5 Written questions
5 Matching questions
- incident report form
- critical pathways
- consent form
- a 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.
- b 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.
- c grants permission to the health care facility and physician to provide treatment.
- d 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.
- e 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.
5 Multiple choice questions
- 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.
- administer if needed
- 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
- Reports of surgery, EEG, ECG, pulmonary function tests, radioactive scans and radiograph reports are usually recorded in this section of the patient's chart
- drugs books and cards; drug inserts; agency policy and procedure; pharmacist physician
5 True/False questions
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
PRN → as needed
adverse drug events (ADEs) → 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.
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,
Contents of patients charts → 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