Nursing Process
Organizing assessment data into themes
What is clustering assessment data?
A legal written record of nursing interactions.
What is documentation?
False imprisonment is considered this.
What is a tort?
PHIPA stands for...
Data that includes what the client states.
What is subjective data?
Content is organized by discipline.
What is a source record?
What is informed consent?
What to do with your worksheet at the end of your shift.
An actual or a potential problem
What is a nursing diagnosis?
Primary purpose of documentation.
What is communication?
Verbal defamation of character.
What is slander?
The people you may share client health information with.
What is the health care team or the "circle of care"?
The step that determines how effective our nursing care has been.
What is evaluation?
10 pm stated as per the 24 hour clock.
What is 22:00?
One type of abuse that must be reported.
What is child abuse?
When you can share patient information with your best friend.
What is NEVER?!
These can be written as short term or long term
What is a plan/goal?
FAIR notes are a type of this documentation.
What is a type of focus charting?
It can be written or verbal.
What is express consent?
When a nurse is obliged to give information to insurance companies.
What is NEVER?