Nursing Process #1
A cyclical, critical thinking process that consists of 5 steps.
What is the Nursing Process?
Data the nurse obtains through observation and examination.
What is objective data?
A legal record of care.
What is the chart/medical record?
A standard approach for communication with the healthcare team. Is used for financial billing, education, research, and auditing.
What is documentation?
Purposeful thinking back or recalling a situation to gain insight into the event.
What is reflection?
A step in the nursing process where tasks are delegated and supervised.
What is implementation?
A step of the nursing process where the nurse does analysis of data to identify trends.
What is assessment?
Documentation that is organized by problems or diagnosis (e.g. SOAP or PIE).
What are problem-oriented medical records?
A disclosure of an occurrence of an accident or an unusual event.
What is an incident report?
Requires lifelong learning and the ability to acquire relevant experiences that can be reflected on to improve nursing judgement.
What is critical thinking?
A step in the nursing process where client problems are prioritized and nurses identify goals and outcomes.
What is planning?
A step in the nursing process where the nurse validates, interprets, and clusters data.
What is assessment?
What is HIPPA?
An element of documentation where information is factual and precise and does not include irrelevant details.
What is accurate and concise?
A level of critical thinking that results from limited nursing knowledge and experience.
What is basic?
A step in the nursing process where a clinical judgment is made regarding the extent to which a goal was obtained.
What is evaluation?
Interventions that nurses initiate as a result of a provider's order or a protocol.
What are provider-initiated interventions?
A documentation format that identifies norms and allows selective documentation of deviations from those norms.
What is charting by exception?
A public platform that may put you at risk for violating HIPPA or violating a company policy.
What is social media?
A level of critical thinking where the nurse makes choices without help from others and assumes the responsibility for those choices.
What is commitment?
A tool that promotes the professionalism of nursing while differentiating the practice of nursing from medicine.
What is the nursing process?
The process of anticipating and planning for clients' needs once they leave the hospital.
What is discharge planning?
Should only be used in an emergency situation and requires you to read back a medication name, dosage, time, and route.
What is a verbal order?
A passing of information that includes significant information about health problems, recent changes in meds, treatments, procedures, and the discharge plan.
What is bed-side-shift report/ face-to-face?
A component of critical thinking where decision-making is made from prior opportunities to observe, sense, and interact with clients.
What is experience?