Assess the Mess
This SBAR step includes suggestions for next steps such as physician orders, procedures, goals of care, or patient education needs.
What is the Recommendation?
The failure to prevent a patient death resulting from complications of medical care or underlying illness.
What is failure to rescue?
The four major purposes of nursing documentation include communication, continuity of care, accountability, and this legal function.
What is a legal record?
Repeated, unwanted harmful actions intended to humiliate, offend and cause distress in the recipient.
What is incivility?
This type of communication uses body language, facial expressions, posture, gestures, and touch to send messages without words.
What is nonverbal communication?
This SBAR component includes information such as admitting diagnosis, recent medical history, medications, allergies, and lab results.
What is the Background?
This prioritization method focuses on airway, breathing, circulation, disability, and exposure.
What is the ABCDE method?
This federal law protects patient privacy and gives patients the right to view and obtain a copy of their medical record.
What is HIPAA (Health Insurance Portability and Accountability Act)?
This ANA document states that nurses must practice with compassion and respect for the inherent dignity, worth, and uniqueness of every individual.
What is the American Nurses Association Code of Ethics?
When verbal and nonverbal messages do not match, this term is used to describe the inconsistency.
What is noncongruent communication?
The part of SBAR where the nurse briefly explains who they are, identifies the patient, and states the immediate problem.
What is the Situation?
A framework that states physiological needs must be met before higher-level psychological or self-fulfillment needs.
What is Maslow’s Hierarchy of Needs?
A report used to document unusual events such as patient falls, medication errors, or visitor injuries that is not part of the patient’s medical record.
What is an incident report (variance report)?
According to the lecture, this is the top priority that uncivil behavior directly threatens in the clinical setting.
What is patient safety?
This assertive communication tool stands for Describe, Explain, State, and Consequences.
What is DESC?
In SBAR communication, this step involves the nurse’s professional opinion about what is happening with the patient based on the available evidence.
What is the Assessment?
A prioritization system that categorizes tasks as critical, urgent, routine, or extras.
What is the CURE hierarchy?
A documentation system where each member of the healthcare team records notes separately in their own section.
What is source-oriented charting?
This phrase describes the pervasive problem of nurse-on-nurse bullying in the workplace.
What is “eating your own”? or What is "nursing eating their young"?
This listening skill is considered a “pillar in nursing” and involves using all senses to interpret both verbal and nonverbal cues.
What is active listening?
A structured communication method used by healthcare providers to quickly and clearly share important patient information.
What is SBAR?
A prioritization trap where a nurse responds to whoever complains the loudest rather than addressing the most critical need.
What is the squeaky wheel trap?
This type of charting tells the story of the patient’s hospital experience in chronological order from admission through discharge.
What is narrative charting?
This Collin College agreement defines civility as behavior that shows respect, makes others feel valued, and promotes effective communication and team collaboration.
What is the Civility Contract?
According to the lecture, nurses cannot use children or family members for this service when a patient has Limited English Proficiency.
What are translation and interpretation services?