SBAR/HIPAA/DELEGATION
The HITECH act offered this to facilities who switched to electronic charting.
What are financial incentives?
Patient teaching begins at this point of the hospital stay.
What is on admission?
If you don't document it.....
What is you didn't do it/it didn't happen?
Sitting down to speak with your patient is this type of behavior that enhances communication.
What is nonverbal behavior?
The is the 1st step in the nursing process used when developing a plan of care.
What is assessment?
Providing information that is pertinent to a current situation is in this step of SBAR communication tool.
What is background?
A picture is worth a thousand words. This is an example of a ________________ learner.
What is visual/non-verbal learner?
"My patient fell out of bed" but I didn't actually see it. This is a type of _____________ documentation.
What is subjective?
Greeting the patient by name, actively listening, and responding honestly are interventions that will help build a ________________.
What is a trusting nurse-patient relationship?
This is the 3rd step of the nursing process.
What is planning?
Contacting a physician about vaginal bleeding after surgery is included in this part of SBAR.
What is assessment?
To help reinforce teaching and encouragement it is a good idea to include the __________.
What is family/support system?
Patient refuses the 0900 dose of Digoxin. This is a type of ___________ documentation.
What is objective?
This response discourages further communication because there are no facts to support it.
What is offering false reassurance?
The 4th phase of the nursing process involves ___________.
What is the delivery/execution of care?
This type of delegation involves the nurse checking on the assistive personnel throughout the shift to determine if they are completing the tasks give.
What is right communication?
After having surgery a patient is discharged home. This barrier to learning will cause the nurse to postpone teaching.
What is pain?
This is one of the most beneficial aspects of election documentation systems when compared with written documentation.
What is improving legibility?
Using this type of communication skill demonstrates empathy and enables a nurse can intervene appropriately.
What is therapeutic communication?
This step in the nursing process will help the patient achieve a goal.
What is an intervention?
You are writing a blog about your adventures as an ICU nurse and post about the patient in ICU bed #4 with lupus. This is a type of ___________ violation.
What is HIPAA?
The Joint Commission requires that all written/handout teaching material be at or below this reading level.
What is 5th grade reading level?
You have charted your patient assessment under someone else's login. This is a type of ________ _________.
What is falsifying documentation?
To ensure the correctness of a telephone order the nurse will ___________ this to the physician.
What is read back/repeat?
This type of goal can be met within a few hours or days.
What is short-term goal?