NURBN1013 MODULE 3 PATIENT IDENTIFICATION, CLINICAL
HANDOVER AND DOCUMENTATION EXAM QUESTIONS AND
ANSWERS
NSQHS Standard 6
Communicating for safety
-> recognises the importance of effective communications and its role in supporting
continuous and safe patient care. Done through both documentation and clinical
handover.
Why Effective Communication Is Important
- essential to provide safe transitions in care
- necessary to ensure patient care
- encourage the other person to openly express ideas, feelings, or concerns
- strengthens nurse-patient rapport
- allows the receiver to accurately perceive the message
- establishes therapeutic relationships
Correct Identification and procedure matching
- ensures patient safety when being cared for.
- includes name (family and given names) date of birth, address and hospital
identification number.
, Its important to verify the patient's wrist band matches the relevant document, example
is the medication chart if administering medication.
Documentation
Documentation provides written records that reflect the person's care provided on the
basis of the information gathered during an assessment and the person's response to
interventions.
Purpose of documentation
-Provides a legal, serial record of client's condition,
-Serves as an information source for client care
-Enhances communication among healthcare or educational team members
-Provides data for use in intervention, program evaluation, research, education and
reimbursement
Legal and Practice standards
A persons's medical record is a legal document and should serve as a description of
exactly what happened to a patient if presented in a court of law.
Requirements for legal and practice standards
- legible handwriting
- correct spelling and grammar
- documentation of care is written in an objective manner
Documentation errors that can be questioned
Failure to record....
- Pertinent health or medication info
- nursing actions
HANDOVER AND DOCUMENTATION EXAM QUESTIONS AND
ANSWERS
NSQHS Standard 6
Communicating for safety
-> recognises the importance of effective communications and its role in supporting
continuous and safe patient care. Done through both documentation and clinical
handover.
Why Effective Communication Is Important
- essential to provide safe transitions in care
- necessary to ensure patient care
- encourage the other person to openly express ideas, feelings, or concerns
- strengthens nurse-patient rapport
- allows the receiver to accurately perceive the message
- establishes therapeutic relationships
Correct Identification and procedure matching
- ensures patient safety when being cared for.
- includes name (family and given names) date of birth, address and hospital
identification number.
, Its important to verify the patient's wrist band matches the relevant document, example
is the medication chart if administering medication.
Documentation
Documentation provides written records that reflect the person's care provided on the
basis of the information gathered during an assessment and the person's response to
interventions.
Purpose of documentation
-Provides a legal, serial record of client's condition,
-Serves as an information source for client care
-Enhances communication among healthcare or educational team members
-Provides data for use in intervention, program evaluation, research, education and
reimbursement
Legal and Practice standards
A persons's medical record is a legal document and should serve as a description of
exactly what happened to a patient if presented in a court of law.
Requirements for legal and practice standards
- legible handwriting
- correct spelling and grammar
- documentation of care is written in an objective manner
Documentation errors that can be questioned
Failure to record....
- Pertinent health or medication info
- nursing actions
