Nursing Documentation and SBAR Communication – Flashcards
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What are the Primary purpose of nursing documentation?
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Provide evidence that practice standards have been upheld Communicate with other health-care providers Ensure the best, most seamless health-care is provided
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Documentation must be these 6 things
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Timely Legible Concise Accurate Complete Logically organized
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Concise documentation means that that it is
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Brief Incomplete sentences Eliminate words that do not change the meaning of the sentence No need to state "patient" - who else would it be?
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this is an example of a ___ nurse note
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Experienced dyspnea ambulating in hall. Returned to bed via WC. RR and effort WNL w/i 5 min
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Accurate documentation means that that it is
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Every entry in a medical record requires: Date Time (24-hour clock) Signature or Initials
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this is an example of how you ____ sign your name
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Your credentials ALWAYS accompany your signature Nancy Nice RN MaryLou Who SN, GBCN
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What is the appropriate signature?
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MaryLou Who SN, GBCN
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what type of documentation is PIE?
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Problem-focused documentation
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what does PIE stand for?
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Problem Intervention Evaluate
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For PIE, what should be included for problem?
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Describe the problem Include abnormal assessment data
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For PIE, what should be included for intervention?
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Describe what was done to alleviate the problem What is your plan What did you do to maintain the problem so that it does not get worse
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For PIE, what should be included for evaluate?
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Describe the patient response to the nursing interventions that were done Was the treatment effective If not effective, then what will you do?
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Things to AVOID when documenting
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Double documentation Subjective data - only with observations and general survey Opinions / speculations Biased statements Abbreviations that are not on the standard or approved abbreviation list
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For documentation errors, you should ALWAYS
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Draw a single line through the mistake Write the word 'error' next to it Write your initials next to the word 'error'
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For documentation errors, you should NEVER
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White-out Scribble or scratch out Erase Tear out and throw away a page from the medical record
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SBAR is
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Professional communication needs to be brief and succinct -Present the facts, not a story -Be prepared before you make the call
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In SBAR, what is S
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situation
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In SBAR, what is B
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background
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In SBAR, what is A
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assessment
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In SBAR, what is R
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recommendation
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what should be included in the situation in SBAR
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S = nurse name, unit, hospital, pt. name, room #, major reasons for call
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this is an example of what in SBAR
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This is Mary Russo, RN, calling from 4 W at St. Elizabeth Health Center. I am calling about your patient, Mary Turney in Room 4065; she became hypoglycemic today at 7:45 a.m. when her blood sugar dropped to 60 and she became diaphoretic and dizzy.
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what should be included in the background in SBAR
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B = reason for admission, date, name of primary physician, relevant hx
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this is an example of what in SBAR
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She is a patient of Dr. Selby and was admitted on 3/23 with an admission diagnosis of right foot infection, possible bacteremia, Type II Diabetes and hypertension
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what should be included in the assessment in SBAR
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A = data organized by identified problems: vital signs, physical assessment, current lab tests, treatments, meds)
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this is an example of what in SBAR
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VS at 8 a.m. were 140/85, 98-86-20. Her physical examination is otherwise not remarkable, other than the hypoglycemic incident. After eating breakfast, she felt much better, and her BG is now 100. WBC's this morning were 9.2
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what should be included in the recommendation in SBAR
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R = what's needed: physician to come to see patient, tests, meds, transfer orders, etc.
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this is an example of what in SBAR
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We held her AM insulin. She may no longer need insulin. We need updated orders for monitoring her blood sugar. Instead of SC insulin, she may need an oral hypoglycemic agent because she is type II and the infection is resolving.
