documenting patient education quizlet

The most appropriate teaching approach in this situation is the: Allow the patient time to express his views and to ask questions. Select all that apply. A multidisciplinary approach to documenting patient care that uses standardized documents; one to two page care plans for the problems, key interventions, and expected outcomes for patients with specific diseases or conditions is known as: Clinical or critical pathway Charting by exception Focused charting A source record Patients report of consistent lack of pain relief reported to his nurse. He knows that he must maintain patient confidentiality. Includes perception, set guided responses, mechanism, complex overt response, adaptation and organization. Factors may include preexisting illness, fatigue, electrolyte imbalance and cognitive function. Which purpose of An ideal environment for promoting learning would be: Assist Spanish-speaking patients to reach optimal health. List the names of family members who were present at the time of death. A. skilled services provided (e.g., materials and strategies, patient/family education, analysis and assessment of patient performance, modification for progression of treatment); session length and/or start and stop time, as required. Which of the following examples of documentation best describes the data? Asking the patient to call the office or even calling the patient a couple of days in advance is not as effective as handing the patient a written appointment slip before they leave the office. T here h ave b een n o c hanges s ince yesterday. To accomplish this, nurses need to constantly improve patient teaching and education prior to discharge. The patient with the most motivation to learn might be: Complimenting the patient on his or her ability to identify the action of the prescribed medications. Response of the patien is the same as evaluation of effectiveness. Examples include role playing and one on one lectures. Choose the inappropriate change-of-shift note from the following: A registered nurse is documenting her patient assessment. The nurse asks the mother to put together a 24-hour meal plan for her son and then reviews the plan with her. What is the best example of factual documentation? A patient states that she is experiencing pain in her lower back. Focus can be a medical diagnosis; 19. A technique method this nurse can use is: A nurse tells a patient with a recent back injury that damage to the nerves is comparable to a water hose that has been pinched off and that time is needed to allow normal nerve transmission. A patient needs to take daily injections of a blood thinner for 7 days following discharge from the hospital. Ideally, copies of the actual teaching materials should be included in the medical record, says Haber. • To ensure the patient receives the best available care, the information must be passed among all members of … The nurse also documents the time and content of two calls made to the patients physician requesting that the physician examine the patient for unexpected complications. Whatever the method, the information must become a part of the patient’s permanent medical record. Purpose is promoting health, preventing illness, preparation for discharge, restoring health and facilitate coping. Must be clear, accurate, accessible and timely. The discharge summary deals with important elements pertaining to the patient's problems and health care after discharge. Part of permanent record. Pain noted at 5 on the number scale at incision site and radiating to right side. involves motor skills. Be realistic. deals w/ feelings and development of values, attitudes and beliefs. Simple, well-organized forms that are accessible work best. Written for the patient at the 5th to 7th-grade level, information is presented in clear, concise, and easy to understand language. All laboratory test handout information is fully referenced. Subscribe to Accreditation Insider!. Patient expense documentation. Pay attention to the patient's concerns. After 20 minutes have passed during an educational session, the nurse notices a patient constantly changing positions, slumped back in the chair, and no longer making eye contact with the nurse. Preventing re-hospitalization is a huge responsibility, especially in consideration of costly penalties that are levied for early readmissions. One major barrier to teaching patients is: An 8-year-old boy has been diagnosed with diabetes. After the nurse receives a medication telephone order for a patient, the proper action is to: Provide a concise and organized description of the patient's status and needs. requires thinking, remembering, understanding, applying, analyzing, evaluating and creating. 12 terms. The nurse should: Identify the equipment necessary for surgical wound care. Ideally, copies of the actual teaching materials should … The patient appears anxious about how this event will affect his future. 2. Documentation standards in United States hospitals are set by. What is the best way for the nurse to document this subjective information? To achieve the best learning outcomes, you should: Performs BSE correctly on herself before the end of the teaching session. Examples include discussions and lectures. Documenting for Practice and Liability. Patient education documentation should include information about the learner’s reactions and feelings as well as responses to open-ended questions.4) When possible, put copies of educational materials in the chart. Documentation of Medical Records Introduction: • In a continuous care operation, it is critical to document each patient’s condition and history of care. document into agreement with the entry-level competencies found in the psychomotor and affective domains as identified in the Commission of Accreditation of Allied Health Education Programs (CAAHEP) 2008 Standards and Guidelines for Medical Assisting Educational It looks like your browser needs an update. Although providing patient education is appropriate and should be included in patient documentation, this activity does not specifically address documentation of medication administration. The patient should be able to: A type of reinforcement that works well with children is: Develop topics for discussion that require problem-solving. The nurse with a patient who complains of severe pain documents every 15 minutes about the steps taken to try to relieve the pain (without success). The nurse is caring for a patient who has had abdominal surgery. Documentation of patient teaching can be done via flow-charts, checklists, care plans, traditional progress notes, or computerized documentation. Chapter 2 NCLEX questions. This is an example of: Aid in the hospital's Quality Improvement program. A nurse is teaching a group of healthy adults about the benefits of flu immunizations. Reading the patient's record in preparation for clinical care. Learn vocabulary, terms, and more with flashcards, games, and other study tools. Used for recording patient assessment and nursing care provided, Framework for documentation: database, problem list, care plan, progress notes (from entire team), Assessment, problem, intervention, evaluation, Subjective, objective, assessment, plan, intervention, evaluation. The goal of this patient education is to: The nurse is preparing to teach a group of new parents about infant care. PRN Oxycodone pain medication administered with pain decrease to 3 within 30 minutes. Which of the following is acceptable for him to write on the clinical care plan that he will give to his instructor? Patient handouts contain general lab test instructions. You know your patient understands BSE when she: A patient in the E.R. Involve activity. For “C,” the teaching physician’s minimal documentation could be used by itself to bill a low-level E/M code. Document after patient care is complete. Which of the following statements are true regarding basic rules for documentation. Documentation on an interdisciplinary patient/ family education record at Shands Hospital at the University of Florida in Gainesville helped show a Joint Commission surveyor there was a collaborative effort toward patient/family education. Document a factual summary of pertinent clinical findings and the rationale for your plan of care. Data, action, response and evaluation, education and patient teaching Learn more about COVID-19 and how it affects specific health conditions in these printable patient education materials. A nurse is teaching his mother how to plan meals that are appropriate for him. Patient Education Summary. Find out how your patient likes to learn. Document the disposition of the patient's body and the name, telephone number, and address of the funeral home. If they weren't present, note the name of the family member notified and who viewed the body. With a team of extremely dedicated and quality lecturers, documenting patient education quizlet will not only be a place to share knowledge but also to help students get inspired to explore and discover many creative ideas from themselves. To ensure the best experience, please update your browser. Examples Of Patient Education Documentation Knowing appropriate Physical Therapy documentation phrases can help to share your intended treatment and also provide justification for more complex treatment such as neuromuscular re-education, therapeutic activity, and self-care.neuromuscular re-education, therapeutic activity, and self-care. This is accomplished by: Recovering from major reconstructive surgery. During a change-of-shift report, the nurse who is going off duty is expected to: The specific teaching plan for the patient and/or family. - Behavior: examples include attention span, memory, concentration. An example of positive reinforcement would be: Reschedule the remainder of the class for another time. Obtaining pre-assessments is important, but the nurse would do so before documenting medication administration. Multidisciplinary team members use a critical pathway to monitor the patient's progress. Focus on what your patient needs to know, not on what is nice to know. COVID-19 (Coronavirus) Patient Education Materials. Patient education documentation should include information about the learner’s reactions and feelings as well as responses to open-ended questions. Tips to improve patient education. 20 terms. Examples Of Skilled And Unskilled Treatment Notes: All documentation should reflect skilled services. Never pre-document care. All evidence-based handouts are available in both English and Spanish. Patient has a 3" oozing wound on her leg. The nurse is anxious to implement this type of system because it: The nurse has just admitted a patient with a medical diagnosis of Rule Out Myocardial Infarction. Therapeutic communication is used to reach goals with the patient. Select all that apply. Your patient's preferences can guide your choice of education materials and methods. During a teaching session for a patient with heart disease, the nurse uses reinforcement to stimulate learning. Refrain from criticizing a previous provider’s care. Patient has an infection r/t lumpectomy on lower left leg 4/01/2020. Remember to use privacy. Some facilities include education or patient teaching. To prove you really do provide effective patient education, you must document your efforts. Want to receive articles like this one in your inbox? A nursing student has been asked to prepare patient education for Spanish-speaking patients regarding diabetes. The nurse is teaching a 74-year-old patient how to apply an ostomy pouch to a new colostomy. There are facilities that require narrative notes for each shift to include a minimum of at least three entries. Includes receiving, responding, valuing, organizing and characterizing. 237 Background: Pharmacist-provided patient education for oral chemotherapy is poorly documented in patient electronic medical records (EMR) at UIC Oncology Pharmacy. Examples include demonstration and practice. When preparing the summary, the nurse needs to include: Can be used to document all aspects of care. E-mail; Print; RSS; Q&A: Documenting patient education Accreditation Insider, April 9, 2013. The purpose of this documentation is to: Provide a "read-back" of the entire order to the physician over the telephone and document his/her acknowledgement in the chart. B. Use of the form decreases time required f … “C” shows evidence the teaching physician saw the patient, but there is no documentation to show the teaching physician reviewed or agrees with the resident’s note. After teaching a patient how to do a sterile dressing change, the nurse evaluates the patient's cognitive domain of learning to see if there are areas that require additional instruction. The nurse knows that an effective principle to incorporate in a teaching session is: Present information slowly and share information in short frequent sessions. The first step is to formulate an interdisciplinary documentation form according to Joint Commission standards. The form improves the consistency of diabetes teaching, the quality of patient care, and the clarity of documentation. Chapter 07: Documentation of Nursing Care Test Bank MULTIPLE CHOICE 1. experiencing chest pain needs to undergo an emergency cardiac catheterization. Regulations from agencies such as The Joint Commission and the Centers for Medicare and Medicaid Services require the monitoring and evaluation of the quality and appropriateness of patient care. The nursing profession is a compilation of many concepts that is used as a template to guide patient care. The nursing unit is conducting a trial on a computerized documentation system. 2. Form provides compliance for JCAHO patient education documentation. What is this type of teaching? The form was developed by an interdisciplinary team according to Joint Commission standards. During this teaching session, the nurse is using the process of: In an empty conference room with the door closed. D. Patient has 3" of redness, swelling, and oozing at incision site on lower left leg, medial side. Our aim is to provide and document patient education … • More than one-third of American adults have limited literacy skills (i.e., reads below a fifth-grade level). The nurse is beginning diabetic teaching for a newly diagnosed 52-year-old patient with Type 1 diabetes. Refer questions about prior care to that provider. Patient may learn by visual, logical (reasoning), verbal/ linguistic or kinesthetic. 20. The nurse completes an incidence report on a patient who fell while walking in the hallway. The nurse shares this information immediately with the provider in a(an): Increased IV fluids to 100 ml per hour according to protocol. Keep room free from distractions and quiet. C. Patient is crying when wound is cleaned because her leg hurts. This is because the patient’s medical record is the most powerful tool attorneys, legal experts, and expert witnesses use to examine the type of care the patient … Teach when awake and rested. self expression and collaborative activity. only those who are involved w/ patient care need to know. Q: How should we properly handle patient education when it comes to care plan assessment documentation? Accurate and complete documentation of the care provided by the nurse is evident by the following notation: The nurse would expect to find which of the following in a Problem-Oriented Medical Record (POMR)? When completing the paperwork, the nurse needs to record: A multidisciplinary approach to documenting patient care that uses standardized documents; one to two page care plans for the problems, key interventions, and expected outcomes for patients with specific diseases or conditions is known as: While caring for a patient on the surgical ward, the nurse notes that the patient's blood pressure has dropped significantly since the last measurement. documenting patient education quizlet provides a comprehensive and comprehensive pathway for students to see progress after the end of each module. After observing the patient's self-administration technique she is comfortable that the following learning domain is intact: A 40-year-old man suffered a myocardial infarction 4 days ago. ... “Patient may shower with nurse.” ANSWERS: 1. Guidelines for patient education documentation are not very different from other types of charting that require specificity and accuracy. 5. Which of the following statements regarding the DARE format of documentation are correct? An older adult is started on a new anti-hypertensive medication. As a new LPN, you are teaching a patient how to perform breast self-examination (BSE). In teaching this patient about the medication, you should: Almost 50 million Americans being illiterate. Start studying Chapter 16: Patient Education & Documentation. Patient clinical reports, providers’ documentation, administrators’ records, and other documents related to patients and organizations providing and supporting patient careare important evidence in legal matters.Documentation that is incomplete, inaccurate, untimely, illegible or inaccessible, or that is false and misleading can lead to a This information will be available to patients in the diabetic clinic. REPORTING & DOCUMENTING: CLIENT CARE ©1998-2011 May be copied for use within each physical location that purchases this inservice. case management documentation, flow sheets, bar coded medication, administration, admission/ discharge summary. ch10- doc, electro health record, reporting. Download COVID-19 Materials. evaluate if patients' ability to learn (physical and cognitive ability). Did you know that the medical record might be the only evidence presented in a lawsuit? What is the best method for demonstrating that an organization is providing quality patient care? Oh no! Analysis Of Dorothea Orem's Theory Of Nursing . Critical pathways can be defined as a: Joint Commission for Accreditation of Healthcare Organizations. Which of the following examples of documentation is most clear? As a school nurse, you must teach a nutrition class to a group of high school freshmen. 4) When possible, put copies of educational materials in the chart. A nursing student is working on his clinical assignment. At baseline, 41% of patients who started new therapy with selected oral chemotherapies had a patient education note documented by a pharmacist in their EMR. Patient may get up A s F ar A s W ire G oes. some facilities include education or patient (E) teaching ... OTHER QUIZLET SETS. Focus is sometimes a significant changes in patient status or behavior or a significant event in the patient’s therapy. ask patient where/ how they get health information. After teaching a patient about cerebral vascular accident (CVA), the nurse prepares to evaluate the patient's psychomotor domain for learning. The DTP/DR is an effective form for planning, implementing, and documenting patient response to diabetes teaching in the inpatient setting. A good form does not guarantee that all staff from all hospital disciplines who may be teaching a patient will comply with Joint Commission on Accreditation of Healthcare Organizations (JCAHO) documentation requirements. The person may have to overcome a fear before being open to teaching. 5 characteristics are factual, accurate, complete, current and organized. "The nasty patient in room 17 called me an ******* while I was doing his stoma care". The nurse records in the chart "the patient states his abdominal pain is worse now than last night". Most patient education materials exceed that level. When preparing to teach a patient how to self-inject a medication, the nurse should begin the teaching session by: Observing the patient use a cane to ambulate. The nurse recognizes that learning can actually improve when the students experience: Discuss the procedure and equipment first. Which of the following choices is an appropriate action taken by a student nurse?

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