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WorksheetsDocumenting, Reporting, Conferring etc. (Chapter 16)
Total questions: 8
Worksheet time: 5mins
What are the characteristics of Effective Documentation?
Consistent with professional and agency standards; Complete; Accurate
Concise; Factual; Organized and timely; legally prudent; Confidential
Opinionized
Incomplete
What is Confidential?
Name, address, phone, fax, social security number
Reason the person is sick
Assessments and treatments patient recieves
Information about past health conditions
Room number
The nurse has her computer open, with a patient's chart open, and leaves to give the patient medication without closing out of her computer. Is this a breach in patient confidentiality?
Yes
No
A nurse has a patient who is having seizures, and has never had them before. The nurse is friends with the patient's doctor, and has his phone number. As this is an emergency, she thinks that she should simply send him a text message telling him what is happening, as she doesn't have time to call him. Is this a breach of patient confidentiality?
Yes
No
A nurse doesn't know what to do about her combatant patient. She pulls her Nurse Supervisor aside to ask what to do, and decides to talk to her in the middle of the hall. Should the Nurse Supervisor let her continue talking when she realizes what it is about, or ask her to stop talking so they can go somewhere more private?
Let her keep talking
Ask her to stop because people could overhear and that is a breach of patient confidentiality
What are a patient's right when it comes to documentation?
See and copy their health record
Update their health record
Get a list of disclosures
Request a restriction on certain uses or disclosures
Choose how to receive health information
How would you record this verbal order?
"Give John Smith 25mg of gabapentin every 3 hours." (said by the surgeon Dr. James, who has a pager number of 1234.
Give John Smith 25mg of gabapentin Q3H. Dr. Mark James, Surgeon, 1234.
Dr. Mark James, Surgeon, 1234. Give John Smith 25mg of gabapentin Q3H
What are the components of ISBARR?
Identity/Introduction
Background
Assessment
Situation
Recommendation
