Charting
This legal document can be used as evidence during a malpractice lawsuit.
What is the medical record?
This should be documented before and after pain medication.
Before leaving a patient's room, these three safety items should be verified.
What are bed low and locked, call light within reach, and personal items accessible?
The most effective intervention to prevent pressure injuries
What is regular repositioning?
The primary goal when considering the use of restraints.
What is ensuring patient safety while using the least restrictive intervention possible?
This communication should be documented including the time, reason for contact and orders/instructions received.
What is provider notification?
You only have an order for PRN Tylenol for fever, but the patient is requesting pain medication and does not have a fever.
What is only give medication for the indicated reason and contact provider for appropriate order?
The most effective way to prevent the spread of infection.
What is hand hygiene?
This needs to be completed at every patient admission.
What is 4 eyes On?
The frequency in charting patient assessment while being in restraints
What is every 15 minutes?
This phrase describes documentation that would be considered reliable evidence in a legal proceeding.
What is charting that can "hold up in court"?
The time limit after removing controlled substance medication to administration.
What is 15 minutes?
A patient falls despite all precautions being followed. This type of fall may be unavoidable due to the patient's condition.
What is an anticipated physiological fall?
This is contraindicated with Inner dry.
What are any topical creams?
The patient's behavior, alternatives attempted, and ongoing monitoring must all be included in this.
What is restraint documentation?
The best action when you make a documentation error in the patient's chart
What is correcting the error, modifying, unchart with comment?
This action is required if you are removing more than the ordered amount of a controlled substance.
What is have a witnessed waste and complete in pyxis?
Name three actions included in purposeful hourly rounding.
What are pain assessment, potty/toileting needs, positioning, and ensuring possessions/call light are within reach?
The two primary mechanical forces responsible for pressure injury development.
What are pressure and shear?
Restraints should be discontinued immediately when this occurs.
What is when the patient no longer meets restraint criteria?
This phrase describes charting an intervention that was not actually completed
What is falsification of documentation?
The appropriate action is a nurse identifies a medication dosage that appears unsafe.
What is hold medication and clarify order with provider?
These are the three most common causes of preventable patient harm in hospitals.
What are falls, medication errors, and healthcare-associated infections?
The most important nursing intervention for a patient with limited mobility and a high Braden score risk.
What is implementing a comprehensive pressure injury prevention plan, including repositioning and pressure redistribution?
The most legally defensible reason for applying restraints.
What is an immediate threat to patient or staff safety that cannot be managed with less restrictive measures?