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Java Games: Flashcards, matching, concentration, and word search. |
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Sara-Fundamentals 1D Unit 3
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| A | B |
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| If it's not documented... | it wasn't done |
| Charting principles... | concise, accurate, complete, specific details, organized, legible, timely |
| Types of documentation... | source oriented (fragmented), problem oriented (problem list), flow sheets, charting by exception (chart abnormals), critical pathways, narrative (running commentary), SOPIER, PIE, DAR (data, action, response) |
| SOPIER stands for... | subjective, objective, assessment, plan, intervention, evaluation, revision |
| Example of SOPIER note... | S -"I hurt all over" O -patient diaphoretic, pulse 110, crying; A -pain, r/t surgery; P - medicate and reassess in 30 min; I - Morphine 10 mg SQ in R arml; E - pain 4/10, pt states feels "much better"; R - reassess patient's pain in 2 hours |
| This is when a telephone order can be taken... | any time but must be signed by the MD within a certain time period |
| Do this if making a mistake with paper charting... | draw a single line through and initial it |
| Discharge planning begins... | on admission |
| Five rights of delegating a task to someone else... | right taks, right circumstances, right person, right direction, right supervision |
| This is the only part of the nursing process that can be delegated... | things in the implementation phase as long as the task is appropriate for the individual to do |
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