Legal Guidelines
In your nurses note, this is written first
What is the time and date
Patient information is to remain what?
What is confidential
This type of documentation is storylike
What is narrative
This is where you would tell the healthcare provider what you think would improve the patient situation
What is recommendation
This type of order is given over the phone
What is telephone order
These essential pieces of information should end all nursing documentation
What is a signature with credentials. You have earned them, so use them!!
This should be turned off if you need to step away from your charting
What is a computer monitor
SOAP stands for....
S = Subjective, O= Objective, A = Assessment, P= Plan
This is where you would include the patient's name, room number, patient problem, when it happened or when it started, etc.
What is the situation (not Mike but the patient situation)
This type of order is given to the RN face-to-face
What is a verbal order
Written entries should be written in this color ink
What is black ink
Log in information should be kept
What is secure
This type of charting is when the nurse documents "WNL" on all systems except the one in question
What is charting by exception
This is what YOU think is happening in regard to the current problem
What is Assessment
This is what you always should do if you receive a telephone order
This should be done if you need to fix a written error
What is draw one line through the entry, write "error" above it with your initials and date
You are not to leave this place with any patient identifying information
What is clinical
The "E" in PIE stands for
This is where you would verbalize the patient's admitting diagnosis, change in mental status, allergies, etc.
What is background
What is ask the provider to repeat the order
Patients who wish to view their health care record have the ability to do so per...
What is hospital policy
These types of machines have caused numerous HIPAA breeches due to being sent to the wrong number
When using the "DAR" acronym, this letter is an example of repositioning a patient, administering oxygen or medication per MD orders, discharge teaching...
Helps improve verbal communication and reduces medical errors
What is SBAR
TORB stands for....
Telephone order read back