Patient Assessment
True or False: Ensure that documentation is completed by the individual who performed the action or observed the event, except when there is a designated recorder.
True
CNO standard: Nurses are accountable for ensuring their documentation of client care is accurate, timely, and complete.
True or False: Access only information for which the nurse has a professional need to provide care.
True
CNO standard: Nurses safeguard client health information by maintaining confidentiality and acting in accordance with information retention and destruction policies and procedures that are consistent with the standard(s) and legislation.
True or False: Document significant communication with family members and significant others in the patient's chart.
True:
CNO standard: Nurses ensure that documentation presents an accurate, clear, and comprehensive picture of the client’s needs, the nurse’s interventions, and the client’s outcomes.
True or False: Document advice, care, or services provided to an individual in the chart.
True
CNO standard: Nurses ensure that documentation presents an accurate, clear, and comprehensive picture of the client’s needs, the nurse’s interventions, and the client’s outcomes.
True or False: During downtime, you should document on any paper available with any colored ink.
False:
Documentation is done only on approved health records form in black or blue ink.
What key factors should be to considered along with MSE?
Patient's social, cultural and educational background.
------ provides a comprehensive set of rules that apply to all parts of the health care sector, in order to protect the privacy of personal health information, while at the same time providing for its collection, use and disclosure in a manner that will facilitate the effective provision of health care.
PHIPA
Personal health Information Protection Act
How do you make changes to your already completed notes in Meditech.
Add an addendum.
What are the documentaion requirements for peersonal belongings?
Personal belongings documents which if filed in patients chart
Inventory of personal belongings
What is the duration to make a late entry in electronic chart according to our hospital policy?
Made on the day and for three days
During an admission physical assessment, the WDS stands for within defined standards, when do we select this and what further documentation is required.
All the parameters mentioned in Meditech system admission physical assessment selected system.
No further documentation required
--------- and its related statutes governing individual professions, recognize that it is an act of professional misconduct for the regulated health professional to provide information about a client to anyone other than the client or his or her authorized representative, except with the consent of the client or representative, or as required by law.
The Regulated Health Professions Act.
One of the important tasks that highlights mental health nurses professional autonomy is documenting----
"Nurse observations"
info on health status, signs and symptoms of illness, behavior of patients, reactions to various therapeutic treatments etc.
What is the protocol for Restraints documentation? How often you have to document in patients chart if a patient is oplaced on restraints.
Q15 x 4
Q30x 2
Q1 hr until removed.
What is the process if late entry has to be made after 3 days?
Notify clinical manager
Manager notifies IT
IT provides a special access.
What are the key factors assessed using VAT?
What is the full frm of VAT?
How often you have to document VAT?.
History of Violence and Observed behaviors
Violence assessment tool
ADM and PRN.
-------is the heart of PHIPA
Consent
What are some of the essential components in nursing narrative note?
Subjective and objective data
Assessments and analysis
Nursing interventions, actions and its effectivness
Communication with family and patient.
What are the documentation requirements for chemical restraints?.
Same as any other restraints. Follow restraints protocol.
Q15x4
Q30 x 2
Q1hr then after until patient settled.
Which computer is the downtime computer on our unit?
What is the icon to access during downtime in that computer?
How do you access it?
ACC computer
Summit DRS Desktop
Use your network Id/password
In case of full network down, use the break the glass log in
During suicide risk assessment, Q shift, if your patient scored high on CSSRS screener version, what other assessments and documentation are required?.
CSSRS full version, assessment of factors(Stengths and protective factors, Long term risk factors, Selfcontrol/Impulsivity, reliability, resources available, Triggers)
Narrative note highlights
Verbal report to MRP and CF/CN and next RN during transfer of accountability.
Are you authorised to disclose PHI to police?
What are the circumstances?.
Based on consent only.
Authorised disclosure without consent usually derives from a warrant, subpoena, or court order.
Organisation should have a procedure/protocol.
List 5 documentation items which has to be avoided in narrative notes?
Subjective opinions and speculations
Staff conflcits
Pesonal comments about patients or family members
Vague descriptions or explanations
Blame and self doubt
RL entry, late entry, Entered in GP book etc.
Copying and pastng as this can result in repetaing the wrong information.
After a code white, what are the documentations required?
Narrative note
VAT
Update MSE
RL
Restraints documentation if used.
Verbal report to CN/CF and next RN
When coming out from downtime, what is the process of MAR documentation?.
Wait for Pharmacys call one they finish any new medication order
Completet MAR by selecting the option see downtime MAR
then save