Medical Record Documentation
Within 24 hours of admission
When is completed psychiatric evaluation and H&P due to be completed?
Twice daily (morning and evening)
How often are patient vitals taken?
30 Minutes
The corridors and hallways need to be clear of cludder. Nothing is to be left in the hallways for more than____
Two nurses must sign off that they verify medication is being administered, as ordered
When administering a high-risk medication such as insulin?
Do not over-speak (if you are not asked) or mis-speak (if you do not know the answer).
How to answer surveyors?
Twice in an 8hr. shift (approx. every 4 hours) conduct and record a set of rounds, and validate other rounds were completed as expected
What is nurse documentation of patient observation rounds oversight?
Handwashing
Primary way to reduce risk of health-care associated infections.
R-Remove/Rescue A-Alarm C-Confine E-Evacuate/Extinguish
What does the acronym R.A.C.E stand for?
Scan patient ID, scan medication label, verify 5 Rs, and document in MAR
Steps to administering medication?
Patients, doctors, nurses, social workers, MHTs, housekeeping, kitchen staff, etc.
Who might a JC surveyor interview or ask questions?
If high risk for suicide and not on 1:1 level of observation
What is a detailed rationale for why patient at high risk for suicide is considered safe without 1:1 level of observation?
When assigned 1:1 and when off unit with patient/s.
When should staff have a walkie on their person?
PASS - P- Pull pin A-Aim nozzle at base of fire, S-Squeeze handle, S-Sweep nozzle from side to side
What does the PASS acronym stand for?
Record date opened on the vile
What to do after opening insulin multi-dose vile?
Do what you would do normally, ask your manager or co-worker for assistance in finding the information.
If unable to locate something in a patient’s EMR during a survey, what should you do?
Written description of investigation and any actions taken.
What patient is provided in response to a grievance?
Wearing yellow wrist band
How to know if someone is on fall precautions?
Describe pain, non-pharm alternatives offered, and response to medication
What to document when administering medication for pain?
Every 3 years
What is frequency of Joint Commission triennial survey?
Behavior, Intervention, Response, and Plan
What is BIRP progress note?
Remain on 1:1 until search can be completed
What to do if patient is uncooperative with search?
Photo, Name (DOB if missing photo)
What two identifiers are used to identify a patient before medication administration?