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Acuity Documentation - RN

NAME: _____________________________
Across
You cannot _______ cares just so you can claim and document 1+ activity.
The need for an _________ automatically gets pulled into the transparent acuity system if it’s charted.
Place your name and time of any lab you draw in the ___ ________ section of the Daily Care tab.
“Extensive wound management by non-RN” cannot be used if the wound management is being performed by a non _____-______ direct care non-RN.
Every time you ambulate, assist to the bathroom or turn a patient you need to document the ____ ___ _______.
Document “1:1 safety observation by RN” if you have a patient in behavioral restraints and are unable to leave the room due to frequent charting and assessments for ___ _____ or more.
"_______ ___ ______ _______ by RN" should be used for patients with a chronic condition who requires continuous education, a patient who has a surgical procedure which may require a change of day-to-day activities or a patient discharging requiring medical equipment support.
In the psychosocial section, document patient _______ every time you complete an intervention for your patient and/or family.
Write in the comment box the _______ the non-RN took the patient for “off unit accompanied by non-RN” and “off unit accompanied by RN” activity.
Select “1:1 _____ observation by non-RN” for a patient who, due to risk or harm to self or others, required one-to-one non-RN observations.
The only 1+ non-RN activity that can be claimed and documented if the activity was completed by a ____ _____ is “1:1 safety observation by non-RN”.
“1:1 safety observation by non-RN” cannot be used if the patient requires someone to sit at the bedside for safety reasons but the _____ has agreed to sit with the patient instead of a companion.
________ determines a patient’s acuity level
Down
“Procedure 1:1 by RN” should only be documented on a patient on telemetry undergoing a procedure requiring _______ _______, which required dedicated 1:1 care by a unit-based direct care RN for one hour or more.
“Off unit accompanied by non-RN” cannot be used if the bedside ______ accompanies the patient off the unit or if the activity does not take more than an hour.
A ____ ____ assessment needs to be documented every shift and with a change in condition.
“Coordination of care by RN” should not be used if the patient requires _______ discharge interventions.
Document “off unit accompanied by RN” if the unit-based direct care RN has to accompany a patient off the unit for one hour or more for a test or _______.
“Multi-disciplinary discharge education >/= 1 hour” should be documented for ___ of our patients
Document the level of assistance needed for ______ cares.
If it is documented that a patient is hearing or visually impaired, the information will _______ get pulled into the transparent acuity system. IVANTIBIOTICS - The following items are automatically pulled into the acuity system: blood products, dual sign-off meds, chemotherapy, chemotherapy precautions, the number of __ ________ and IV meds given, and the number of vital signs documented.
Document urine/stool occurrences or volumes under _______ _______.
___ ___ _____ alarms needed to be documented when on, off or the type of alarm changes.
Document all precautions (fall, isolation, seizure, etc.) ____ _ _____.
Chart 1+ ______ when the activity takes one hour or more.
If you give a medication for anxiety, go back and ______ your patient’s reaction to the medication.
17. If ___ staff RNs on any unit need to be present during a procedure for at least one hour and neither can leave the patient’s bedside document “procedure 2:1 by RN”
Document the level of assist every time you give someone a _____ ______.
All 1+ activities require a start and ____ time.