of?
What is putting their mother at severe, immediate risk of severe hypoglycemia (dangerously low blood sugar), which can escalate to fatal consequences if not corrected?
A member reports worsening shortness of breath, Lower leg swelling and rapid weight gain over the last three days. What could this be?
What is possible heart failure eaxcerbation?
A member states that they "took thier prescribed medication twice by accident and now I am dizzy and faint". What is the first step?
What is call posion control and/or seek an emergency evaluation.
The nurse charted "left leg dressing changed" but it was actually the right leg. The best action to correct this would be?
What is correct the documentation immediately according to the policy?
A member reports to you that they "stopped taking thier antibiotics because they felt better". This can cause the following issue.
What is Antibiotic resistance, or Recurrence of Infection?
This is the best way for a family member to stay informed about a patient’s care while respecting privacy laws and ensuring accurate, up‑to‑date information.
What is being designated as an authorized contact or healthcare proxy and communicating directly with the care team?
CMS requires SNP members who report an inpatient admission to be identified and outreached within this limited timeframe to support safe discharge planning and reduce readmission risk.
What is 72 hours (or as soon as possible post‑notification)?