Shared Flashcard Set

Details

Nursing Documentation
Smith's Week 7 lecture
9
Nursing
Graduate
10/09/2013

Additional Nursing Flashcards

 


 

Cards

Term
Why good documentation is important (at the end of the day, good nursing practice aside)
Definition
assessments, interventions, and daily care notes are all LEGAL DOCUMENTS; they can be held against you in court
Term
When abbreviating words in notes...
Definition
...use only AGENCY STANDARD abbreviations, don't make any up, and don't use them if they're not allowed
Term
you go into the room, your pt is crying, refusing to eat, and says, "will you please leave me alone, i'm too depressed to talk..."

you document this as:
Definition
pt is depressed <--NO, NEVER

YES--> pt was crying, refused to eat, and asked me to leave them alone, reporting depression
Term
The proper way to correct a mistake is...
Definition
...to draw a single line through it and sign and date next to the line
DO NOT SCRIBBLE/WHITE-OUT
Term
Documenting in a timely manner means...
Definition
...documenting within 30 min of action
Term
Nurse's can take medical orders from
Definition
MDs, APNs, DMDs, psychiatrists, and podiatrists
NOT PAs
Term
Orders should detail
Definition
pt, drug, dose, route, frequency/time, and indication; signature of prescriber and signature of recipient
Term
VO/TO
Definition
verbal orders/telephone orders; must write "VO" followed by name of prescriber where they would sign, followed by order; STUDENTS CANNOT TAKE THESE

must later be signed by prescriber
Term
Progress Notes
Definition
SOAP and SOAPIER
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