Unit 8: Observation, Reporting and Documentation
When you offer to give Mrs. Jones a bath, she says, "Get out of here and don't come back." You report this to the nurse and say:
"Mrs. Jones told me to leave her room and not come back."
In international time, midnight would be called:
2400
A point-of-care testing device:
Is used at the patient's location
An approach is sometimes called an intervention.
T
Assessment involves the collection of data.
T
Evaluation is an ongoing step of the nursing process.
T
Implementation is the activation of the care plan.
T
In some situations, the nursing assistant may be expected to report "normal" observations.
T
Taking a patient's weight is an example of an objective observation.
T
The care plan is developed at the care plan conference.
T
The patient's chart is a legal document.
T
The patient's goal is called an outcome.
T
The evaluation step of the nursing process determines all of the following except:
What should be done to assist the patient to reach the goals.
The statement of a patient's problem and its cause is called:
a nursing diagnosis
The purpose of the nursing process is to:
achieve patient-focused care.
The nursing assistant contributes to the nurse's assessment of the patient by:
reporting observations and vital signs.
The HIPAA rules:
restrict the use and disclosure of patient information.
Medical records and other patient data:
should be accessed only by those with a need to know the information
Audit trails:
track the computer, user, date, time, and which records are accessed.
Pain is normal in some conditions.
F
The nursing assistant is responsible for completing an assessment on all patients assigned to him or her.
F
The nursing process is a method used by the nurse to supervise the work of others.
F
When using SBAR reporting, you know that:
B stands for background information.
Nursing diagnosis and medical diagnosis are the same thing.
F
Critical (clinical) pathways:
Detail the course of treatment and expected outcomes.
A statement of a patient's medical condition is called a nursing diagnosis.
F
Nursing assistants are not responsible for the development or implementation of the care plan.
F
An EHR is stored in:
digital format
Charting should always be
done after care is given
The device that prevents patient information from being inadvertently transmitted over the Internet is the:
firewall
An example of an objective observation is that the patient:
has a pulse of 72
The purpose of making observations is to:
note changes in condition or new problems developing
The form on which nurses enter daily information about the patient is called the
nurse's notes.
The purpose of evaluation is to determine whether the:
patient is reaching the goals on the care plan.
