A Yes, you can accept an H & P from a physician office if it is within 30 days from the date of admission and as long as the physician reviews the H & P, exams the patient and deems the history and physical represents the patient current condition. The history and physical should then be stamped with the H&P update stamp and signed, dated and timed by the physician. Q When should care planning begin? A A care plan reflecting the problems identified should be initiated on admission denoting the problems identified on admission. Q What do nurses do when a new patient problem is identified post admission? A The care plan should be updated a minimum of every 24 hours or as the patient’s condition changes including addition of problems, noted resolution of problems, modification, deletion and/or addition of interventions. Restraints Q Describe appropriate use of restraints. A Good Shepherd will use restraints or seclusion only when less restrictive interventions are ineffective and when the patient is at risk of harm or injury to themselves or others. Q Describe your training regarding use of restraints? When were you trained and what did your training include? A Trained during orientation; training is repeated annually. Training included alternatives to restraint, reasons for use, safe application and removal of restraints, assessment and monitoring of response and documentation based on current policy. Q Give an example of a least restrictive measure you would try before initiating restraints. A Move the patient to a more visible location, provide an observer, provide a visual/auditory cue not to get up without assistance, use bed/chair alarms, maintain a quiet environment. Q When the patient’s behavior requiring restraint resolves and you assess that restraints can be discontinued what do you do? A Remove the restraints; and as soon as possible and regardless of the scheduled expiration of the order. Document the time the restraints were discontinued and the rationale in my progress note or on the restraint document.
A Yes, you can accept an H & P from a physician office if it is within 30 days from the date of admission and as long as the physician reviews the H & P, exams the patient and deems the history and physical represents the patient current condition. The history and physical should then be stamped with the H&P update stamp and signed, dated and timed by the physician. Q When should care planning begin? A A care plan reflecting the problems identified should be initiated on admission denoting the problems identified on admission. Q What do nurses do when a new patient problem is identified post admission? A The care plan should be updated a minimum of every 24 hours or as the patient’s condition changes including addition of problems, noted resolution of problems, modification, deletion and/or addition of interventions. Restraints Q Describe appropriate use of restraints. A Good Shepherd will use restraints or seclusion only when less restrictive interventions are ineffective and when the patient is at risk of harm or injury to themselves or others. Q Describe your training regarding use of restraints? When were you trained and what did your training include? A Trained during orientation; training is repeated annually. Training included alternatives to restraint, reasons for use, safe application and removal of restraints, assessment and monitoring of response and documentation based on current policy. Q Give an example of a least restrictive measure you would try before initiating restraints. A Move the patient to a more visible location, provide an observer, provide a visual/auditory cue not to get up without assistance, use bed/chair alarms, maintain a quiet environment. Q When the patient’s behavior requiring restraint resolves and you assess that restraints can be discontinued what do you do? A Remove the restraints; and as soon as possible and regardless of the scheduled expiration of the order. Document the time the restraints were discontinued and the rationale in my progress note or on the restraint document.