Hand-off communication tools such as the SBAR are used in the following situation:
patient leaving against medical advice
patient transfer to another facility
visitor fall
needle stick injury to a nurse
The Correct Answer is B
A. Patient leaving against medical advice:
When a patient decides to leave the hospital against medical advice, it's crucial to communicate this decision effectively. However, this situation does not specifically require a structured communication tool like SBAR. Rather, it necessitates clear communication to ensure the patient understands the risks and implications of leaving against medical advice.
B. Patient transfer to another facility:
During a patient transfer, especially between different healthcare facilities, it's essential to provide a comprehensive hand-off communication. SBAR is commonly used in such situations.
Situation: Describes the current situation and why the patient is being transferred.
Background: Provides relevant medical history and context.
Assessment: Presents the patient's current condition and vital signs.
Recommendation: Specifies what care and interventions the receiving facility should provide.
Using SBAR in this context ensures that all critical information is passed on accurately, minimizing the risk of errors and improving the continuity of care.
C. Visitor fall:
While a fall involving a visitor is an important incident, it doesn't typically require a structured communication tool like SBAR. Instead, it necessitates immediate response, assessment, and appropriate reporting within the hospital’s incident reporting system.
D. Needle stick injury to a nurse:
In the case of a needle stick injury, prompt reporting and proper follow-up are vital. While communication is crucial, it doesn't usually follow the structured format of SBAR. The nurse needs to report the incident to their supervisor or employee health, which would initiate appropriate protocols for testing, treatment, and documentation. Clear communication is necessary, but it doesn’t typically involve the use of the SBAR tool.
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Related Questions
Correct Answer is B
Explanation
A. The case management system:
Case management involves coordinating comprehensive healthcare services for patients across different settings and healthcare professionals.
This choice doesn't describe the specific style of documentation used in the scenario provided.
B. SOAP Note:
Subjective: Information reported by the patient, like feelings or symptoms.
Objective: Observable and measurable data, such as physical examination findings.
Assessment: The nurse's professional judgment about the patient's condition.
Plan: Interventions and treatments planned for the patient.
In the scenario, the documentation includes subjective information (patient denies itching, happy with improvement), objective data (rash fading, no visible hives), the nurse's assessment (skin integrity improving), and the plan (check rash daily until discharge). This aligns with the structure of a SOAP note.
C. Narrative style:
Narrative charting involves writing out the patient's story in a paragraph form.
While it can contain similar information to a SOAP note, it doesn't follow the structured format of SOAP (Subjective, Objective, Assessment, Plan) and tends to be more detailed and descriptive.
D. Charting by exception:
Charting by exception involves documenting only abnormal findings or significant events.
This method reduces redundant documentation, focusing on deviations from the expected or normal findings.
The scenario provides a mix of both normal (improvement in skin, patient satisfaction) and abnormal (initial rash and hives) findings, so it's not solely charting by exception.
Correct Answer is A
Explanation
A. Stroke Rehabilitation:
Explanation: Stroke rehabilitation is a long-term goal because it involves a process of recovery and adaptation over an extended period. Stroke survivors often need ongoing therapy, medical management, and support to regain lost functions and improve their quality of life. Achieving the maximum possible recovery can take months or even years, making it a long-term goal in healthcare.
B. Adequate Fluid Intake:
Explanation: Adequate fluid intake is essential for maintaining good health, but it is generally considered a short to medium-term goal. While ensuring a patient's proper hydration is crucial, it is typically resolved within a short timeframe by encouraging the patient to drink more fluids. Health professionals can monitor this relatively easily and make adjustments accordingly, making it a shorter-term goal compared to stroke rehabilitation.
C. Treatment of a Urinary Tract Infection (UTI):
Explanation: Treating a UTI is typically a short-term goal. Once diagnosed, UTIs can be effectively treated with antibiotics. Patients are usually prescribed a course of antibiotics, and symptoms generally improve within a few days. Monitoring the effectiveness of the treatment and ensuring the infection is completely resolved are parts of the short-term care plan.
D. Treatment of Pneumonia:
Explanation: Similar to a UTI, treating pneumonia is usually a short to medium-term goal. Pneumonia often requires a course of antibiotics and supportive care. Patients can experience improvement within a few days to a couple of weeks, depending on the severity of the infection. Monitoring the patient's response to treatment and ensuring complete resolution are essential short to medium-term objectives in pneumonia management.
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