Examples of necessary referrals include therapy services (physical, occupational, speech), wound care, nutritional services, and so forth Recognize the need for referrals and obtain necessary orders Identify community resources for the client with health care team (Meals on Wheels, respite services, public transportation, various programs and shelters) Identify which documents to include for referrals (actual […]

Important to ask about all allergies, not just medication allergies Some medications may have ingredients from different foods in their coating or capsules Must ask about allergies to IV dyes or contrast Ask about all food, environmental, and medication allergies Ensure this is charted appropriately Make sure to chart what happens when the patient has […]

Call lights Adaptive call lights can be used for patients with poor dexterity Phones, or other technology

Participate in performance improvement/quality improvement process Utilize research and other references for performance improvement actions Report identified patient care issues and problems (utilize chain of command) Evaluate the impact of performance improvement measures on patient care and resource utilization

Know your state board of nursing Do not attempt to provide care outside of this scope – it is illegal Example: Texas Board of Nursing https://www.bon.texas.gov/practice_scope_of_practice_rn.asp

Substance abuse/diversion Improper care Staffing practices

Abuse and neglect Child, elderly, domestic Know your local reporting agencies (Child Protective Services) Communicable diseases Vaccine Adverse Event Reaction System (VAERS, vaers.hhs.gov) Report to Center for Disease Control (CDC) 2016 list of reportable conditions: https://wwwn.cdc.gov/nndss/conditions/notifiable/2016/ Adverse reactions to vaccinations Local organ procurement organizations with patients with a GCS less than 5 (may depend on […]

To be clinically appropriate medical interpreter, you must have appropriate credentials This is important because medical jargon is very different from fluency in a language, therefore competency and knowledge of specific medical jargon in various languages must be verified prior to the facility being able to say one is an official medical interpreter

Be able to know when something is outside of your comfort zone High risk, low frequency procedures Know your chain of command for both clinical “how-to” situations and also administration issues Document appropriately

Most facilities have policies and procedures to properly secure valuables Ideally, valuables are given to family/friends to be taken home and secured If this is not possible, there should be a secured and locked location within the facility to keep valuables Paperwork must be completed, appropriate documentation maintained Patients may experience a sudden trauma (MVA) […]