Summary
Summary Nur 1020C Exam 2 Study Guide
- Course
- NUR 1020C
- Institution
- Florida State College At Jacksonville
This is a comprehensive and detailed study guide on Exam 2 for Nur 1020C. *Essential Study Material!!
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Exam 2 Study GuideModule 3 Lecture 1
1. Describe the scope and categories of professional communication. (SLOs 3,4,6)
2. Define the phases of professional relationships. (SLOs 2,3,6)
Verbal (written or electronic) vs Nonverbal (body language, facial expressions)
Interpersonal vs Intrapersonal (self-talk)
Small-group vs Public (seminar/conference)
The Nurse-Patient Helping Relationship
Focuses on 5 Areas:
1. Building trust
2. Demonstrating empathy (relating not comparing)
3. Establishing boundaries (establish preferred name)
4. Recognizing and respecting cultural influences
5. Developing a comprehensive plan of care – patient is at the center of plan of care
3 Phases:
1. Orientation
Making introductions, establishing boundaries / expectations, and clarifying my role as a nurse.
Observing, interviewing, and assessing the patient, followed by validation of perceptions.
Identifying the needs and resources of the patient.
No hands-on patient.
Establish therapeutic relationship.
2. Working
Development of plan of care
Implementation of the plan of care
Enhancement of trust between the nurse and patient
Use of therapeutic communication to keep interactions focused on the patient
3. Termination
Goals have been met, and the patient is ready to walk out the door.
Concluding the relationship and transitioning patient care to another caregiver, as needed.
Factors that Affect the Timing of Patient Communication
Pain or anxiety – Meet the ABCs and Maslow’s basic needs first
Location or distractions – privacy (not a room full of visitors)
Essential Components of Professional Nursing Communication
Respect – eye contact, cultural beliefs, let them know that you care (verbally and nonverbally)
Assertiveness – the ability to express ideas and concerns clearly while respecting the thoughts of
others.
Collaboration – depend on other members of various teams
Delegation – communicate therapeutically with colleagues – very clear and concise
Advocacy – defend the patient’s rights
Review social (mutual sharing of ideas, informal), therapeutic (set my own opinions and judgements
aside), and nontherapeutic communication (hurtful).
Question: Contracts for a therapeutic helping relationship are formed during the following stage:
Orientation Stage
,3. Define and describe the concept of Technology and Informatics. (SLO 4)
4. Identify ways that technology and informatics impact health care. (SLO 4)
5. Discuss the uses of technology in health care. (SLO 4)
6. Explain the importance of using standardized terminologies in electronic health records. (SLOs 4,6)
Documentation
Reimbursement purposes
Legal proof – clear, concise, factual
Only objective
Paper – Only one person could use chart at a time / storage space / not confidential
Electronic – Make sure to close out of the screen before you leave the computer
Document as soon as it is done to the patient – whoever does it, documents it.
Nursing process: Assessment, diagnosis, planning, implementation, and evaluation.
Documentation Standards
Acceptable vs unacceptable terminology – text lingo
TJC – standards of acceptable medical terminology – having a medical record for each patient
that is accessed only by authorized personnel.
Documentation Principles
Medicare and Medicaid Services – reimbursement
ANA principles of nursing documentation – characteristics of documentation, education and
training, policies and procedures, protection systems, entries, and standardized
terminologies. Accessibility, accuracy, relevance, auditability, thoughtfulness, timeliness, and
retrievability.
Diagnostic-Related Groups (DRGs)
Reimbursement requires accurate documentation
Medical Record
EHR – hour – includes everything
EMR – minute – one isolated occurrence
Computerized provider order entry (CPOE) – allows doctors to enter orders that are sent
(spider-webbed) to the appropriate departments.
Nursing Documentation
Look professional
Chronological
Factual, clear, and concise data (objective)
Approved nursing terminology
Document in a format that reflects the needs of the patients (i.e. narrative, charting by
exception, and flow charts)
NANDA format – terminologies and nursing diagnoses
7. Describe types of Problem Oriented Medical Records (POMR) used in healthcare facilities. (SLO 4)
Formats
Narrative Charting – chronologic, with a baseline recorded on a shift-by-shift basis. Set baseline and say if
they stay or deviate. “Abdominal pain is worse now than last night.”
Charting by Exception (CBE) – records only abnormal or significant data.
Problem-Oriented Documentation – everything except CBE
PIE – problem, intervention, and evaluation
APIE – assessment (subjective), problem, intervention, and evaluation
SOAP – subjective, objective, assessment, and plan.
SOAPIE – subjective, objective, assessment, plan, interventions, and evaluation.
SOAPIER – subjective, objective, assessment, plan, interventions, evaluation, and revision.
DAR – data about problem, action initiated, and the patient’s response.
, SBAR -
Situation: What is happening at the current time? Chest pain
Background: What are the circumstances leading up to this situation?
Diabetic ulcer, blood sugars stable
Assessment: What does the nurse think the problem is? Vital signs (subjective and objective)
Recommendation: What should we do to correct the problem? EKG, oxygen, etc.
Case Management Documentation – focused on providing and documenting high-quality, cost-effective
delivery of patient care.
Flow Sheets and Checklists – intake/output – used to document routine care and observations that are
recorded on a regular basis, such as; vital signs, medications, and intake/output measurements.
Worksheets (taken, and then documented).
eMAR – electronic medication administration record – list of ordered medications, dosages, routes, and
times of administration, notes reason why medication is not given (if patient refuses), nurse initials and
signs.
Bar-coded Medications Administration (BCMA) – scans the patient’s wristband and the medication to be
given.
Kardex – mini-chart, quick reference, held at nurse’s station.
Admission and Discharge Summaries
Admission – patient’s history, a mediation reconciliation, and an initial assessment that
addresses the patient’s problems.
Discharge – addresses the patient’s hospital course, plans for follow-up, and documents the
patient’s status at discharge.
Legal Issues of Documentation
Single line strike through, write “error” and initial
Line out extra space and put full name and credentials
Confidentiality
Share on need to know basis
Health Information (Insurance) Portability and Accountability Act (HIPPA) – protects
information from leaking out.
Handoff Reports e.g. SBAR/ISBAR – “I” is identification of health care providers (point of contact)
End-of-shift report – “hall pass”
May be oral, written, or recorded
Promotes continuity of care – no gap in care
Opportunity for collaborative problem solving – more eyes on the patient.
Specific information
Verbal and Telephone Orders
Limited to emergency situations
WAR – written and read back
Incident Report
Factual accounts of an incident involving a patient, visitor, or staff member that are not part of
the medical record.
Purpose: To document the details of the incident immediately to ensure accuracy
Objective, non-judgmental, factual reports of the occurrence and its consequences.
It is not part of the medical record and the fact that an incident report was completed is not
recorded in the medical record; however, the details of the patient’s incident are
documented.
Aid in hospital quality improvement plan so that it won’t happen again.
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