This is a method of problem-focused charting
What is DARP?
>than 95%
What is the expected SpO2 level.
The four skills used in physical assessment.
What is inspection, palpation, auscultation, percussion?
The "A" in I-SBAR-R
What is Assessment
The form or place in the chart where the nurse documents his or her observations, care given and patient's responses.
What is Integrated Progress Notes.
This flowsheet is used in the WRHA to track vital signs and patients at risk for sepsis
What is NEWS
What is jaundice?
This nurse-to-nurse interaction happens when a patient switches units
What is a transfer report?
This type of report occurs when there is an actual or potential injury; this report is not a part of the patient record.
What is an incident report?
Accessory muscle use, Respiration Rate of 24 breaths per minute, tripod posture, distressed facial expression are signs of this
What is respiratory distress
The second "R" in I-SBAR-R
What is Repeat Back!
In military time, 9:00 pm is ___________.
What is 2100?
PHIA stands for this
What is Personal Health Information Act
PERRLA is an acronym that stands for
Pupils Equal Round Reactive to Light and Accommodation
The best source of information about a patient's care and progress
What is the medical record
Five characteristics of quality documentation.
What is factual, accurate, complete, current, and organized?
This is a major risk factor for skin breakdown
What is immobility
This artery is used to manually assess peripheral pulse in the upper extremity
What is the radial artery
This bowel sound is not an abnormal finding, but it is hyperactive
What is borborygmus
Yourself, your role, patient's name and room number are features of this
What is the "I" (identification) in I-SBAR-R
What accreditation agency specifies guidelines for documentation?
What is Accreditation Canada