Completing and documenting an accurate medication history from ...

[sheilaspns]

Completing and documenting an accurate medication history from the patient is the important first step in the _____________ process.
 
  Fill in the blanks with correct word

Question 2

The nursing assistant tells the RN that when the patient's vital signs were taken, the patient complained that she was in a lot of pain.
 
  The nursing assistant then tells the nurse that she charted the patient's complaint when she charted the vital signs. What instruction does the nurse need to provide to the nursing assistant?
  a. The nursing assistant needs to make sure she uses the SBAR format when entering notes.
  b. Nursing assistants are not allowed to chart vital signs.
  c. Only the nurse can write in the progress notes.
  d. The nursing assistant needs to write using blue ink to distinguish from the RN note.

[Viet Thy]

Answer to Question 1

medication reconciliation
Medication reconciliation compares the patient's home medication list versus the medication orders at admission, transfer, or discharge to avoid medication errors such as omissions, duplications, dosing errors, or drug interactions.

Answer to Question 2

C
The task of writing a progress note may not be delegated to nursing assistive personnel (NAP). The nurse instructs the NAP about what repetitive care activities should be documented on flow sheets, including vital signs, intake and output (I&O), and routine care related to ADLs.