What’s up Doc (u-workload)
You document on the wrong patient, what do you do next?
Correct the error by voiding the original entry, leaving it visible (crossed off), and document on the correct patient
A nurse meets the Communication Standard by ensuring that documentation is a complete record of nursing care provided and reflects all aspects of the nursing process. Name each aspect of the nursing process.
Assessment, Planning, Intervention and Evaluation
SBAR is a corporate communication structure. What does the acronym SBAR stand for?
Situation, Background, Assessment, Recommendation
A nurse practicing telepractice records notes on client information on a telephone log. After the telephone interaction, the nurse enters information into the client’s permanent health record. What should a Odette nurse do with the telephone logs?
Return to the log binder. This will ensure that it is destroyed in a secure way.
While documenting you inadvertently select Bleeding on your first Symptom Type drop down. How will you clear this incorrect entry?
Click on it so there is a dotted line around the box then press control + delete and the field will clear
A nurse that documents in a timely manner is meeting which Practice Principle of the CNO Documentation Standard.
Accountability
Seeking and embedding the voice of the patient subjectively is how we provide care using this approach
Person Centred Care
Personal Health Information Protection Act
This keyboard key will allow you to move between fields without needing to use the mouse
Tab
Documenting both subjective and objective data is meeting which Practice Principle of the CNO Documentation Standard.
Communication
Documenting the patient’s vital signs is communicating _______ data
Objective
Nurses safeguard client health information by maintaining which of the following:
a. advocacy, b. confidentiality, c. informed consent.
Confidentiality
Control C and Control V will allow you to do this function to relevant components of your email into your Telephone Patient Care record
Copy and Paste
Providing a full signature or initials and professional designation with all documentation is meeting which Practice Principle of the CNO Documentation standard.
Communication
Documenting that you have removed staples is reflective of what phase of the nursing process?
Intervention
Personal health information belongs to who?
The client! it is simply being housed in health care facilities. Clients have the right to give, refuse, or withdraw their consent to the collection, use and disclosure of their personal health information
If direct care is provided, why is it important to include documenting the date and time of the interaction?
It is a CNO standard
Accessing only information for which the nurse has professional need to provide care is meeting which Practice Principle of the CNO Documentation Standard.
Security
Documenting the “patient states his pain has decreased to a 3 on a scale from 0 to 10 after taking dilaudid” is reflective of what phase of the nursing process?
Evaluation
Why is it important to ensure that patient information is not visible in public areas (e.g. leaving a computer screen unattended with a patient's care record open)
Potential breech of privacy