Clinical Shift Note
What part of the clinical shift note (during initiation) must be included to help improve the effectiveness of communication among caregivers?
Reviewed Previous shift recommendations”, New admission”
What is the benchmark for BAMC Clinical Shift Note Audit Compliance?
90%
Who stages pressure ulcers?
Wound care
Who is the first personnel that lab attempts to notify for critical values?
MD;
Lab calls the physician and waits 10 mins for a call back; if no call back, lab will then call the patient’s RN for notification)
o Ensure we put the MD number on the lab order when sending down labs
o The RN will then have 50 remaining minutes to notify the MD.
False: It is not recommended to send a text page to MD with critical lab details; however, you can send a page stating "I received a critical value, please call 916-7757"
What important piece must be addressed in the education block of the clinical shift note?
"Verbalized understanding"
Problem identification is based on current assessment and up to _____ problems can be identified.
8
In what time frame do RNs have to complete a Nurse Admission Assessment?
24Hours
True or False: LVNs can take critical lab values only if it is their assigned patient.
False; Only RNs can take critical lab values.
True or False: RNs must have written order before applying restraint to patient?
False: RN can initiate restraints and give order for the Docs to put in within an hour.
Ensure MD order match the time that the restraints were applied.
Specific, Measurable, Attainable, Relevant/Realistic, Timely
Only actual identified problems are documented in the Nurse Clinical Shift Note. Name three problems that are not recommended as primary problems in the clinical shift note.
Pain, falls, “potential for” or “risk for”
You suspect the patient is at risk for aspiration. What note must be filled out?
Swallow Risk Assessment
How long do we have to notify the physician of a critical lab value?
Within 60 minutes.
True or False: All employees can be sued individually here at SAMMC?
True: 5 cases/year at SAMMC; maternal child with highest payout (40%) of lawsuits.
If the goal was met/not met/partially met AND How was it met.
Name at least 3 events that we should document in our clinical shift note.
1. Additional education – new meds, diet or procedure;
2. unexpected finding or occurrence from assessment;
3. psychosocial events that occurred with the family or caregivers the patient has outside of hospital;
4. pertinent conversations with providers concerning the plan of care,
5. critical labs or
6. Unexpected events
If the patient is deemed “high falls risk” using the Johns Hopkins falls assessment tool or humpty dumpty, how long do they remain on high falls risk?
Throughout hospital stay
What must be documented when obtaining a critical lab value?
Time critical result received, Lab test, lab result, results rec’d from (lab tech), Readback verification (nurse documenting critical), initial time provider contacted, provider name contacted, & intervention/resolution
If patient has an AMD and has not been provided to be on file, when should we follow-up?
24 hour follow-up: 1st attempt date and 2nd attempt date should be 24 hours later (not within the same date)