| A | B |
|---|
| what are the four reasons that we document in the medical record | proof care was rendered, provides data continuity, communication tool, permanent legal record |
| list 6 occurrences when to document | change in baseline, change in condition, procedure performed or treatment provided, med given/response, pt teaching, careplan reviewed/interventions |
| what does smart stand for | simple, meaningful, actual, read, teach |
| what does the S in smart | keep message clear and simple |
| what does the M in smart | think about what and why you are sending the message |
| what does the A in smart | just report the facts |
| what does the R in smart | make sure you are sending the message you intend |
| what does the T in smart | teach others about smart communication |
| what are the possible consequences of not using Smart communication | exposes you and davita to liability, reputationa injury, jeopardizes the pt, potentially career threatening, |
| how do you document late entries | the teammate is to make the appropriate entry asap |
| electronic late entries | the notation will automatically contain your electronic signature, date and time |
| paperchart late entries | late entry must be signed by the person making it, late entry must be timned and dated at the time it is entered |
| how do you document charting errors | draw a single line through the entry, date/signature/teammate credentials, chart the correct information |
| nurse assessment vs PCT data | determining the depth of edema, HR, rhythm, quality of heart sounds, RR, rhythm, effort being put into breathing, identifying unusual lung sounds |
| PCT data vs nurse assessment | noting presence of edema, counting HR, Counting RR, recognizing unusual breath sounds, machine parameters, safety checks |
| what is the role of the RN prior to treatment initiation | assess abnormal findings from data collection, determine appropraite interventions based on MD orders, and contact MD if needed |
| when is a pre-tx assessment by the RN required | for a CKD HD pt, may be before tx initiation or within an hour of tx initiation or if data collection has abnormal findings |
| for patients with AKI | a pre tx assessment is Always required |
| what is the role of the PCT prior to tx initiation | complete data collection and Pct must notify the RN if there are any abnormal findings prior to initiation of tx |
| what are the appropriate times for documentation | pre treatment safety checks: prior to tx initiation |
| appropriate times for documentation | completed pre tx/assessment: prior to tx initiation if required by state law or within the first hour of dialysis tx |
| appropriate times for documentation: observations during tx | document assessment pre tx, continuous monitoring during tx, as they occur |
| what are post tx documentation | must be done when tx is completed, documentation of clearance of dialyzer after rinse back, BP, HR, Temp, RR, weight |
| what is the preferred bp cuff location | upper, non vascular access arm |
| what bp reading error can be casued by an incorrect cuff size | cuff too small-cuff reads higher, cuff too large--bp reads lower |
| what is a normal pre tx bp? | systolic 80 to 180, diastolic 50 to 100 |
| what is a normal HR range | 60-100 Heart rate |
| what is the normal respiratory rate | 12-20 bpm |
| what is the normal temp | less than 100 degrees or 37.8 C or less than 2 F |
| the three words davita uses to easily recall the pre tx avf/avg access evaluation are | look, listen, feel |
| when is post tx assessment by the RN required | if required by state law, if there were abnormal findings, |
| what are the key concepts related to reasonable and prudent care | standard of care, actions, skills and knowledge of a nephrology nurse would give under same or similar circumstances |
| who establishes the standard of care | american nephrology nurse association ANNA, base for policy/procedures, protocols, education, regulatory systems |
| what are the three considerations when delegating nursing care activities | within scope of practice, delegable by state board of nursing, personnel must be adequately trained to perform the activity |
| what role does davitas P&P play? | provides evidenced based guidance, meets cms conditions of coverage, complies with state and federal laws |
| what are the risks of performing activities your way | not providing safe evidence-based care can lead to civil liability |
| what the the 6-W's to be used when completing a REM? | what, when, where, why, witness, who |
| what are the 3 things you should NOT include in a REM | personal opinions, speculation or theories, vendettas--remember to only include the facts |
