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, Who is able to access an EMR? (electronic medical record) - Answer: people with appropriate need for
access with a login username and password
Why should medications be documented immediately after they are given? - Answer: To avoid
confusion and double dosing.
If a mistake is made while paper documenting how should you proceed? - Answer: Draw a line through
and write error above or after the entry along with the nurses initials followed by the correct entry
SBAR - Answer: Situation
Background
Assessment
Recommendation
Orientation or introductory phase - Answer: • Making introductions, establishing professional role
boundaries (formally or informally) and expectations, and clarifying the role of the nurse
• Observing, interviewing, and assessing the patient, followed by validation of perceptions
• Identifying the needs and resources of the patient
working phase - Answer: development of a contract or plan of care
enhancing trust
collaborating among nurse and patient
Termination phase - Answer: Alerting pt of impending closure of relationship
evaluating the outcome achieved
concluding the relationship and transitioning patient care to another caregiver
What should you do before obtaining a health history from the patient? - Answer: Make sure they are
alert and oriented