NPSG
Documentation
Compliance
What is PI?
PI Monitors
100
We do this prior to providing medications, specimen collections (all bodily fluids), passing meal trays, dressing changes and other treatments.
What is ask the patient for 2 patient identifiers? (Name and DOB)
100
Any paper documents that are used to note any patient data require staff to endorse the notation with these four legible items.
What is Date, Time, Legible Signature (first initial, last name) and Title e.g. 2/25/15 1330 S. Smith, MHC
100
Communicating abnormal values (Vital Signs, Pain, changes in Mental Status), timely and accurate documentation and providing quality patient centered care.
What are ways I contribute to Performance Improvement?
100
A systematic approach to improving processes that affect the care we provide. We do this by identifying the process needing improvement, measuring it, taking action to correct it and then re-measuring it to make sure it is improved. We use Plan-Do-Study-Act methodology.
What is Peformance Improvement (PI)?
100
Progress note documentation reflects identified problems, interventions and goals.
What is documenting to the treatment plan?
200
Assess and document this every shift. Communicate any identified risks to the charge nurse who will then develop and document a safety plan and notify the physician.
What is suicide and safety risks?
200
Incorporating patient's own words and using quotes in the medical record.
What is documentation that paints a clear picture of the patient's mood and thoughts and shows evidence that we are engaging the patient to actively participate in their treatment.
200
The Patient's Rights Advocate, The Joint Commission (TJC), Health Plans, California Department of Public Report (CDPH), Boards of Licensure to name a few.
What are individuals and organizations that can receive a complaint?
200
Identifying high risk or problem prone areas
What is how we determine what areas of care need monitoring?
200
Shift suicide and safety screening and nurse communication documentation, progress note documentation and verbal communication to Charge Nurse.
What are 3 things that always need completion for any positive suicide or safety risks identified during your shift?
300
Clinical Alarms: bed alarms, panic buttons, fire pulls, smoke detectors, biomedical equipment, AED box.
What are used to alert staff of potential or actual emergencies at JMBH?
300
Specific signs and symptoms related to the problems that were identified on admission or have developed since admission.
What is documenting to the treatment plan?
300
The proactive intervention the hospital uses to promote patient safety and improve patient satisfaction. The strategy of checking patient whereabouts and activity reduces patient aggression, self destructive behavior and falls while increasing patient satisfaction scores
What is purposeful rounding/safety checks?
300
The location of the PI playbook, how to use the PI playbook, what is the purpose of each PI monitor, and all staff are expected to participate in the PI monitoring process.
What are the things all staff must know about performance Improvement (PI)?
300
Checking all refrigerator ad freezer temperatures on the unit every day and evening shift and documenting result. Notifying charge nurse and PSA of any out of range temperatures and documenting this notification.
What is Refrigerator Temperature Monitoring per TJC requirements?
400
HAND HYGIENE-Engage in proper hand hygiene techniques (Soap and water or use of alcohol based hand sanitizer)(giving and accepting polite reminders to fellow staff)
What is the most important role in infection prevention?
400
Reviewing previous shift notes by physician, nursing staff or other discipline prior to entering your documentation.
What is ensuring continuity of care?
400
DBS Certification every 18 months, CPR certification every 2 years, Knowledge Center Assignments per Health System due dates.
What is the employees responsibility to ensure one's competency compliance is current?
400
Unit Staff identifying strategies and protocols if more action is needed for further improvement or developing strategies to hold improvement gains.
What is Acting on Results in PDSA methodology?
400
After removing gloves
What is an opportunity for hand hygiene?
500
Shift suicide and safety screening and nurse communication documentation, progress note documentation and verbal communication to Charge Nurse.
What are 3 things that always need completion for any positive suicide or safety risks identified during your shift?
500
cc, qd, qod, iu, cfs
What are unapproved abbreviations? Use only approved abbreviations in your medical record documentation.
500
Specific approaches for early recognition and intervention focus on verbal control, limit setting, and decreased stimulation. It is important that staff have a clear understanding of their range of treatment strategies from most to "least restrictive" measures during stressful times when patients become confused, angry, or frightened and may lose control. Patients must be made aware of their choices during this cycle and understand the consequences of their behavior
What is always using least restrictive measures?
500
In addition to the medical record documentation, document any and all significant behaviors and incidents on this form (serious self-harm behaviors, threats, patient injury, falls, contraband found on unit, AMA discharges, R&S events, code blue, medical transfers, privacy breaches, delay/omission of treatment, plus others 24 total specific incident types). Do not document in the patient medical record that this form has been completed. You will find these in a white binder labeled on each unit; to find a specific form look in the table of contents.
What are Occurrence Screens?
500
Epic pictures are not acceptable for this use.
What is using two patient identifiers prior to any meal tray, med, lab or procedure?
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