Procedures and policies for this will look different at each facility Paperwork and processes will different but it is essential to know what to do to ensure a smooth transition Correct orders must be in place from physician to facilitate … Continued

Abbreviations are incredibly helpful and significantly reduce time to document and communicate Abbreviations are standardized because they can be easily confused and result in miscommunications and poor outcomes Example: QD = daily QID = 4 times a day Because of … Continued

If it wasn’t documented, it wasn’t done! Nurses are responsible for documenting many things. Some of which include: Care plans Medications (many facilities use barcode scanning) Nursing notes Assessments (focused, head to toe, vascular access devices, lines, tubes, airways, pain, sedation, restraints) Patient education Pay close attention to documentation training courses; the faster and more […]

Report will look different in various areas of the hospital ED report is very short and concise Critical care report is very detailed Floor report is more detailed than the ED, but less detailed than critical care Some facilities use standardized report forms (for example, SBAR) Basically communicating info from one shift to the next: […]

This can happen via technological devices (phones, social media, EHR breaches) or in person (discussing sensitive information in a public area or in the presence of others) This can be intentional or unintentional Facilities will have differing policies and procedures … Continued

Keep your password of EHR’s protected and confidential Don’t talk about sensitive information in public areas Speak with patient about which members of their support system they want involved in their care and identify anyone they may not want visiting Ask visitors to leave the room before discussing private health information with the patient

Make sure the patient knows that their privacy is a priority to us It is one of their rights, it is not optional Intervene if necessary (episode 018)

The nurse is at the bedside with the patient 24 hours/day and they typically feel most comfortable with their nursing staff.  Therefore, if a problem or personality conflict arises, the patient will most likely verbalize this to the nurse and look for guidance Find the balance of supporting the patient, making them feel heard, but […]

Nursing staff Continual care provider, advocate, administer medications and orders placed by medical team, evaluate effectiveness, notify medical staff of concerns, facilitate collaboration of entire healthcare team, work with health care team to optimize care Manage additional nursing support staff, … Continued

This needs to be done daily to ensure we are facilitating the appropriate plan of care As other members of the health care team assess the patient and develop plans and goals, we need to update our plans and goals, and update one another as things change and progress (or digression) occur