Nurs 211 (SLOs Unit 4,5,6,7) Questions with Complete
Solutions
Define professional communication and explain how it relates to
collaboration and care coordination. CORRECT ANS Professional
Communication (Workplace):
- Verbal
- Non verbal
- Written
- Visual
Relation:
- Communication is a huge aspect in collaborating
- Ex: Hand off reports
- Without communication care coordination would not happen, each
healthcare worker would have different plans than another worker
Explain how nursing documentation reflects the nursing process
CORRECT ANS Nursing documentation:
- Clear, concise, factual, accurate, nonjudgmental, free of grammatical
errors
- Documentation should be done ASAP after events occur
- Clearly describe the patients health status and include care plan
- Documentation is the written form of the nursing process (Includes
documentation on the assessment, any findings/diagnoses, planning,
implementation, and evaluation)
,Summarize nursing responsibilities related to documentation of
assessment CORRECT ANS The nurse should document pertinent
information, when it comes to assessment the nurse is responsible for
noting anything new or changing from initial assessment. The nurse is
responsible to document as soon as an assessment is complete and make
sure to do in order!
Discuss the legal implications of nursing documentation CORRECT
ANS - Nursing notes ARE legal documents
- Medical record is the most reliable source in any lawful event related
to healthcare
- Attorneys first action is to obtain a copy of medical record
- Every entry should include: date, time, and signature
- Notes should never be changed
- Documentation mistakes must be known
- Documentation should be completed ASAP after events with patient
Relate concepts of confidentiality and privacy to interdisciplinary
communication CORRECT ANS - Confidentiality: principle that
assumes all healthcare workers will hold secure information relating to
patient
-Privacy: right to be free from intrusion or disturbance in a persons
private life
-Confidentiality and privacy are very important among everyone no
matter the barriers. HIPAA is always playing a role no matter who the
patient is.
- HIPAA should be applied anywhere(on phone, email, etc.)
, - Patients have the right to view, obtain, or even update there own
medical records
Describe the purpose and components of a standardized hand-off of
report CORRECT ANS -Handoff report is the process in which the
nurse or health care worker passes on patient information to another
nurse or health care worker.
- Provide accurate and timely information about care
- Information about treatment
- Information about services given
- Addresses patients current condition/ changes that may occur
- Hand offs is a opportunity for collaboration on a specific patient and
that patients problem. The purpose of handoff is promote patient safety
and positive outcomes
- Wagner("implementing standardized process for handoffs help nurses
deliver safe, effective care.") (Yoost)
Explain the nursing responsibilities relevant to verbal and telephone
orders CORRECT ANS Verbal/Telephone Order:
- Order must be taken by registered nurse
- Repeats order verbatim to confirm accuracy
- Enters order into the paper or electronic system
- Documenting it was a verbal order
- MUST INCLUDE: date, time, physicians name, and RN signature
Solutions
Define professional communication and explain how it relates to
collaboration and care coordination. CORRECT ANS Professional
Communication (Workplace):
- Verbal
- Non verbal
- Written
- Visual
Relation:
- Communication is a huge aspect in collaborating
- Ex: Hand off reports
- Without communication care coordination would not happen, each
healthcare worker would have different plans than another worker
Explain how nursing documentation reflects the nursing process
CORRECT ANS Nursing documentation:
- Clear, concise, factual, accurate, nonjudgmental, free of grammatical
errors
- Documentation should be done ASAP after events occur
- Clearly describe the patients health status and include care plan
- Documentation is the written form of the nursing process (Includes
documentation on the assessment, any findings/diagnoses, planning,
implementation, and evaluation)
,Summarize nursing responsibilities related to documentation of
assessment CORRECT ANS The nurse should document pertinent
information, when it comes to assessment the nurse is responsible for
noting anything new or changing from initial assessment. The nurse is
responsible to document as soon as an assessment is complete and make
sure to do in order!
Discuss the legal implications of nursing documentation CORRECT
ANS - Nursing notes ARE legal documents
- Medical record is the most reliable source in any lawful event related
to healthcare
- Attorneys first action is to obtain a copy of medical record
- Every entry should include: date, time, and signature
- Notes should never be changed
- Documentation mistakes must be known
- Documentation should be completed ASAP after events with patient
Relate concepts of confidentiality and privacy to interdisciplinary
communication CORRECT ANS - Confidentiality: principle that
assumes all healthcare workers will hold secure information relating to
patient
-Privacy: right to be free from intrusion or disturbance in a persons
private life
-Confidentiality and privacy are very important among everyone no
matter the barriers. HIPAA is always playing a role no matter who the
patient is.
- HIPAA should be applied anywhere(on phone, email, etc.)
, - Patients have the right to view, obtain, or even update there own
medical records
Describe the purpose and components of a standardized hand-off of
report CORRECT ANS -Handoff report is the process in which the
nurse or health care worker passes on patient information to another
nurse or health care worker.
- Provide accurate and timely information about care
- Information about treatment
- Information about services given
- Addresses patients current condition/ changes that may occur
- Hand offs is a opportunity for collaboration on a specific patient and
that patients problem. The purpose of handoff is promote patient safety
and positive outcomes
- Wagner("implementing standardized process for handoffs help nurses
deliver safe, effective care.") (Yoost)
Explain the nursing responsibilities relevant to verbal and telephone
orders CORRECT ANS Verbal/Telephone Order:
- Order must be taken by registered nurse
- Repeats order verbatim to confirm accuracy
- Enters order into the paper or electronic system
- Documenting it was a verbal order
- MUST INCLUDE: date, time, physicians name, and RN signature
