Term
| Why good documentation is important (at the end of the day, good nursing practice aside) |
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Definition
| assessments, interventions, and daily care notes are all LEGAL DOCUMENTS; they can be held against you in court |
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Term
| When abbreviating words in notes... |
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Definition
| ...use only AGENCY STANDARD abbreviations, don't make any up, and don't use them if they're not allowed |
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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: |
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Definition
pt is depressed <--NO, NEVER
YES--> pt was crying, refused to eat, and asked me to leave them alone, reporting depression |
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Term
| The proper way to correct a mistake is... |
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Definition
...to draw a single line through it and sign and date next to the line
DO NOT SCRIBBLE/WHITE-OUT |
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Term
| Documenting in a timely manner means... |
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Definition
| ...documenting within 30 min of action |
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Term
| Nurse's can take medical orders from |
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Definition
MDs, APNs, DMDs, psychiatrists, and podiatrists
NOT PAs |
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Term
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Definition
| pt, drug, dose, route, frequency/time, and indication; signature of prescriber and signature of recipient |
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Term
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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 |
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Term
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Definition
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