ADMISSIONS
This needs signed within 30 minutes of admission
Consent to treat
Every patient needs one of these initiated at admission
Plan of Care
This needs done when charting pain interventions
Pain reassessment after an hour
This gets documented if a medication is not given
a reason why
This is what you tell a surveyor when they ask you a questions and you don't know the answer
"I can find out for you"
These forms must be filled out and all boxes checked
Admissions packet
Care plans need to reflect what?
Their diagnosis, comorbidities, problems we are treating during their stay
You should relay this in report so that it doesn't get missed
Last time pain medication was given and if reassessment needs documented
Time critical meds should be administered within this time frame
30 minutes
This is the dwell time for sani clothes and bleach
sani 2 mins bleach 5 mins
This needs completed when the patient requests for their PCP or family to be contacted upon admission
Documentation of the date and time that they were contacted under "time of contact" on consent forms
Patients who have a change in condition or some type of event (like a fall) need what?
An updated care plan
When giving Tylenol, what should you check to ensure that it is appropriate
Parameters, is it for pain or for fever?
These are time critical meds
Antibiotics, insulin, thyroid medications
Issues that aren't resolved in real time are considered this
A grievance
Patients who are A&O x4 must do this
Sign their own consents
What should almost every patient have in their care plan?
Pain management care plan
This is used to complete a full pain assessment when documenting
PQRST
This is the time you have to pull and give controlled substances
30 minutes
Glucometer control solutions must include this
date opened and exp. date
If a patient doesn't sign their own consent, the nurse must document what?
Why the patient isn't signing for themselves and who the person is signing for them (MPOA, daughter, husband etc.)
We can find comorbidities and diagnosis to craft care plans using what?
H&P
These should be checked before any PRN medication is given and ensure that the pain scale documented matches.
Parameters , where does the intervention land on the pain scale. Order and assessment has to match.
This is who you call when a medication is not stocked on a night or weekend
On call pharmacist
This is our safety officer
Tyson Kliendel, DPO