Reference no: EM133554485

Question 1:

1. State purpose and describe importance of client records.
2. List guidelines for effective documentation including those of the American Nurse Association.
3. Identify approved abbreviations and symbols used for documentation and distinguish these from error-prone abbreviations and symbols.
4. Identify the role of the nurse in documentation as related to protecting confidential client information. Health Insurance Portability and Accountability Act (HIPAA).
5. Compare and contrast different methods of documentation: electronic health record, source-oriented record; problem-oriented record; PIE-problem, intervention, evaluation; focus charting; charting by exception; and case management model.
6. Describe the purpose and correct use of each of the following formats for nursing documentation: nursing assessment, nursing care plan, critical/collaborative pathways, progress notes, flow sheets, discharge summary, and home care documentation.
7. Document nursing interventions completely, accurately, currently, concisely, and factually-avoiding legal problems.
8. Describe the nurse's role in communicating with other health care professionals by reporting.
9. Describe nursing informatics and its contributions to nursing and health care

Question 2: Communication

1. Describe the communication process, identifying factors that influence communication.
2. List at least eight ways in which people communicate nonverbally.
3. Discuss professional responsibilities when using electronic communication.
4. Describe the interrelation between communication and the nursing process.
5. Identity client goals for each phase of the helping relationship.
6. Describe effective communication for clients across the lifespan with various cultures and disabilities.
7. Identify techniques used to assist clients with special communication needs.
8. Identify factors that promote and inhibit therapeutic communication.
9. Identify the guidelines for quality documentation and reporting (SBAR).
10. Use a standardized communication technique to communicate with physicians (ISBAR) and transfer client information to other nurses (SBAR).
11. Describe how each type of ineffective communication hinders communication.
12. Describe strategies that counteract disruptive professional behaviors.