evaluate if patients' ability to learn (physical and cognitive ability). What is the best example of factual documentation? Most patient education materials exceed that level. 5 characteristics are factual, accurate, complete, current and organized. D. Patient has 3" of redness, swelling, and oozing at incision site on lower left leg, medial side. 20 terms. 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. The nurse shares this information immediately with the provider in a(an): Increased IV fluids to 100 ml per hour according to protocol. Which of the following is acceptable for him to write on the clinical care plan that he will give to his instructor? Document a factual summary of pertinent clinical findings and the rationale for your plan of care. Refrain from criticizing a previous provider’s care. Which purpose of Which of the following choices is an appropriate action taken by a student nurse? He knows that he must maintain patient confidentiality. To prove you really do provide effective patient education, you must document your efforts. Written for the patient at the 5th to 7th-grade level, information is presented in clear, concise, and easy to understand language. deals w/ feelings and development of values, attitudes and beliefs. Purpose is promoting health, preventing illness, preparation for discharge, restoring health and facilitate coping. Learn more about COVID-19 and how it affects specific health conditions in these printable patient education materials. Be realistic. 5. • More than one-third of American adults have limited literacy skills (i.e., reads below a fifth-grade level). One major barrier to teaching patients is: An 8-year-old boy has been diagnosed with diabetes. 2. The discharge summary deals with important elements pertaining to the patient's problems and health care after discharge. Ideally, copies of the actual teaching materials should be included in the medical record, says Haber. The DTP/DR is an effective form for planning, implementing, and documenting patient response to diabetes teaching in the inpatient setting. The nurse is teaching a 74-year-old patient how to apply an ostomy pouch to a new colostomy. E-mail; Print; RSS; Q&A: Documenting patient education Accreditation Insider, April 9, 2013. Which of the following statements are true regarding basic rules for documentation. Examples include demonstration and practice. Ideally, copies of the actual teaching materials should … Teach when awake and rested. The nursing profession is a compilation of many concepts that is used as a template to guide patient care. The nurse is beginning diabetic teaching for a newly diagnosed 52-year-old patient with Type 1 diabetes. Simple, well-organized forms that are accessible work best. Patient Education Summary. Must be clear, accurate, accessible and timely. Focus on what your patient needs to know, not on what is nice to know. You know your patient understands BSE when she: A patient in the E.R. Patient has a 3" oozing wound on her leg. As a school nurse, you must teach a nutrition class to a group of high school freshmen. ask patient where/ how they get health information. Start studying Chapter 16: Patient Education & Documentation. The form was developed by an interdisciplinary team according to Joint Commission standards. The patient should be able to: A type of reinforcement that works well with children is: Develop topics for discussion that require problem-solving. 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 The nurse should: Identify the equipment necessary for surgical wound care. After teaching a patient about cerebral vascular accident (CVA), the nurse prepares to evaluate the patient's psychomotor domain for learning. A nursing student is working on his clinical assignment. Documenting for Practice and Liability. An older adult is started on a new anti-hypertensive medication. COVID-19 (Coronavirus) Patient Education Materials. Want to receive articles like this one in your inbox? case management documentation, flow sheets, bar coded medication, administration, admission/ discharge summary. For “C,” the teaching physician’s minimal documentation could be used by itself to bill a low-level E/M code. Data, action, response and evaluation, education and patient teaching - Behavior: examples include attention span, memory, concentration. Analysis Of Dorothea Orem's Theory Of Nursing . Guidelines for patient education documentation are not very different from other types of charting that require specificity and accuracy. 2. During this teaching session, the nurse is using the process of: In an empty conference room with the door closed. List the names of family members who were present at the time of death. Keep room free from distractions and quiet. 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. In teaching this patient about the medication, you should: Almost 50 million Americans being illiterate. 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. Refer questions about prior care to that provider. All evidence-based handouts are available in both English and Spanish. The form improves the consistency of diabetes teaching, the quality of patient care, and the clarity of documentation. self expression and collaborative activity. 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 examples of documentation best describes the data? T here h ave b een n o c hanges s ince yesterday. Subscribe to Accreditation Insider!. The nurse knows that an effective principle to incorporate in a teaching session is: Present information slowly and share information in short frequent sessions. This is accomplished by: Recovering from major reconstructive surgery. C. Patient is crying when wound is cleaned because her leg hurts. 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. The nurse asks the mother to put together a 24-hour meal plan for her son and then reviews the plan with her. Documentation standards in United States hospitals are set by. Patients report of consistent lack of pain relief reported to his nurse. The nursing unit is conducting a trial on a computerized documentation system. ... “Patient may shower with nurse.” ANSWERS: 1. Chapter 2 NCLEX questions. 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. It looks like your browser needs an update. There are facilities that require narrative notes for each shift to include a minimum of at least three entries. Remember to use privacy. REPORTING & DOCUMENTING: CLIENT CARE ©1998-2011 May be copied for use within each physical location that purchases this inservice. “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. Learn vocabulary, terms, and more with flashcards, games, and other study tools. 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. Choose the inappropriate change-of-shift note from the following: A registered nurse is documenting her patient assessment. 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. only those who are involved w/ patient care need to know. 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