Questions and Answers
What does WDL stand for in nursing documentation?
What is Charting by Exception (CBE)?
The philosophy that the patient meets all standards unless otherwise documented.
The nurse writes a progress note when a patient's condition meets the standard normal criteria.
False
Telephone orders occur when a healthcare provider gives therapeutic orders over the ______ to a registered nurse.
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What is the purpose of an incidence or occurrence report?
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What is SBAR used for in nursing communication?
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Which of the following is NOT a common record-keeping form?
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Nurses should include references to incident reports in the patient's medical record.
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What is the Nursing Process?
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Which of the following phases are part of the Nursing Process? (Select all that apply)
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What is the purpose of the assessment phase in the Nursing Process?
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Define objective data in nursing assessment.
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What is subjective data?
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What does the acronym SMART stand for in the context of care planning?
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What defines a nursing diagnosis?
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Differentiate between nursing diagnosis and medical diagnosis.
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What does the term 'clinical judgment' refer to?
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What are the principles of critical thinking in nursing? (Select all that apply)
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What are the three columns used in Focus Charting?
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What does POMR stand for?
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The client's record is not considered a legal document.
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What is the significance of documentation in nursing?
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What are the legal implications of poor documentation?
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What should documentation be? (Select all that apply)
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Study Notes
What is the Nursing Process
- Systematic, critical thinking framework used by nurses for patient care.
- Involves problem-solving to identify and treat patient health issues.
- Emphasizes individualized, client-centered care and collaboration with patients.
Phases of the Nursing Process
- Assessment: Collect data to establish baseline and identify health concerns.
- Diagnosis: Analyze collected data to identify strengths, problems, and nursing diagnoses.
- Planning: Develop individualized care plans with SMART goals.
- Implementation: Execute nursing interventions and document results.
- Evaluation: Assess the effectiveness of interventions and modify care plans as needed.
Types of Data
- Objective Data: Measurable information (e.g., BP 120/75).
- Subjective Data: Patient-reported symptoms (e.g., "My pain is 10/10").
- Primary Data: Information collected directly from the patient.
- Secondary Data: Information from other sources (e.g., medical records, reports).
Data Collection & Validation
- Importance of validating data for accurate analysis and interpretation.
- Cues: Information through sensory observation (subjective or objective).
- Inferences: Nurse's interpretation of cues (e.g., linking diaphoretic state to pain).
Concept Mapping
- Visual tool to connect client issues and problems.
- Enhances critical thinking and understanding in nursing assessments.
Nursing Diagnosis/Problem Statements
- Derived from clinical reasoning and data analysis.
- Nursing diagnoses can be classified as actual or risks, focusing on patient-centered concerns.
Writing a Nursing Diagnosis (NANDA Format)
- P: Problem statement.
- E: Etiology (causes of the problem).
- S: Signs/symptoms.
Critical Thinking
- Involves judgment and problem-solving in patient care.
- Requires systematic, reflective, reasonable, and evidence-based decision-making.
Characteristics of a Critical Thinker
- Curiosity: Desire to understand deeper concepts.
- Systematic Thinking: Organized approach to problems.
- Open-Mindedness: Willingness to consider alternatives.
- Self-Confidence: Assurance in decision-making.
- Truth-Seeking: Passion for knowledge and inquiry.
Clinical Judgment
- Application of knowledge and experience to make informed decisions about patient care.
- Involves synthesizing data from various sources to guide treatment plans.
Ways of Knowing in Nursing
- Empirical: Objective knowledge based on evidence.
- Aesthetic: Use of creativity and intuition in care.
- Ethical: Guided by professional values and standards.
- Personal: Knowledge from personal interactions and relationships.
Planning in the Nursing Process
- Identify urgency and prioritize problems based on patient needs.
- Use Maslow's hierarchy of needs for determining priorities.
Implementation
- Execute the individualized care plan with appropriate interventions.
- Assessment of patient culture, values, and goals is crucial during implementation.
Evaluation
- Continuous assessment of the nursing process.
- Collaborate with patients to evaluate the success of interventions.
Documentation
- Crucial for documenting nursing care and patient progress.
- Provides a legal record and ensures continuity of care.
Ethical and Legal Implications
- Compliance with codes of ethics and guidelines for documentation.
- Documentation serves as a legal record and can be used in future court cases.
Methods of Documentation
- Various formats include narrative, problem-oriented, and focus charting.
- Each method serves specific organizational and communication needs.
Incident Reporting
- Documenting non-routine events such as adverse patient occurrences.
- Objective descriptions aid in quality improvement without including them in patient records.
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Description
Explore various nursing charting methods, including their advantages and disadvantages. This quiz focuses on the principles of Charting by Exception (CBE) and how it impacts patient care documentation. Learn the nuances of effective nursing records management.