Effective Communication
-essential to the coordination and continuity of care
-enables personnel to support and compliment one another's services
-avoid duplications and omissions of care
Purposes of Documentation
-communication
-planning client care
-quality assuranc...
NSC 232 FINAL EKU QUESTIONS AND
ANSWERS 2024/2025
Effective Communication
-essential to the coordination and continuity of care
-enables personnel to support and compliment one another's services
-avoid duplications and omissions of care
-complete, accurate, concise, factual
-reflecting nursing process
-record observations, not interpretation
-terminology
-sequencing
-include safety precautions
-medical visits, consultations
-document nursing response to questionable medical orders
-avoid use of stereotypes or derogatory terms
Documentation Guidelines: Timing
-timely
-include date and time
-24 hour clock
-do not document before carrying out
Documentation Guidelines: Format
-correct chart
-appropriate form
-write legibly
-use standard terminology
-date and time each entry
-chart interventions chronologically
-use consecutive lines, do not skip lines
Documentation Guidelines: Accountability
-sign first name, last name, title to each entry
-do not use dittos, erasers, correcting fluids, etc.
-identify each page record
-record is permanent
-admission notes
-change of shift notes
-assessment notes
-interval or progress notes
-transfer and discharge notes
-client teaching notes
What is Documented??
-descriptions of observations
-symptoms and complaints
-dressings,tubes, or attached devices
-medications and treatments
-observations of psychosocial status
-activities of daily living
-valuable
-spiritual care
-safety concerns
-narrative charting
-focus charting
-charting by exception (CBE)
-problem oriented medical record (POMR)
-PIE
-flow sheets
-graphic records
-clinical pathways (care maps)
POMR
subjective, objective, assessment, plan
Vital Signs
-temperature
-pulse
-respiratory
-blood pressure
-(pain is referred to as the 5th vital sign)
When to Assess Vital Signs
-upon admission
-change in clients health status
-client reports symptoms such as pain, feeling hot, or faint
-pre and post surgery/invasive procedure
-pre and post medication administration that could affect the cardiovascular system
-pre and post nursing intervention that could affect vital signs
Thermometers
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