Assessment
At every clinic visit and inpatient admission, nursing staff ask the patient if he/she is depressed or has thoughts or plans for death.
What is a Suicide Assessment? NPSG 15.01.01
The first language a person learned as a child.
What is primary language? PC.02.01.21 EP1
An aggressive patient needs a extra large dose of Thorazine to control his/her very aggressive physical activity. The patient immediately is under staff's protective watch and "quiets" down. The medication used in this way is classified as ....
What is a Chemical Restraint? CMS 482.13 (e)(1)(i)(B) PC-77HAM Restraint and Seclusion: Non-Violent, Non-Self Destructive Behavior and Violent or Self-Destructive Beh.
The Medical Assistant has patient information that the provider needs to know, but the provider is not in the office. This is how the MA should securely and electronically contact this provider.
What is emessaging?
Length of time our HMC organization retains patient's records.
What is forever?
Every 4 hours, the in-patient RN assesses each patient for current pain level. The Medical Group Practice staff member who "rooms" a patient, asks if the patient has any pain, level 0-10, and pain location.
What is Pain Assessment? PC.01.02.07
An inpatient's plan is reviewed by the nurse at least every 24 hours for meeting healthcare needs/goals. Specific content and goals are added to provide care appropriate to the specific needs of that particular patient.
What is "Individualized" Plan of Care? PC.01.03.01 EP1
A family member is frequently abusive to staff taking care of her mother. Care is frequently interrupted by the family member and is very difficult to complete. Talking to the family member has not changed behaviors. This is the next step the manager can take to try to decrease the family member's interference with needed care.
What is a Behavioral Management Contract? PC 85 HAM Disruptive Patients PC-92 HAM Disruptive Family Members
A person appointed by the patient to decide health care options when the patient is unable to do so (aka Health Care Agent).
What is a Health Care Power of Attorney? Informed Consent Policy L-07 HAM
A document which states what health care decisions the patient would choose to have if able (feeding tube, placement on a ventilator, etc.)
What is Advance Directive/Living Will? Policy PC-13 HAM Guide to Advance Directives
A child has odd bruises or patterns on his/her back. This patient seems withdrawn and doesn't speak much.
What is an assessment for abuse or neglect? PC.01.02.09 EP 1
An IV arm board, mitts not tied down to the bed, head helmet, and all bed side rails up in PACU.
What are items not considered to be restraints? CMS 482.13(e) (1) (i) (C)
During shift changes, transfer to another nursing unit and transporting a patient to a testing location, patient care information is given from one staff member to another staff member.
What is Hand-Off Communication between care team members?
The provider, first year Resident, Nutritionist, and Pharmacist are rounding in MICU. This rounding group represents this.
What is Interdisciplinary Care Team? PC.02.01.05 EP 1
Say hello/state your name and role; Explain what you will be doing and the time it will take; Ask for questions, Achieve understanding; and Thank & close
What is S E A T Communication Model?
One hour after an oral pain medication or 30 minutes after an intravenous medication is given, the nurse does this to ensure adequate pain control.
What is Pain Reassessment? PC.01.02.07
A patient is interviewed and you determine his/her native language is not English. When asked which language he/she prefers to receive any healthcare information, he/she replies that English is well understood.
What is Preferred Healthcare Language? PC.02.01.21 EP1
A patient with a terminal illness decides to discontinue his dialysis treatments and discusses this desire with his care team. This type of consult should be ordered by the provider?
What is palliative care consult? PC.02.02.13 EP1, 2
The lab tech calls the RN with a critical lab value. The RN follows this process to assure the information was correctly understood.
What is Validate and Verify? CMS 482.23(c)(3)(i) Verbal Orders Verification
The type of consent that can be used to give blood to a patient who needs transfused for a specific procedure.
What is the surgical/procedural consent.
Information on a patient's cultural and religious beliefs, emotional barriers, desire and motivation to learn, physical or cognitive limitations, and barriers to communication are obtained during this.
What is a learning needs assessment? PC.02.03.01 EP1
Patient's care, treatment, and services are based on identified patient needs determined through assessment, reassessment and test results.
What is the patient's written plan of care? PC.01.03.01
The cardiac monitor keeps beeping every few minutes for low oxygen levels. The oxygen limits are set at default high and low settings. The patient is fine, but he/she is playing on a computer and moving his/her fingers a lot.
What is Clinical Alarm Management? NPSG 06.01.01
Based on the patient's assessed home care needs,the Social Worker, provider, physical therapy, the patient and family members work to develop the discharge plans/care.
What is Discharge or Transitions of Care Plans ? PC.02.02.01
The pieces that must be included in all documentation to make it an authenticated part of the medical record.
**For example, should these pieces must be included on Informed surgery/procedural consents, Time out for procedures, office notes, outside test results, History & Physical exams from primary providers
What is date, legible signature of author and time documented?