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Assessment
Physical
Plan of Care
Patient Safety
Patient Rights
Medication Management
100
Required time-frame for documentation of initial physical assessment.
What is prior to end of admitting nurses shift?
100
Individualized to the patient's needs. Completed a minimum of two times in 24 hours (Example: one time per 12 hour shift) and when patient condition warrants
What is Individualized Plan of Care (IPOC)
100
The National Patient Safety Goal, and process that requires using name and FIN# (two patient identifiers) when giving medications, drawing lab work, conducting procedures etc.
What is the process for patient identification?
100
Posted in public places and given in a packet to all patients on admit.
What are patients rights and responsibilities?
100
This medication related activity is a National Patient Safety Goal and is required on and off the sterile field
What is labeling medications, med containers and other solutions?
200
Completed a minimum of two times in 24 hours (Example: one time per 12 hour shift), with change in caregiver and when patient conditions warrants; twice daily in Behavioral Care.
What is the time-frame for physical re-assessment in the EMR?
200
The process in which the RN modifies and adds additional comments or details, and adds additional nursing diagnoses based on assessment of the individual patient
What is individualizing the plan of care or making the care plan patient specific?
200
The process of obtaining a list of each patient’s current home and hospital medications including name of drug, dosage, route, frequency and time of last dose taken, and comparing it against the physician’s admission, transfer and discharge orders. This information is documented in the EMR.
What is medication reconciliation?
200
This is the department to notify when placing a patient in restraints
What is nursing services? (nursing services as to have one location for list of patients in restraints)
200
Colleagues are instructed not to do this for medications or solutions transferred from a container to a syringe prior to the procedure (not for immediate use)
What is pre-labeling syringes/solutions?
300
Completed a minimum of twice daily, when patient condition warrants and when patient falls.
What is Fall/Safety Assessment (Morse Fall Scale)
300
The process/planning for moving a patient to Rehab or Behavioral or to any other agency. It may be a discharge to home or a dismissal to a skilled care facility, home health care, etc.
What is discharge planning? Additional conversation: Found in the EMR adult/ped admission profile or pre-procedure form and in case management notes.
300
U (for unit) IU (for international unit) Q.D., QD, q.d., qd Q.O.D., QOD, q.o.d., qod Avoid these to eliminate errors for patient safety!
What are examples of unapproved abbreviations?
300
Patient complaints managed (at unit level and if not satisfied have manager on call to assist)?
What is the patients grievance process?
300
Another element of NSPG 3 states use of this medication/therapy requires nursing and pharmacy to provide education to patients
What is anti-coagulation therapy?
400
Documented in the EMR it's known as the 5th vital sign.
What is Pain Level? (assessed with all vital signs, change in caregiver and when patient conditions warrants and documented in the EMR under IVIEW Frequent Assessment band, Pain Assessment section)
400
Provided to all patient/family on admission and at least once per eight (8) hour shift throughout the hospital stay, and documented in the EMR.
What is the requirement for providing patient/family education?
400
Heparin infusion, insulin infusion, TPN, Chemo, second witness nurse is required.
What are examples of high risk medications?
400
There are two types of this "patients instructions" document; Durable Power of attorney Living Will (A copy of this document is made on admit and kept in the paper chart/scanned into EMR for all patients.)
What is an Advance Directive?
400
What you should do if you find a medication in a syringe or container that does not have a label or a date of expiration on it
What is discard the medication? (as cannot verify what is in the bottle or when expires.)
500
A screening tool completed for all adult inpatients as a part of the nursing admission process to assess for self harm
What is Suicide Risk Assessment?
500
Required documentation when a patient transfers from one level of care to another.
What is the transfer note? (The sending RN assesses the patient within one (1) hour prior to the transfer time. The sending RN documents the pre-transfer patient assessment in the EMR in IVIEW on the Physical Assessment section.)
500
Any resultant test values/levels/interpretations where delays in reporting have the potential for causing or definitely will cause serious adverse outcomes for patients. (INR, BS, Creat, EKG results outside the range of normal),
What are critical test results? Additional info: Components required in the documentation: time and who critical test results were reported to
500
Use of this for a patient is not to be used as a means of coercion, discipline, convenience or retaliation. Documentation must prove it is justified as a means to keep the patient safe and protect from injury.
What are restraints?
500
Prior to administering medication from a multi-use vial this is required
What is labeling with the patients name and 28 day expiration date. Label these meds with the date of expiration which is 28 days after the vial is first entered.