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standards of care guidelines developed for the practice of nursing. These guidelines are defined by the nurse practice act of each state, by state and federal laws regulating health care facilities by JCAHO and by professional organizations such as the ANA and other agencies. summary sheet gives the patient's name, address, date of birth, attending physician, gender, marital status, allergies, nearest relative, occupation and empooyer, insurance carrier and other payment arrangments, religious preference, date and time of admission to the hospital, previous hospital admissions and admitting problem or diagnosis. consent form grants permission to the health care facility and physician to provide treatment. physicians order form all procedures and treatments are ordered by the health care provider on this form which include general care, lab tests to be completed, other diagnostic procedures, and all medications and treatments such as physical therapy or occupational therapy. history ad physical exam form physician on admission to the hospital interviews the patient and given this which lists the problems to be corrected, often referred to as the H&P progress notes physician records frequent observations of the patient's health status on this critical pathways also referred to as integrated care plans, care or clinical maps and clinical trajectories, this document is a comprehensive standardized plan of care that is individualized at admission by the physician and nurse case manager. It describes a multidisciplinary plan used by all caregivers to track the ind's progress toward expected outcomes within a specified period. nurse's notes and nurse history nurses record ongoing assessments of the patient's condition; responses to nursing interventions ordered by the physician or those initiated by the nurse; evaluations of the effectiveness of nursing interventions; procedures completed by other health professionals and other pertinent info such as physician or family visits and the patient's responses after these visits. Guidelines for entries made on nurse's notes 1. completing records, including vital signs, immediately ater making contact with and assessing of the patient, that is when first admitted or returning from a diagnostic procedure or therapy. 2. recording all PRN medications immediately after administration and the effectiveness of the med. 3. Changes in a client's status and who was notified. 4. Treatment for a sudden chang in a client's status. 5. Transfer, discharge or death of a client. nursing care plan after initial data collection, this is done and this incorporates nursing diagnoses, critical pathway info, and physician-ordered and nursing-ordered care. laboratory tests record all lab test results are kept in one section of the chart called this graphic record is an example of manual recording of temp, pulse, resp and bp. Pain assessment nka the 5th vital sign can also be recorded on this. flow sheets This is a condensed form for recording info for quick comparison of the data. Ex would be diabetic, pain and neurological. consultation reports When other physicians or health professionals are asked to consult on a patient, the specialist's summary of findings, diagnoses, and recommendations for treatment are recorded in this section other diagnostice reports Reports of surgery, EEG, ECG, pulmonary function tests, radioactive scans and radiograph reports are usually recorded in this section of the patient's chart medication administration record (MAR) medication profile this is printed from the computerized patient database to ensure that the pharmacist and the nurse have identical medication profiles for the patient. This lists all meds to be administered PRN as needed unscheduled medication orders PRN medications are recorded on a separate MAR sheet referred to as this case management coordinate patient care provided to individuals, their families, and significant others on a continuum, providing efficient transitions to services that may be needed after discharge at home, in clinics or in other health care facilities such as rehabs or nursing homes. patient education record provides a means of documenting the health teaching provided to the patient, family, or significant others and includes statements regarding the learner's mastery of the content presented Kardex a large index-type card usually kept in a flip-file or separate holder that contains pertinent info such as the patients name, diagnosis, allegies, schedules of current medications with stop dates, treatments and the nursing care plan. floor or ward stock system all but the most dangerous or rarely used meds are stocked at the nursing station in stock containers. This system has been used most often in very small hospitals and hospitals where there are no charges directly to the patient for meds such as in some government hospitals. Advantage to this is readily available meds and fewer inpatient prescription orders and minimal return of meds. Disadvantages are: increased potential for med erros because of large array of stock meds from which to choose and lack of review by pharmacist; increased danger of unnoticed passing of expiration dates and drug deterioration; jeopardizing of patient safety; economic loss caused by misplaced or forgotten charges and misappropriation of med by hospital personnel; increased amounts of expired drugs to be discarded; need for larger stocks and frequent total drug inventories; storage problems on the nursing units in many hospitals individual prescription order system meds are dispensed from the pharmacy upon receipt of a prescription or drug order for an ind patient. Pharmacy sends supply of med ina bottle or box for patient, may hold 3-5 day supply. Meds are stored in med cabinet at nurse's station, med is removed as needed. ADVANTAGES: Review of prescription by nurse and pharmacist so greater patient safety; less chance for deterioration or expiration; easier inventory control; less chance for misuse by others; easier to charge patient; med is available for stat or prn usage. DISADVANTAGES: Frequent need to return or discard unused meds; complex ordering, preparing, administering, controlling, and recording systems required-time consuming computer-controlled dispensing system newer system for med ordering an administration is this that is supplied by the pharmacy daily, stocked with single-unit packages of medicines. Nurse uses a security code and password, thumb print unit dose drug distribution system single-unit packages of drugs, clearly labeled package is dispensed byt the pharmacy into drawers assigned to the patient, dispensed to fill each dose requirement as it is ordered. Each package is labeled with generic and brand name, manufacturer, lot number and expiration date.Every 24 hrs the pharmacy refills the drawers (3-7 days in LTC); this is the safest and most economical method of drug distribution in use today. ADVANTAGES: Little nursing time required; pharmacist is more involved, able to evaluate each order; less drug calculations by the nruse needed so less chance of error; less wastage and misappropriation; pt can be credited for unopened drugs. DISADVANTAGES: Nurses must administer a med prepared by someone else; may lead to delays in starting meds if no stock is on unit; requires presence of pharmacist which may be unavailable or expensive long-term care unit dose system is an adaptation of the system used in the acute care setting. This is designed with ind drawers to hold one resident's med containers for 1 week. Drawer is labeled with the resident's name, room #, pharmacy name and telephone number and name of the health care facility. adverse drug events (ADEs) medication errors can result in serious complications known as this, 7000 death in hospitals annually from this computerized prescriber order entry (CPOE) computer system that integrates the ordering system with the pharmacy, stocked by pharmacy, central system keeps track of inventory, only those meds ordered for the pt can be removed, there is a method to bypass system to obtain drugs in an emergency. ADVANTAGES: Reduces time for nurses, med is automatically recorded at time of delivery, tight control over med, narcotics are counted and verified each time one is removed. DISADVANTAGES: Costly, requires a pharmacist, requires password, only one nurse at a time, clinical decision-making support systems (CDSS) CPOE is supported by this verification nurse makes a professional judgment on its acceptability and safety of drug order, including type of drug dose and dose preparation, therapeutic intent, route potential allergic reactions or contraindications transcription after verification of an order, a nurse or another designated person does this to the order from the physician's order sheet onto the Kardex or onto a MAR. stat order generally used for emergency basis single order administration at a certain time but only one time. standing order indicates that a med is to be given for a specified number of doses. Ex. cefazolin 1 g q6h x 4 doses. or until said time renewal order must be written and signed by the phsycian before the nurse can continue to administer the med. PRN order administer if needed Before administering medication, nurse must have this: currently license to practice; clear policy statement authorizing the act; signed med order; understanding of rationale for drug use; UNDERSTANDING of drug action, dosing, dilutino, route and rate of administration, side effects adverse effects to report, contraindications Contents of patients charts summary sheet; consent forms; physician's order form; H&P form; progress notes; critical pathways; nurses notes; lab tests record; graphic record; flow sheets; consultation reports; other diagnostic reports; MAR: PRN or unscheduled med record; case management; patient education record What is included in the safe preparation and administration of the drug? Drug Distribution Systems, interpreting Dr's orders, documentation; three checks, six rights, handling controlled substances; helpful resources Drug Distribution Systems floor or ward stock system, ind presc. order system, unit dose system, automated dispensing system narcotic control systems Paper system; narcotic/controlled substances is delivered to the unit and signed for by RN and she verifies that meds are all there and in good condition before signing; kept locked in specified cabinet; narcotic keys are carried by nurses and turned over to the next shift when narcotics are counted; at end of each shift, narcotics are counted, inventoried by 2 nurses one from oncoming shift and one from ending shift; narcotics are signed out as they are used. Procedure for signing out a controlled drug check the order, check med record to see when med was last given; obtain keys/open cabinet; fill out inventory before removing med (compare # in record to # in cabinet pt name, date, drug, dosage, sig of nurse), document that med was given immediately after administration; document effectiveness wasting if a portion of med must be discarded due to smaller prescribed dose, two nurses must check the dose, preparation, and portion; both must cosign the inventory control record to verify transaction medication orders client's full name; date and time of order, drug name; drug dosage; route of administration and specific directives; time and frequency of adminstration; duration of order for outpatient; sig of physician or health care provider ordering drug prescription pad prescriptions for patient's leaving hospital; presc given at clinics, outpatient surgeyr; additional info may be written "take with meals"; duration; pharmacies require patient's age and address on the presc verbal orders institutions have policy regarding who can take these orders and transcribe to the order form; must be signed by the MD within 24 hours; v/o or t/o Dr. Smith/A. Sondreal RN time and date Six Rights of Medictaion administration Right patient, drug, time, dose, route and documentation Drug administration resources drugs books and cards; drug inserts; agency policy and procedure; pharmacist physician The right patient ask the pt's name as you are checking the bracelet, errors may occur on a busy unit; at risk for errors: pediatric pt, geriatric pt, non english speaking pt, confused or critically ill pt; nursing home patients ay not be wearing a bracelet The right drug check the drug name; similar names; check expiration date; know the drug action, read label 3 times (before removing the drug from the shelf, before preparing or measuring the actual prescribed dose before replacing drug on shelf or before administration) THe right time the order will specify time; hospitals have policies that determine which hours meds will be given when they are ordered; such as daily (be familiar with the policy), to be effective many meds be given on a rigid schedule; often has to be planned around pt's schedule; meals; drug interactions; one time only for emergency meds (check to see if med has already been given, document immediately, prn meds should be charted immediately) The right dose althought the physician may order the correct dosage of the med, changes in the pt's status may require that the dosage be altered; the nurse must use the proper equipment, the proper drug form and the proper concentration; calculations must be right; check usual drug dosage The right route the order will specify the route; never substitute one route for another; the nurse must be knowledgeable about the preferred route of a med (affects absorption, some meds are painful IM so IV is preferred); document injection site on chart The right documentation notation on chart should be made ASAP after administering; parenteral; MAR; progress notes. CAUTION: Never record meds that you did not give or record meds before they are given; never give med prepared by another nurse; you cannot assume that all of the rights were followed unless you do it yourself Evaluation look at results (response to drug, therapeutic effects, adverse effects) Medication errors a drug is given to wrong pt; wrong drug is given; wrong route; wrong dose; wrong time; wrong rate of administration; drug that is contraindicated given; drug given to pt that has known allergy; unordered or unsage med is given; given with an incompatible substance; protocals for reporting errors differ between institutions when error is detected you: evaluate pt's safety; if error poses a risk to the pt notify the dr ASAP and follow their orders; monitor patient, notify supervisor; document in pt's chart; fill out reports as required by institution nurse consequence for med error depends on severity of effects on the pt; if due to carelessness or negligence of the nurse, the nurse may be held legally liable; repeated errors cannot be ignored incident report form each institution has their own form and procedure for completing the form; purpose of the form is for follow-up by the RIsk Management department (Is this an incident that can lead to litation?); this form never goes in the pt's chart. Special documentation circumstances pt refuses med (thoroughly record incident and reason for refusal in nurses notes; notify dr; med error occurs What is included in the safe preparation and administration of the drug Durg Distribution System, interpreting dr's orders, documentation, three checks, six rights, handling controlled substances, helpful resources