Page 2 - Coordinated Care Study Guide for the NCLEX-PN Exam

Using Resources

Information Technology

Technology is a newer tool in healthcare and has been evolving over the last 20 years or so. Electronic medical records, Internet research databases, and online employee resources are just a few components of available healthcare technology. This information technology gives healthcare members easily accessible resources for facility policies to ensure correct practice, reduces errors with electronic charting, and puts evidence-based research in their hands as soon as they need it. It is helping to shape healthcare into a safer, smarter world.

Accessing and Using Data

Nurses use research and online data quite frequently to ensure knowledgeable, appropriate practice. It is important, however, to access reliable sources, as not everything on the Internet is correct. Nursing scholarly journals, information from within the last five years or less, credentialing of the author, and reputable, known websites are required for accurate medical data.

Entering Data

Accuracy is especially important when charting in the electronic medical record. It is essential to document objectively, with appropriate grammar and spelling, as it is a legal record. Factual information, not subjective, is what will be taken seriously. It is also important to document in real time or as close to the time of occurrence as possible. This preserves the accuracy of your record of care with the client and gives it much more credibility than documenting occurrences hours or a day after the fact.

Resource Management

This is another part of nursing that can trickle down to each level. Nurse managers have to analyze costs of materials, staffing (and assign schedules accordingly), etc. Charge nurses focus on staffing ratios and adjust staff to reflect low census on the floor by floating or sending extra staff members home. Staff nurses need to pay attention to reducing waste of materials, correctly using equipment, etc.

Recognize Client Needs

Nurses are in charge of caring for and supplying materials for their clients. It is important to recognize when the client needs the use of material or equipment as well as when these things are no longer necessary. For example, if a nurse doesn’t notice that a client is no longer in need of a specific piece of equipment, the unit may unnecessarily order another, believing they do not have enough. This causes an unnecessary expense for the unit, which can affect everyone.

Monitor Material Use

It is easy to overuse a material or waste supplies unintentionally in healthcare, as part of efficiency is being organized with the materials you need for each client’s care. Nurses need to monitor each other as well as other staff to ensure overuse or waste is not occurring. For example, if you know a way to do a wound dressing that uses fewer supplies than your teammate, it is important to share this to help reduce waste.

Cost-Effective Care

Cost-effective care ties a lot of nursing and healthcare sections together. Managing your supply/material use is one way. Ensuring employee satisfaction to decrease turnover is a task for a nurse manager. Collaborative care to reduce unnecessary or duplicate tests, procedures, etc., is a way for all team members to contribute to this.

In nursing, it is your responsibility to know what is legally required of you in your practice of caregiving. Your scope of practice in your current state, appropriate actions to take when caring for clients, and client rights are a few broad concepts to understand. When a nurse does not practice within the confines of his or her legal obligation, a few repercussions include dismissal, suspension or revocation of license, and involvement with the judiciary system (going to court/prison). These are dependent on the type and severity of the offense.

Common Issues

Negligence, malpractice, breach of privacy, assault/battery, and false imprisonment (not allowing a client to refuse a treatment) are a few common legal issues that nurses and other healthcare providers may face. As a nurse, you will need to be aware of what these mean and how to avoid these situations when practicing care for clients.

Following Healthcare Provider Orders

In healthcare, primary healthcare providers write prescriptions for nurses and other staff to follow in order to care for their clients. Confirming, performing, documenting, and addressing problems with orders fall within the responsibility of the nurse giving care at that time.

Receiving and Processing Orders

When a nurse gets an order from a prescribing provider, there are several different routes: verbal, telephone, written, electronic, etc. Regardless of the method, it is important to always fully understand what the order requires you to do as the nurse. For example, if you receive a written order and cannot easily read the writing, you need to speak with the prescribing provider to confirm what the order says.

Providing Ordered Care

When the order has been clearly stated, the nurse moves to carrying out the order. Before doing so, always know your scope of practice and whether this order falls within it. In the event that a prescribing healthcare provider gives the nurse an order that is not within his or her scope of practice, the nurse needs to notify either the prescribing provider or charge nurse. The order should then be routed to the appropriate individual.

Documenting Care

When the order is completed or redirected to the appropriate personnel, the nurse must document what occurred. Objective, factual information is what should be recorded. For example, if you administered a medication per a prescribing provider’s order within your scope, you would document the medication, route, dose, time, two client identifiers used, that the client was educated on the reason for medication/side effects, etc.

Addressing Problems

Unsafe practice by any healthcare provider, no matter what level, should immediately be addressed. It is the nurse’s duty to provide, and ensure others provide, safe, correct client care. You should report any issues to the next person in the chain of command. You can also intervene in the moment if it directly affects client care at that time. For example, you are in the operating room and a physician is about to perform the first incision before a time-out is completed. It is appropriate to stop that individual and perform the time-out to ensure client safety.

Client Rights

Clients have many rights when it comes to their healthcare, and it is a nurse’s position to make sure they are informed of and given these rights and to advocate/address when or if the client’s rights have been violated. A few of these rights include the right to privacy, refusal of healthcare, and involvement in decision making in their healthcare.

Nursing Ethics

Ethics in nursing is being able to differentiate right from wrong. There is a code of ethics as well as principles to practice by, but these are typically dictated based on the individual’s cultural and/or religious background. Understanding how to navigate this to practice in a way you feel is right by the client and your beliefs is the general concept of this content.

Nursing Code of Ethics

The nursing code of ethics entails protection of the client’s privacy, caring for clients in a respectful/dignified/individualistic manner, prioritization of client safety, accountability of, as well as collaboration with, team members, and competent/high quality practice. It is expected that all nurses will work under these terms and be held to the utmost standard in doing so.

Promote and Intervene

If any of these ethics or principles are violated, it is the responsibility of the nurse to rectify the situation by reporting appropriately, informing the client about facility policy/procedure, intervening, etc.

Confidentiality/Information Security

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) is a sacred column in the framework of healthcare due to the importance of confidentiality and protecting clients’ right to privacy regarding information about their healthcare. Nurses have a professional commitment to practice strictly within this framework.

Identify and Intervene

Nurses should be well versed in their facility’s policies and procedures with regard to client confidentiality. Shift reports with only need-to-know information about the client, not discussing client information in public areas such as the nurses’ station or an elevator, and only accessing medical records of clients you are directly caring for are a few to note as common practice. It is required that any violations in client confidentiality be reported to the appropriate personnel and that action is taken to stop violations from occurring. This would include stopping a conversation between two nurses on an elevator about a client’s healthcare information and reminding them to do so only if pertinent to care and in private.

*##### Privacy

Client privacy involves several layers in healthcare. As stated above, no healthcare team member should discuss client information of any sort in public areas or with individuals who are not directly caring for the client or if the information is not pertinent for them to care for the client. Another component is actually giving the client privacy. Examples of this are closing the door when the client is dressing or closing the curtain in a bay area (such as a preoperative area) where clients can see each other, etc. Respect and dignity involves knowing when to give privacy for the client to feel those elements of care.

Follow Specific Issue Reporting Policy

In healthcare, there are matters that need to be reported in relation to safety of the client or public or both. You need to know your facility, state, and federal policies on when and how to report. For example, the Centers for Disease Control (CDC) has a surveillance program for reporting HIV cases. These are based on state requirements and policies on when and how to report. Another example is abuse reporting: most healthcare personnel are expected to report any suspected abuse to the proper authorities.

Client Advocacy

Advocacy for clients is one of the principles expected of nurses. This means standing up for what is right for the client, including heavy client involvement in treatments and decision-making related to their own healthcare and allowing clients to make these decisions without telling them what you think they should do. Additionally, encouraging clients to advocate for themselves and have a voice in every aspect of their healthcare is a vital practice. You will need to also be sure clients understand all of the information being given to them by explaining in understandable terminology, using interpreters in cases of language barriers, and making sure all questions are satisfactorily answered.


When working with paperwork in nursing, it is important to follow facility policy with regard to using appropriate forms when reporting, following facility procedure when filling out documents/paperwork, and thoroughly, as well as legibly, completing this paperwork.

Informed consent is documentation that provides evidence of clients making educated decisions in relation to their healthcare. It is the physician’s responsibility to obtain this signature from the client. The nurse is responsible for ensuring the client made the decision in an informed manner by witnessing this consent between the client and physician. It is also the nurse’s responsibility to make sure the physician obtained the client’s consent via signature prior to any treatments or procedures being done. Consent forms must contain the procedure/treatment to be performed, potential risks/benefits of procedure/treatment, risks if procedure/treatment is refused, and alternative treatments/procedures.

Advance Directives

Advance directives are legal requests from the client with regard to his or her healthcare in the event he or she cannot make a decision at a specific time. The directive would be used if a client was mentally or physically incapacitated and unable to be involved with his or her healthcare treatments/options. It is important to have this information prior to surgeries/procedures or upon admission and appropriately documented in the client’s chart. You also must have actual copies of legal documents uploaded or attached to the client’s medical record.

Living Will— This is a legal document that states what clients want to happen during end of life care. This can be concerning resuscitation measures, healthcare treatments to prolong life (feeding tube, ventilator, etc.), and/or their level of acceptable quality of life.

Healthcare Proxy— This involves clients appointing an individual to make medical decisions with regard to their healthcare/treatment if they are ever unable to do this for themselves.

Durable Power of Attorney for Healthcare— This is a legal document that appoints an adult to be in charge of the client’s property and finances and gives that adult the ability to appoint a healthcare proxy for the client for medical decisions.

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