Legal/Policy
If it wasn't documented, it wasn't this
Done
The process where a nurse transfers responsibility for specific tasks to another qualified healthcare professional
Delegation
Changes in HR, RR, SBP, 02 sat and oxygen needs, mental status changes
Reportable Values
This should be done when the PCA notices there is no output from the drain.
Document zero and notify the nurse per delegation.
making eye contact, paying attention, and asking questions are examples of ...
Active listening
Copy and pasting documentation
What is not permissible per policy
PCAs can go through disciplinary action through the State Board for Nurses (potential loss of CNA certification) by documenting this.
Fraud or deceitful documentation, record, and health documents.
Ensures messages are understood by verbal feedback and confirmation from both the sender and the receive.
Closed loop communication
An accurate and legal record of patient care, ensuring continuity of care among health care providers, and protecting legal rights of the patient and caregiver.
The purpose of documentation
According to governing regulatory bodies and banner Policy, record of treatments and response to treatment must be documented during this time.
As soon as possible after the occurrence.
A supportive and respectful environment where team members feel valued and work together to achieve success.
Mutual Respect and Trust
Includes but is not limited to VS, I &0, bowel and bladder habits, food, and fluid consumption, patient mobility, and repositioning, observations and care provided (bathing, grooming, feeding etc).
Information a PCA should document
The PCA documents oral intake before the patient drink anything.
Deceit or false documentation
Improved patient outcomes, increased efficiency, enhanced staff moral and retention and improved patient safety.
The benefits of teamwork
Provides scope and standards of practice and care guidelines
Wyoming State board of Nursing and Banner Policy