DEVELOPING YOUR KNOWLEDGE BASE
FILL-IN-THE-BLANKS
1.Patient record
2.Variance
3.Minimum data sets
4.Outcome and assessment information set
5.Resident assessment instrument (RAI)
6.Change-of-shift report
7.Incident report
8.Nursing care conference
MATCHING EXERCISES
1.c 2.f 3.i 4.e 5.h
6.a 7.g 8.b 9.j 10.k
SHORT ANSWER- a.Nursing care data related to patient assessments
b.Nursing diagnoses or patient needs
c. Nursing interventions
d.Patient outcomes - a.Change-of-shift reports: Given by a primary
nurse to the nurse replacing him/her or by the
charge nurse to the nurse who assumes responsi-
bility for continuing care of the patient. Can be
written, oral, or audiotaped.
b.Telephone reports: Telephones can link
healthcare professionals immediately and enable
nurses to receive and give critical information
about patients in a timely fashion.
c. Telephone orders: Policy must be followed regard-
ing telephone orders; they must be transcribed on
an order sheet and co-signed by the physician
within a set time.
d.Transfer and discharge reports: Nurses report a
summary of a patient’s condition and care when
transferring or discharging patients.
e.Reports to family members and significant others:
Nurses must keep the patient’s family and signifi-
cant others updated about the patient’s condition
and progress toward goal achievement.
f. Incident reports: A tool used by healthcare agen-
cies to document the occurrence of anything
out of the ordinary that results in or has the
potential to result in harm to a patient,
employee, or visitor.
g.Conferring about care: To consult with someone
to exchange ideas or to seek information, advice,
or instructions.
h.Consultations and referrals: When nurses
detect problems they cannot resolve because
they lie outside the scope of independent nurs-
ing practice, they make referrals to other profes-
sionals.
i. Nursing care conference: Nurses and other
healthcare professionals frequently confer in
groups to plan and coordinate patient care.
j. Nursing care rounds: Procedures in which a
group of nurses visit selected patients individually
at each patient’s bedside to gather information,
evaluate nursing care, and provide the patient
with an opportunity to discuss his/her care.- a.Communication: The patient record helps health-
care professionals from different disciplines who
interact with the same patient at different times
to communicate with one another.
b.Care planning: Each professional working with
the patient has access to the patient’s baseline and
updated data and can see how he/she is respond-
ing to the treatment plan from day to day. Modifi-
cations of the plan are based on these data.
c. Quality review: Charts may be reviewed to evalu-
ate the quality of nursing care and the
competence of the nurses providing that care.
d.Research: The record may be studied by
researchers to determine the most effective way
to recognize or treat specific health problems.
e.Decision analysis: Information from records
review often provides the data needed by strate-
gic planners to identify needs and the means
and strategies most likely to address these needs.
f. Education: Healthcare professionals and students
reading a patient’s chart can learn a great deal
about the clinical manifestations of health prob-
lems, effective treatment modalities, and factors
that affect patient goal achievement.
g.Legal documentation: Patient records are legal
documents that may be entered into court
proceedings as evidence and play an important
role in implicating or absolving health
practitioners charged with improper care.
h.Reimbursement: Patient records are used to
demonstrate to payers that patients received the
care for which reimbursement is being sought.
i. Historical document: Because the notations in
patient records are dated, they provide a chrono-
logic account of services provided. - a.Nurses should identify themselves and the patient
and state their relationship to the patient.
b.Nurses should report concisely and accurately the
change in the patient’s condition and what has
already been done in response to this change.
c. Nurses should report the patient’s current vital
signs and clinical manifestations.
d.Nurses should have the patient record at hand so
that knowledgeable responses can be made to
the physician’s inquiries.
e.Nurses should record concisely the time and date
of the call, what was said to the physician, and
the physician’s response. - a.Residents respond to individualized care.
b.Staff communication becomes more effective.
c. Resident and family involvement increases.
d.Documentation becomes clear.
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