Explain home healthcare documentation - ANSWERUnique documentation because it is remote yet accessed by different healthcare providers
provides quality control and reimbursement from insurance companies
notes pt education a demonstration of learning
coordination of services and compliance o...
Explain home healthcare documentation - ANSWERUnique documentation because it is remote yet
accessed by different healthcare providers
provides quality control and reimbursement from insurance companies
notes pt education a demonstration of learning
coordination of services and compliance of regulation reflected by all members of the healthcare
team
what are the DO's and DON'Ts when correcting an error when documenting in a patient's chart? -
ANSWERDo's :
- Use black ink only
- have legible handwriting
draw a single line through the error, write the word error above it and sign name or initial
Don'ts:
scratching out information
using white out
being vague in entries
what is the RNs responsibility with the initial assessment? - ANSWERgather information about the
patient's physical, emotional, sociological, and mental health needs,
meaning they are responsible for the initial admission nursing hx, physical assessment, and
development of care plan
, Explain the steps of SBAR and its importance - ANSWERIs a safety measure to prevent error from
poor communication during interactions with healthcare personnel
Situation - What is the situation, AKA chief complaint
Background- Pertinent background information related to the situation could include the following:
- the admitting dx and date of admission
- list of meds, allergies, IV fluids, and labs
- most recent vital signs
- lab results; date/time of test, results of prev. test for comparison
- other clinical info
code status
Assessment: what is the nurse's assessment of the situation?
Head to toe assessment- assessment of their systems
Recommendation: What is the nurse's recommendation or what does he/she want?
- notification that pt has been admitted
- pt needs to be seen now
- order has changed
what information should the incident report contain? - ANSWERexplains an unexpected occurrence
such as medication error, fall, needlestick injury. It is given to risk manager and unit manager in order
to help prevent future problems, provide objective, observed information.
provide examples of medical asepsis - ANSWERconsidered "clean technique"
- object or area is clean: nonpathogens may be present (not sterile)
- pathogen is an organism causing disease to its host
EXAMPLES:
handwashing, keeping clean linen off floor, the use of antiseptics, clean environment
Define a fomite vehicle - ANSWERit is an indirect mode of transmission
inanimate objects such as surfaces, glasses, soil, wound drainage, soiled/unsterilized medical
instruments
what are the signs and symptoms of inflammation? - ANSWERredness/rubor, heat, swelling/edema,
pain/tenderness, loss of function
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