HM Fundamentals
to reduce hospital length of stay and unplanned readmission to hospital, and to improve the co-ordination of services following discharge from the hospital
discharge planning
NAVMED 6550/12
Patient Profile
DD Form 792
24 hour intake/output worksheet used for fluid intake/output over 24 hour period
The three elements of infectious agents within a healthcare setting
source (reservoir), agents, susceptible host with a portal of entry, and mode of transmission for the agent
when should a note me bate in the chart that the pt's care was transferred to another MD at a particular time.
shift change
Hospital-Acquired Pressure Injuries aka
bedsores, decubitus ulcers, pressure ulcers/sores
Three purposes of bathing
1.
2.
3.
A federal agency of the US Gov that provides investigation, ID, prevention, and control of disease
CDC
SF 508
Doctor's Orders
Why would an HM review a patient chart data?
increase their knowledge of the patients situation and antici[ate the needs of the patient as a member of their inpatient healt care team
infectious agents that remain infectious over long distance when suspended in air
airborne
This is the 5 step nursing process
1. assessment
2. nursing dx
3. planning
4. implementation
5. eval
HAPI are more likely to occur when a pt suffers from the following
there are 9
influencing factors for patient hygiene
body image
phys condition
to move from place to place
ambulate
SF 509
Progress Notes
is a person or other living animal including bird and arthro-pods that affords subsistence or lodgment to an infectious agent under natural conditions
host
the following are considered when developing a nursing dx
1. phys needs
2. emotional needs
3. social needs
4. spiritual needs
Depending on the acuity of the pt, tissue ischemia can occur in as alittle as ___ min but may take as long as __
30 min 4 hours
two types of bedpans
regular - metal/plastic
fracture - for pts with lower extremity fracture
a manner of walking or moving on foot
gait
SF 510
Nursing Notes
is an infection occuring in a patient in a hospital or other health care facility
nosocomial infection
HAPI Classifications
Stage I-IV
:)
while assisting a pt with a bed pan lift the head of the bed this many degrees
30
only these specific duty inpatient records (IREC) are retired two years after the last inpatient discharge
non-active duty
T/F are SF 510 (Nursing Notes) filed in chronological order?
T
these arre the concepts in which all body fluids are assumed to be infected with blood-borne pathogens
standard precautions
Wound care basic techniques
surgical debridement, hydrotherapy, irrigation, larval therapy, biosurgery,
if pt is unable to assist with bed pan you will
lower head of the bed flat
these are the three major categories of primary medical records
1. inpatient
2. outpatient
3. health records
DENTAL RECORDS ARE NOT SEP CATEGORY
All SF 510 entries are made using a what coloured pen?
BLACK
T/F Standard precautions need to be ordered by a physician regardless of patient contact
FALSE USED FOR EVERY PT ENCOUNTER
a health record
Examples of a phrases to avoid to ensure personal judgement is not written in SF 510
"appears to be" or "seems to be"
CDC Isolation procautions: Tier 2 =
How many categories of Tier 2:
Isolation Precautions
3
this is a medical file which documents care provided to a patient assigned to an inpatient bed at a MTF
inpatient record
Each nursing note entry is signed by whom?
by the person who wrote the note.
First/Last Name and RANK
HCW (Health care workers will wear what when caring for patients with airborne precautions?
respirator or mask
a clinical summary is required for all inpatient hospitalizations lasting more than how long?
48 hours
How many formats for writing nursing notes? And what are they.
TWO formats
most common: block format (written in paragraphs briefly who/what/where)
Second: ADL flow sheets
these precautions are intended to prevent transmission of pathogens spread through close respiratory or mucous membrane contact with resp secretions
droplet
This is the information that must be documented in a Nursing Note
1. Date
2. Medication
3. Treatments
4. Sign all notes
Documentation guidelines
1. Accurately
2. Objectively
3. one line errors, initial, and date the line
Place (inpatient) PT where under droplet precautions?
single pt room
NAVMED 6550/8 is what form and documents what
Medication Administration Record (MAR) used to document medication admin over a 7 day period
SF 558
emergency care and treatment