Fundamentals ATI (the things you may be tested on)
Chapter 1
State board of Nursing
o Determines laws and regulation that governs nursing in their state
o Ensure health care providers comply with state regulations
o Issue and revoke nursing licenses
o Nurses must have a license in every state that they practice in
JCAHO
o Develops accreditation standards for health care facilities
o They do surveys, interviews, check charting
Medicare / Medicaid
o Medicare Eligibility:
>65 years
Receiving disability for at least 2 years
diagnosed with ALS OR end stage renal disease and dialysis
o Medicare Parts:
A: covers inpatient hospital limited skilled care
B: outpatient care [diagnostic, PT, OT]
C: combines A and B and is provided through private insurance company
D: provides prescription drug coverage
o Medicaid Eligibility:
Low socioeconomic status w/ no insurance
Household size
Income
Chapter 2
Registered dietitian: assist w/ nutritional needs
Lab technician: blood draws
Pharmacist: medications
PT: works on mobility
OT: can help patient regain ability to perform ADLs
Providers [doctor, APRN, PA]: sometimes have to work underneath doctors
Social worker: identifies and coordinates community resources, medical equipment, and
other needs for patients to be discharged.
Speech pathologist: help with speech and do swallowing assessments
Chapter 3:
Autonomy: patient has the right to make his/her own decision even if it’s not in their
best interest. [Jehovah’s witness refuses blood transfusion]
Beneficence: doing what is best for the patient [doing good]
Fidelity: keeping your promises [follow through]
Justice: fairness in care and allocation of resources [allocating money, resources, and
time fairly across multiple groups]
Non-maleficence: do no harm [doctor prescribes wrong prescription; you should
question it]
Veracity: telling the truth [if patient asks about diagnosis you have to tell them]
Chapter 4:
Unintentional torts:
o Negligence: Had patient who is at high risk for falls and you forgot to set bed
alarm and they hurt themselves
You did not mean to hurt patient but they did
o Malpractice: medication error – gave the wrong dose or type of medication
Intentional torts:
o Assault: you threaten the patient
o Battery: follow through with threat
o False imprisonment: inappropriately restrain, or give chemical restraint
[sedative]
Informed consent:
o Provider is responsible for communicating purpose of procedure and description
of procedure in the person’s language. Explaining the risks vs benefits of
procedure. Alternative options to treat conditions.
o RN: provider gave patient all the information they need. Patient is competent to
give informed consent [drunk, high]. Have patient signs document. Notify
provider if patient has more questions or does not understand.
o Who can give informed consent:
Competent adults
Child: parent or legal guardian
Durable Power of Attorney
Emancipated minors
o Refusal of treatment:
Patient has right to autonomy
Make patient sign document that they are refusing treatment despite
risks
If patient wants to lease against medical advice then we need to notify
provider, patient, and then sign AMA
Advance directives
o Living will: document created by patient that communicates wishes regarding
treatment if they become incapacitated
o DPOA: individual that the patient designates that is their health care proxy
o Providers order: prescription for DNR or AND [allow natural death].
Mandatory reporting
o If you suspect abuse you have to report it [do not have to gather more data, do
not need proof, suspicion needs to be reported]
o Communicable diseases that need to be reported to local or state health dept. –
mandated by the state
o Co-worker is impaired at all [drinking, drugs, etc.] you need to report to
appropriate manager
Chapter 5
Nursing documentation
o Objective
See, hear, feel, smell
Never include opinion or interpretation
Describe what you see (not medical diagnosis)
o Subjective
Direct quotes or identified as information gathered from patient
Patient state “__”
o Never leave black spaces
o Never fluid, black out works, or scratch.
o Always include name and title in documentation
o Incident needs to be created if there is a fall, accident, medication error
Good to do incident reports because it prevents these from occurring
again
Do not refer to your incident report in patient charting
It is NOT part of the patients record
Telephone order
o Have a second RN listen in
o Read back prescription to provider
o Makes sure provider signs prescription within 24 hours
HIPPA
o In place to ensure confidentiality of health information
o Only those responsible for patient care may have access to that patient’s medical
record
o You are not allowed to look up patient you are not caring for
o Never use a patient name on public display board
o Communication about patients should be discussed in private places [nurses’
station]
o Everyone should have own unique password that they do not share
o Do not share patient information with unauthorized people
Code system
o Used if a patient is concerned about patient information being released
o If someone calls in to find out about a patient, they need to give you the code
created by person to
Chapter 6
Delegation
o Do not delegate
Patient assessment