Charting
Who is responsible for initiating orders on a new admission?
Primary nurse and Supervisor to ensure completed in a reasonable time frame
The night before a team conference what additional documentation must be completed?
Team conference sheet
Team conference in Cerner
If there is a call out during your shift which will leave the next shift short, what should you do ASAP.
Contact any staff not working already to see if they can pick up.
Once a patient is sent out and admitted to an outside hospital, what must be done in Cerner?
Patient must be placed in an LOA bed.
If a nurse removes a narcotic during their shift what must be done prior to that nurse leaving?
They must ensure narcotic has been documented in Cerner MAR!
How often does an order for a restraint need to be reordered?
Every 24 hours.
A nurse comes to you at 10 am and tells you that their patient is not discharging until 4pm. What would you do with this information?
Inform Nursing management and admissions of patients late discharge time.
If you cancel a PRN staff member for a 12 hour shift how much PTO are you requesting on their behalf?
NONE they are PRN
Once a patient has been sent to the ER who should be called?
The ER and the Patients family.
How often must the count be performed on the Omnicell?
At the end of every shift.
Before administering blood what must be present in the chart?
Signed Consent and Type and Cross
(If patient has not received blood in SMMC system they will need TWO pink tubes sent!)
A patient has a fall during your shift. What tasks must be completed between you and the nurse caring for the patient?
1. Incident Report
2. Post Fall Evaluation
3. Doc Halo
4. Update Care Plan
5. Notify family
When cancelling staff what is the order in which it is done?
1. Overtime
2. PRN
3. Requests
4. Full time
Before sending a patient out who must be notified of the patient's declining status?
PM&R
Internal Medicine
Nursing Management
A nurse fails to document a narcotic on their previous shift and comes to you for assistance in fixing their documentation. Where are the two places they can document to resolve their error?
The MAR
Nursing Narrative Note
If you were to hang blood at 1200 what would be the next 3 times you would be checking vitals?
1215
1300
1400
You are informed that a patient has an appointment scheduled during their stay that they are insistent they go to. What should you do with this information?
Send a Doc Halo to PM&R, (Kokroo if relevant), Nursing management, Unit Clerks.
A nurse comes to you at 0630 and reports that they have a family emergency at 2pm and will be leaving. What would you do?
Tell the nurse that we do not schedule family emergencies. If they need to leave at 2pm they can find coverage for their assignment or they will be abandoning their patients. If they proceed to leave at 2pm you are to tell them at minimum they are being written up and then inform Nursing Managment.
A nurse calls you reporting concern over their patient. What is the very first thing you would do?
Go assess the patient.
If a patient brings in a patient own Narcotic what steps must be taken before administering to the patient?
Medication form must be filled out and signed by 2 nurses and patient/representative
Number of pills must be counted.
Medication given to pharmacy to verify. (Two RNs can verify medication if overnight and urgent need, pipeline can also verify over the phone)
Medication stored in safe on unit until properly loaded into Omnicell.
When should the RNs be updating the care plan?
On admission
Weekly with conference
After new diagnoses or incident (Fall, fx, aspiration, dvt...)
On Discharge
What are two examples of things that LPN's cannot do that RNs can.
Administer Blood
Admission Assessment
Supervise
Update Care Plan
Give report to an LPN (Unless RN to verify all assessments performed.)
At the end of your shift how must you communicate staffing with Nurse Management?
Send an email with staffing sheet and listing and call outs and cancellations
Once a patient is sent out and admitted what must be done with patients room?
Belongings packed and housekeeping notified of dirty room
A nurse calls you and tells you their patient refused their scheduled gabapentin. What must you ensure is done with the gabapentin?
If opened it must be wasted in the Omnicell. If closed it must be returned to the omnicell.