Midterms (Docs)

• Clear, accurate, and accessible documentation is an essential element of safe, quality, evidence-based nursing practice
• Nurses practice across settings at position levels from the bedside to the administrative office
• Documentation of nurses' work is critical for effective communication with each other and with other disciplines
• Documentation of nurses' work is how nurses create a record of their services used by payers, the legal system, government agencies, accrediting bodies, researchers, and other groups and individuals directly or indirectly involved with health care
• Documentation of nurses' work provides a basis for demonstrating and understanding nursing's contributions both to patient care outcomes and to the viability and effectiveness of the organizations that provide and support quality patient care
• The provision of patient education at the point of care improves patient satisfaction and outcomes, improves quality of care, and lowers health care costs
• Meaningful Use (MU) reimbursement requires health care providers to fulfill patient and family engagement standards
• Ensuring that providers can access current patient-specific education material quickly and easily within the electronic health record (EHR) is increasingly important
• Nurses provide consumer health information and patient education, both of which contribute to improved health care quality, improved patient outcomes, and lowered health care costs
• Factual, objective and client centered

  • Descriptive and objective information based on first-hand knowledge, the nurse's assessment and the client's needs
• Accurate and relevant

  • Clear and easy to understand information containing sufficient details
• Complete


  • All the components of the nursing process
• Current


  • Information that is up-to-date and is recorded during or as soon as possible after the intervention or interaction occurred
• Organized, logical and sequential


  • Information is in a chronological manner so that nursing decisions
• Compliant with standards of practice and other legal requirements


  • Information reflects the delivery of safe, competent, ethical, and compassionate nursing care and is consistent with standards of practice
• Confidentiality


  • Health care professionals should view the security of client documentation as a serious issue
  • Failure to comply with legislation, falsifying information or providing information without the client or agency's consent may constitute professional misconduct
  • Sharing confidential information is only acceptable in an effort to support the provision of quality care with health care team members who are a part of the client's circle of care
  • Documentation, in any format, should be maintained in areas where the information cannot be easily accessed by casual observers or those not directly involved in the care of the client
• Purpose of nursing documentation

  • Communication among the health care team
  • Continuity of Care
  • Professional Accountability
  • Legal
• Evaluation

  • A systematic process by which the worth or value of something, teaching and learning, is judged
  • The last step of the teaching process
  • A continuous and crucial step in the teaching process
  • Includes determining if the teaching session was successful and if the patient learned the intended information
  • Provides the needed evidence that the patient received and understood the educational material
• Evaluation Models

  • Process (Formative) Evaluation
  • Content Evaluation
  • Outcome evaluation
  • Impact Evaluation
  • Total Evaluation Program
• Evaluation of Program Implementation

  • Provides feedback information for program management and provides measures of accountability for resources appropriated
  • Analyzed on assessment of programmatic efforts, examination of programmatic operations, investigation of the extent to which specific activities compromising the program actually are implemented, and evaluation of the extent to which such activities contribute to the impact of evaluation
• Evaluation of Teaching

  • A major purpose is to assess the effectiveness of the teaching activities and decide which modifications, if any, are necessary
  • When learning objectives are not met, reassessment is the basis for planning modification of teaching-learning activities
  • Activities can include feedback from the learner, feedback from colleagues, situational feedback, and self-evaluation
• Interpersonal Skills


  • Effective teaching is based on the nurse's ability to establish rapport with the patient
  • The nurse who is empathic to the patient shows sensitivity to the patient's needs and preferences
  • An atmosphere in which the patient feels free to ask questions promotes learning
• Implementation

  1. Measuring the attainment of process, objectives, or determining the achievement of means designed to accomplish program goals

  2. The nurse must constantly assess the patient's response during this phase

  3. The nurse needs to speak in terms the patient understands, be specific on what is to be covered and keep the message short and concise
• Steps in Implementation

  1. Decide what will be taught

  2. Plan when teaching will occur

  3. Plan where teaching takes place

  4. Plan who will teach and learn

  5. Plan how teaching will occur
• Goal

  • The final outcome of what is achieved at the end of the teaching–learning process
  • Global and broad in nature; serve as long-term targets for both the learner and the teacher
  • Desired outcomes of learning that are realistically achievable in weeks or months
  • Multidimensional in that a number of objectives are incorporated into an overall goal
• Objective

  • Short-term in nature and should be achievable at the conclusion of one teaching session or within a matter of a few days following a series of teaching sessions
  • Describes a performance that learners should be able to exhibit before they are considered competent
• Types of Objectives

  • Educational objectives
  • Instructional objectives
  • Behavioral objectives or learning objectives
• Types of Behavioral Objectives

  • Cognitive
  • Affective
  • Psychomotor
• Importance of Using Behavioral Objectives

  • Helps to keep educators thinking on target and learner centered
  • Communicates to others what is planned for teaching and learning
  • Helps learners understand what is expected of them so they can keep track of their progress
  • Forces the educator to organize educational materials so as not to get lost in content and forget the learner's role in the process
• Common Mistakes in Writing Objectives

  • Describing what the teacher does rather than what the learner is expected to do
  • Including more than one expected behavior in a single objective
  • Forgetting to identify all four components of objective writing
  • Using terms for performance that are open to many interpretations, that are not action oriented and difficult to measure
  • Writing objectives that are unattainable and unrealistic given the ability level of the learner
  • Writing objectives that do not relate to stated goal
  • Cluttering objectives by including unnecessary information
  • Being too general so are not to specify clearly the expected behavior to be achieved
• Domains of Behaviors for Educational Objectives

  • Knowledge level
  • Apprehension level
  • Application level
  • Analysis level
  • Synthesis level
  • Evaluation level
• Prerequisite behavior


  Knowledge and comprehension that are required before a learner can demonstrate a higher level of learning
• Application level


  Ability of the learner to use ideas, principles, abstractions, or theories in particular and concrete situations, such as figuring, writing, reading, or handling equipment
• Analysis level


  Ability of the learner to recognize and structure information by breaking it down into its constituent parts and specifying the relationship between parts
• Synthesis level


  Ability of the learner to put together parts and elements into a unified whole by creating a unique product that is written, oral, pictorial, and so on
• Evaluation level

  Ability of the learner to judge the value of something, such an essay, design, or action, by applying appropriate standards or criteria
• Receiving level (Affective Domain)

  Ability of the learner to show awareness of an idea or fact or a consciousness of a situation or event in the environment
• Responding level (Affective Domain)


  Ability of the learner to respond to an experience
• Valuing level (Affective Domain)


  Ability of the learner to regard or accept the worth of a theory, idea, or event, demonstrating sufficient commitment or preference to be identified with some experience seen as having value
• Organization level (Affective Domain)


  Ability of the learner to organize, classify, and prioritize values by integrating a new value into a general set of values, to determine interrelationships of values