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perioperative health care information management Questions and Answers 100% Solved
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perioperative health care information management
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perioperative health care informationmanagement
What information does the documentation in the patient's health care record include? -
answer current and past health status, nursing diagnoses and interventions, expected
patient outcomes, and evaluation of the patient's response.
Repeated patient care and electronic documentation can become a nursing cognitive
disruption. What are some things you can do to work efficiently and timely in this multi-
task process? - answer By simplifying processes, standardizing and organizing data
capture.
What is PNDS? - answer A controlled, structured, and coded nursing language that
describes perioperative nursing's influence in the effectiveness and safety of patient
care deliver, and the contributions of perioperative nursing toward patient outcomes.
What are the phases of the perioperative patient care continuum? - answer
preadmission, preoperative, intraoperative, postoperative
As a perioperative nurse, what should you be familiar with about the structured
vocabularies in your clinical documentation? - answer The value that structured
terminology brings to clinical documentation, the conceptual framework of the PNDS,
the contributions of the PNDS to perioperative nursing practice and patient outcomes
and how standardized documentation facilities benchmarks, comparative analysis, and
efficiency reporting.
What are included in the patient care orders in the perioperative documentation? -
answerorders for interventions (must be entered as close to the time when the order is
communicated), verbal orders, standing orders, orders on surgeon preference cards,
and order sets. All must be dated, timed, and authenticated by the ordering health care
practitioner.
The standards of nursing practice require that documentation is base on which of the
following? - answerPatients's condition or need and the relationship of the condition or
need to the proposed intervention.
What does a properly executed informed consent include? - answerName of the health
care facility providing the surgery, specific name of the intervention, indications of the
proposed intervention, name of the responsible health care provider performing the
intervention, statement identifying the risks and benefits associated with the proposed
intervention and indication that a discussion took place with the patient or patient
, representative, signature of the patient or patient's representative, date and time the
patient or patients representative signed the informed consent document, date and time
and signature of the witness signing the informed consent document, signature of the
responsible health care provider who discussed the informed consent document with
the content or the patient's legal representative.
Important guidelines to remember that you make nursing diagnoses and not medical
diagnosis or conclusions - answeryou are a nurse who has sound nursing judgment but
not a physician, your description should be free from bias, when patient makes a
statement make a statement do not make it appear as a statement of fact (instead write,
"Patient stated that...), use the patients statement to verify your findings but write it
accordingly, document significant changes in a timely manner, document any patient
education as well as all discharge instructions, be a patient advocate, document any
communication with the patient
important guidelines about not postdating info - answerDon't add info after the fact,
forensics lab are able to test the ink and tell if something was altered,
True or false? - answerThe Privacy Rule, a Federal law, gives an individual rights over
their health information and sets rules and limits on who can look at and receive
individual's health information.
components of perioperative documentation includes - answerPatient indentification,
patient assessment, patient history, verification of surgical procedure, informed consent,
perioperative orders, development of a plan of care
Patient assessment info should be recorded in the chart. this information should include
- answerrisk of hypothermia, DVT, difficult airway, surgical site infection, order of
antibiotic prophylaxis, perioperative visits by the surgeon and anesthesia care provider,
assessments of any cuts, bruises, skin problems in close proximity to the surgical site,
and, if warranted, addressing these with the anesthesia care professional and or the
surgeon, skin prep and hair removal, verbal consent for any preoperative procedure
performed on the patient (includes IV), the need for any special precautions like
airborne and isolation.
history and physical info as well as any test results are reviewed. the preoperative nurse
should include - answernote abnormalities in any lab or radiology results like CBC, PT,
PTT, EKG, chest x-rays and U/A. allergies/sensitivities, and implants, prostheses, or
piercing's. discuss discharge plans, complete a medication profile, note patient's
nutritional status, discuss cultural consideration, ask for reactions to anesthesia, secure
personal items.
preoperative order should be recorded and includes - answerorders for meds, labs, skin
prep, catheter placement, orders for NPO (nothing by mouth), administration of any
meds, dose, time and route
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