CJM
This step of the CJM involves noticing important clinical data
What is recognizing cues?
This documentation type is written like a chronological story.
What is Narrative Documentation?
When an RN delegates a task, this responsibility always remains with the RN.
What is accountability?
This federal law protects patient privacy and health information.
What is HIPAA?
ABCs
The “A” stands for this.
What is Airway?
This step involves organizing, interpreting, and linking the cues you observed.
What is Analyzing Cues?
The “S” in SOAP stands for this.
What is Subjective?
This “Right” ensures the patient’s condition is stable before delegation.
What is Right Circumstance?
This law requires reasonable accommodations for individuals with disabilities.
What is the Americans with Disabilities Act?
Physiological needs fall into this level of Maslow’s hierarchy.
What is the first (basic) level?
This step requires ranking possible problems based on severity and likelihood.
What is Prioritizing Hypotheses?
In PIE documentation, the “P” stands for this.
What is Problem Identification?
A task appropriate to delegate to UAP:
“Taking vital signs on a stable patient.”
What is taking vital signs?
This law prohibits “patient dumping.”
What is EMTALA?
This factor is considered after ABCs and Maslow when planning care.
What are patient preferences?
This step develops possible nursing actions for the identified problem.
What is Generating Solutions?
In DAR, the “A” stands for this.
What is Action?
This principle states the RN must give clear, understandable directions.
What is Right Communication?
This type of law defines the nursing scope of practice in each state.
What is state statutory law?
The “M” in SMART goals stands for this.
What is Measurable?
This step of the model determines if interventions were effective.
What is Evaluating Outcomes?
Charting by Exception
This documentation style only records this type of finding.
What are abnormal findings?
This determines what a nurse can delegate legally.
What are state Nurse Practice Acts?
Choosing which patient to see first based on need is guided by this principle.
What is Justice?
A patient with difficulty breathing vs. a patient in pain — which is treated first?
Who is the patient with difficulty breathing?