Podcast
Questions and Answers
Which action should be taken when documenting patient information according to HIPAA regulations?
Which action should be taken when documenting patient information according to HIPAA regulations?
- Avoid documenting sensitive information
- Secure electronic records and limit access (correct)
- Use patient names freely in public areas
- Include personal opinions about patient behavior
Which of the following should be included in a change-of-shift report?
Which of the following should be included in a change-of-shift report?
- Complete patient medical history
- Family's opinion on care
- Patient's current status and plan of care (correct)
- Any changes or updates in the patient's condition (correct)
What does the SBAR communication tool stand for?
What does the SBAR communication tool stand for?
- Situation, Background, Analysis, Recommendation
- Systematic, Brief, Analysis, Reporting
- Symptoms, Background, Assessment, Response
- Situation, Background, Assessment, Recommendation (correct)
Which statement is true regarding ISBARR?
Which statement is true regarding ISBARR?
What is the most appropriate action a nurse should take if they realize they made an error in documentation?
What is the most appropriate action a nurse should take if they realize they made an error in documentation?
What is the nurse's most appropriate response when a family member asks to view the electronic health record (EHR)?
What is the nurse's most appropriate response when a family member asks to view the electronic health record (EHR)?
Which of the following statements about unauthorized abbreviations in documentation is true?
Which of the following statements about unauthorized abbreviations in documentation is true?
Which of the following considerations are appropriate uses of technology in documenting client information?
Which of the following considerations are appropriate uses of technology in documenting client information?
Which type of bath is most appropriate for patients with mobility limitations who wish to bathe independently?
Which type of bath is most appropriate for patients with mobility limitations who wish to bathe independently?
Is it true that oral care for a patient with a nasogastric (NG) tube can be performed only once daily?
Is it true that oral care for a patient with a nasogastric (NG) tube can be performed only once daily?
What precaution should be taken when providing hygiene care for a patient with an oxygen mask?
What precaution should be taken when providing hygiene care for a patient with an oxygen mask?
What is the best approach for a nurse giving a bed bath to a culturally modest patient?
What is the best approach for a nurse giving a bed bath to a culturally modest patient?
Which description accurately defines a closed bed?
Which description accurately defines a closed bed?
Which action demonstrates correct procedure when making an occupied bed?
Which action demonstrates correct procedure when making an occupied bed?
What should a nurse consider before providing foot care to a patient with calluses?
What should a nurse consider before providing foot care to a patient with calluses?
When providing eye care for a comatose patient, which of the following is a proper action?
When providing eye care for a comatose patient, which of the following is a proper action?
What is the best way a nurse can support a patient with impaired mobility in performing personal hygiene?
What is the best way a nurse can support a patient with impaired mobility in performing personal hygiene?
Which hygiene intervention is appropriate for a patient with sensory deficits?
Which hygiene intervention is appropriate for a patient with sensory deficits?
What should a nurse do regarding a patient's decision to wear dentures at night?
What should a nurse do regarding a patient's decision to wear dentures at night?
When teaching about personal hygiene practices, which of the following should be included?
When teaching about personal hygiene practices, which of the following should be included?
What is the correct approach to performing a back rub on a frail elderly patient?
What is the correct approach to performing a back rub on a frail elderly patient?
Which statement is true regarding the care of patients with dentures?
Which statement is true regarding the care of patients with dentures?
Which hygiene intervention should a nurse NOT assume when caring for patients with sensory deficits?
Which hygiene intervention should a nurse NOT assume when caring for patients with sensory deficits?
Which practice is considered effective when communicating with a sensory-impaired patient?
Which practice is considered effective when communicating with a sensory-impaired patient?
Which factor would facilitate learning for a patient?
Which factor would facilitate learning for a patient?
What is a common principle of effective teaching that a nurse should follow?
What is a common principle of effective teaching that a nurse should follow?
Which characteristic is essential for a good learning environment?
Which characteristic is essential for a good learning environment?
The affective domain of learning primarily involves which of the following?
The affective domain of learning primarily involves which of the following?
When educating a patient from a different cultural background, what should a nurse do?
When educating a patient from a different cultural background, what should a nurse do?
Which domain of learning is primarily addressed when a nurse demonstrates insulin injection techniques?
Which domain of learning is primarily addressed when a nurse demonstrates insulin injection techniques?
Which nursing intervention can improve patient compliance with their care plan?
Which nursing intervention can improve patient compliance with their care plan?
True or False: The nursing process and the teaching-learning process share similar steps including assessment, planning, intervention, and evaluation.
True or False: The nursing process and the teaching-learning process share similar steps including assessment, planning, intervention, and evaluation.
What best describes surgical asepsis?
What best describes surgical asepsis?
Is it true that surgical asepsis is necessary for any procedure that involves contact with mucous membranes?
Is it true that surgical asepsis is necessary for any procedure that involves contact with mucous membranes?
What is the correct order of the infection cycle?
What is the correct order of the infection cycle?
Which organism is known for being resistant to methicillin and often associated with healthcare-acquired infections?
Which organism is known for being resistant to methicillin and often associated with healthcare-acquired infections?
Which of the following are considered standard precautions to prevent infection?
Which of the following are considered standard precautions to prevent infection?
Are redness, swelling, and warmth at the site indicative of local signs of infection?
Are redness, swelling, and warmth at the site indicative of local signs of infection?
What is the primary nursing action to differentiate between a local and systemic infection in a patient with high fever and elevated WBC count?
What is the primary nursing action to differentiate between a local and systemic infection in a patient with high fever and elevated WBC count?
What best describes droplet precautions?
What best describes droplet precautions?
What is the role of narrative documentation in electronic health records (EHR)?
What is the role of narrative documentation in electronic health records (EHR)?
What does the acronym SBAR stand for in patient communication?
What does the acronym SBAR stand for in patient communication?
Which of the following practices can enhance documentation accuracy?
Which of the following practices can enhance documentation accuracy?
How does technology impact the accuracy of documentation in nursing?
How does technology impact the accuracy of documentation in nursing?
What is the significance of HIPAA in the context of electronic health records?
What is the significance of HIPAA in the context of electronic health records?
Which statement best describes the documentation responsibilities in nursing?
Which statement best describes the documentation responsibilities in nursing?
In what situation is it appropriate to share patient updates on social media?
In what situation is it appropriate to share patient updates on social media?
What does the abbreviation BID signify in medical documentation?
What does the abbreviation BID signify in medical documentation?
Flashcards
HIPAA Documentation
HIPAA Documentation
HIPAA regulations require protecting patient information by securing electronic records and limiting access, avoiding sensitive information, and avoiding using patient names in public areas.
Change-of-shift report
Change-of-shift report
Includes patient status, plan of care, and recent changes in the patient's condition. It excludes complete medical history and opinions of family members.
SBAR
SBAR
A communication tool in healthcare: Situation, Background, Assessment, Recommendation
Correcting Documentation Errors
Correcting Documentation Errors
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Unauthorized Abbreviations
Unauthorized Abbreviations
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EHR Access
EHR Access
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Technology in Documentation
Technology in Documentation
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ISBARR
ISBARR
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EHR Documentation
EHR Documentation
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Accuracy of Documentation
Accuracy of Documentation
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Narrative Documentation
Narrative Documentation
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HIPAA Compliance
HIPAA Compliance
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Shift Report
Shift Report
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Correcting Errors
Correcting Errors
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Normal Adult Resting Pulse Rate
Normal Adult Resting Pulse Rate
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Surgical Asepsis
Surgical Asepsis
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Infection Cycle: Order
Infection Cycle: Order
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MRSA
MRSA
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Standard Precautions
Standard Precautions
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Local Infection Signs
Local Infection Signs
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Systemic Infection Indicator
Systemic Infection Indicator
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Droplet Precautions
Droplet Precautions
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Culture and Sensitivity
Culture and Sensitivity
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Best bath for limited mobility
Best bath for limited mobility
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Oral care with NG tube
Oral care with NG tube
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Oxygen mask hygiene
Oxygen mask hygiene
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Bed bath for modesty
Bed bath for modesty
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Closed bed
Closed bed
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Occupied bed procedure
Occupied bed procedure
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Perineal care
Perineal care
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Foot care for diabetic patients
Foot care for diabetic patients
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Eye Cleansing
Eye Cleansing
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Supporting Impaired Mobility
Supporting Impaired Mobility
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Hygiene for Sensory Deficits
Hygiene for Sensory Deficits
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Back Rub for Frail Elderly
Back Rub for Frail Elderly
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Dentures at Night
Dentures at Night
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Home Hygiene Teaching
Home Hygiene Teaching
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Denture Care
Denture Care
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Foot Lotion
Foot Lotion
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Learning Environment Factor
Learning Environment Factor
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Nursing & Teaching Processes
Nursing & Teaching Processes
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Effective Teaching Principles
Effective Teaching Principles
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Good Learning Environment
Good Learning Environment
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Affective Domain of Learning
Affective Domain of Learning
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Teaching Patients with Cultural Beliefs
Teaching Patients with Cultural Beliefs
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Effective Teaching Principle
Effective Teaching Principle
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Psychomotor Learning
Psychomotor Learning
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Study Notes
Final Exam Al Practice Questions
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Ethical/Legal Practice Exam:Â Unit 1
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Mission Statement of PRCC ADN: To provide innovative, patient-centered care and prepare students for professional nursing practice with a strong foundation in ethics.
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Accrediting bodies recognized: The Joint Commission, Accreditation Commission for Education in Nursing (ACEN), American Nurses Credentialing Center (ANCC), Centers for Medicare & Medicaid Services (CMS)
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Purpose of the American Nurses Association (ANA) Code of Ethics for Nurses: To provide nurses with ethical guidelines to support ethical decision-making.
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Ethical conflicts in healthcare: Can arise from differing values among healthcare professionals.
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Ethical decision-making when confronted with dilemmas of patient autonomy versus beneficence: Consulting hospital ethics committees, considering patient values, and discussing options with the healthcare team are critical elements.
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Actions that can lead to suspension or revocation of a nursing license in Mississippi according to the Nurse Practice Act: Administering prescribed medication without documenting the dose.
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Other actions that could lead to violations of patient rights: Documenting patient information inaccurately, violating patient confidentiality, and taking a day off without prior notice.
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Scope and Standards of Practice: Establish guidelines for professional accountability and quality of nursing care.
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Intentional vs. unintentional torts: Intentional torts are deliberate actions causing harm—unintentional torts are accidents causing harm.
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Malpractice: A nurse ignores patient requests for assistance, causing a fall; a nurse misses vital signs due to a computer malfunction.
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HIPAA Regulations: Govern the confidentiality of all Protected Health Information (PHI).
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Good Samaritan Act: Provides legal protection in emergency situations outside of a hospital.
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Essential elements for carrying out healthcare providers' orders: Checking order for completeness and clarity; consulting a senior nurse; ensuring the order is appropriate for the patient; documenting actions.
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Informed consent: Nurses are responsible for obtaining it from patients before surgical procedures.
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Incident report: Include objective information about the incident and share with the healthcare team. Do not include it in the patient's chart
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Essential elements for carrying out healthcare providers' orders: Checking orders for completeness, consulting a senior nurse, ensuring the order is appropriate for the patient, documenting all actions.
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Medical documentation: Accurate records are crucial to meet legal standards and reduce liability. Types of documentation include narrative, source oriented, charting by exception, and verbal communication.
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**Electronic health records (EHR):**Benefits include enhanced data security, reduction in errors, and immediate access to patient information.
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Abbreviations: Familiarize yourself with common abbreviations used in documentation. BID, QD, PRN, TID.
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Documentation vs. reimbursement: Accurate documentation directly affects reimbursement of services, which may explain some documentation guidelines.
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JCAHO (now ACHC): Standards require healthcare documentation to be complete, accurate, and timely
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HIPAA Regulations: Immediate access to patient information is not always permissible
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Communication/Teamwork Practice Exam: Effective communication is crucial for patient outcomes and team coordination in nursing.
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Therapeutic communication: Includes Orientation, working, and termination phases (or Establishment, interaction, and evaluation); consider the patient's feelings and experiences. Avoid offering advice or personal opinions when discussing the patient's concerns, using silence is not a good strategy.
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Ethical communication: Involves self-reflection, collaboration with interdisciplinary teams, and patient's family input. Relying on ethical guidelines can support ethical decision-making.
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Unprofessional behavior: Avoiding sharing patient information with unauthorized personnel, provide constructive feedback during team meetings, and engaging in appropriate delegation are key characteristics of professional behavior.
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Assertiveness: Expressing your needs and opinions respectfully without aggression. It is a crucial skill in health care.
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