NCLEX-PN

questions or concerns they may have. By actively participating in shift reports, nurses can help ensure that the care provided is thorough and consistent and help ensure continuity of care for their clients. Record & Communicate Nurses are responsible for documenting accurate and complete records of their client's care to ensure continuity of care. This includes using documents and proper forms to enter client information into medical records or complete transfer/referral forms. The nurse should use approved abbreviations and standard terminology when documenting and use a format that is consistent with the facility's policies, procedures, and guidelines. Abbreviations are essential for efficient healthcare documentation, but standardization is key to preventing misunderstandings and protecting clients. Standardized abbreviations ensure universal recognition, facilitating clear communication among healthcare providers. Non-standard or incorrect abbreviations, often labeled as "do-not-use" abbreviations, can lead to serious errors. For instance, "U" (for units) can be confused with "0" (zero) , potentially affecting medication dosages. To maintain client safety and effective documentation, nurses should be aware of the risks associated with non-standard abbreviations and strive to use approved, standardized ones. You can find a list of ISMP-approved abbreviations on the Institute for Safe Medication Practices (ISMP) , which is a valuable resource for nurses to ensure best practices in healthcare documentation. Nurses should check their documentation for accuracy before signing any documents and should update or add to the medical record as new information becomes available. Additionally, it is important to note any discrepancies or incomplete information in client records so that the next person caring for the client is aware and can take the appropriate action. By recording complete and accurate records and properly communicating information between healthcare professionals, nurses can help ensure continuity of care for their clients.

Admission, Transfer, Discharge It is important to note that when admitting a client, hospitals participating in Medicare must provide a medical screening examination when a request is made for examination or treatment for an emergency medical condition (EMC), including active labor, regardless of an individual's ability to pay. Hospitals must also provide stabilizing treatment at the hospital for clients with EMCs. If a hospital is unable to stabilize a client or the client requests a transfer, then the hospital is responsible for transferring the client to an appropriate medical facility that is capable of providing the necessary care and treatment. This transfer must be conducted in accordance with the Emergency Medical Treatment & Labor Act (EMTALA) in order to ensure public access to emergency services regardless of ability to pay.

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