2023/2024
what is the difference between data collection and assessment?
who does what? - CORRECT ANSWER data collection:yes or
no
assessment: the extend.
what is the role of pct prior to treatment initiation? - CORRECT
ANSWER data collection notify nurse of any abnormalities
what is the role of the licensed nurse prior to treatment initiation? -
CORRECT ANSWER nurse assessment
when us a pre-treatment assessment by the licensed nurse
required? - CORRECT ANSWER if vitals were abnormal
when is post treatment assessment by the licensed nurse
required? - CORRECT ANSWER up normalities during
treatment.
note about bp - CORRECT ANSWER squeezing the auto blood
pressure cuff to speed deflation can damage machine internal bp
module.
why do we document in the medical record? 4 reasons -
CORRECT ANSWER 1.proof that care was rendered
2.provide data continuity
3.permnent legal record
4.communication tool
list 6 occurrences when to chart? - CORRECT ANSWER
1.change from baseline assessment
, 2.change in patient condition
3.procedure for treatment
4.medication given
5.patient teaching
6.care plan review and intervention
pre-treatment data collection/ assessment - CORRECT
ANSWER before treatment intuition
assessment within one hour if pt is stable for nurse
post treatment data collection/assessment - CORRECT
ANSWER post treatment only
what are possible consequence of proof or incomplete
documentation? - CORRECT ANSWER poor or incomplete
documentation can open an attack on your care
what are the 6 items included in charting administered -
CORRECT ANSWER 1.medication dosage
2.data and time
3.route for administeration
4.pt response
5.signiture of teammate adminsteration
6.allergies always check the allergy screen in screen in falcon for
a list of your pt.
how do you document charting errors - CORRECT ANSWER
single line sign and date
what does SMART communication stand for - CORRECT
ANSWER Simple and clear
Meaningful
Actual
Read
Teach