Documenting Nursing Activities (Record System Used in an Agency)
Documenting Nursing Activities (Record System Used in an Agency) ( 27 Questions)
A nurse is giving a change of shift report to the nurse on the next shift.
Which of the following statements by the nurse is appropriate for handoff communication?
it is subjective and disrespectful to the patient.
It does not convey any useful information about the patient’s condition, needs, or preferences.
It may also create a negative bias or impression on the next nurse, which could affect the quality of care.
This statement is appropriate for handoff communication because it provides relevant and specific information about the patient’s care plan and any pending tasks that need to be completed by the next nurse.
It also allows for the opportunity for discussion and clarification between the nurses.
it is not timely or relevant for handoff communication.
The patient’s allergies should be documented in the electronic health record (EHR) and verified with the patient before administering any medications.
It is not necessary to repeat this information during every handoff, unless there is a change or concern.
it is too vague and incomplete for handoff communication.
It does not provide any details about the patient’s current status, vital signs, medications, interventions, or goals.
It also does not indicate any anticipated changes or potential complications that the next nurse should be aware of.
“The client in room 14 has a wound dressing that needs to be changed at 10 a.m.”
This statement is appropriate for handoff communication because it provides relevant and specific information about the patient’s care plan and any pending tasks that need to be completed by the next nurse.
It also allows for the opportunity for discussion and clarification between the nurses.
Choice A is wrong because it is subjective and disrespectful to the patient.
It does not convey any useful information about the patient’s condition, needs, or preferences.
It may also create a negative bias or impression on the next nurse, which could affect the quality of care.
Choice C is wrong because it is not timely or relevant for handoff communication.
The patient’s allergies should be documented in the electronic health record (EHR) and verified with the patient before administering any medications.
It is not necessary to repeat this information during every handoff, unless there is a change or concern.
Choice D is wrong because it is too vague and incomplete for handoff communication.
It does not provide any details about the patient’s current status, vital signs, medications, interventions, or goals.
It also does not indicate any anticipated changes or potential complications that the next nurse should be aware of.
Handoff communication is a critical element of patient safety and continuity of care.
It involves the transfer of essential patient data from one caregiver to another during transitions of care across the continuum. It should be interactive, accurate, concise, and standardized. Some examples of handoff communication tools are SBAR (Situation, Background, Assessment, Recommendations), I PASS the BATON (Introduction, Patient, Assessment, Situation, Safety concerns, Background, Actions, Timing, Ownership, Next), ISHAPED (Introduction, Story, History, Assessment, Plan, Error prevention, Dialogue), and kardex.
These tools help to structure and organize the information exchange between providers and ensure that nothing is missed or misunderstood.
References:.
: 12 patient handoff communication tools to know - Becker’s ASC.
: Handoff communication - standardizing nursing protocols.
: Communication Strategies for Patient Handoffs | ACOG.
: 8 Tips for High-quality Hand-offs - The Joint Commission.