Sample interview questions: How do you manage and document patient information and medical records accurately?
Sample answer:
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Patient Identification:
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Verify patient information upon admission, including name, date of birth, medical record number, and any identification bands.
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Ensure accurate patient identification throughout the hospital stay to avoid medication errors and other adverse events.
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Medical History and Physical Examination:
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Record patient’s medical history, including past illnesses, surgeries, allergies, medications, and social history.
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Document physical examination findings systematically, including vital signs, respiratory status, cardiovascular status, neurological status, and musculoskeletal status.
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Nursing Assessment:
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Conduct comprehensive nursing assessments on admission and at regular intervals thereafter.
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Document assessment findings, including patient’s chief complaint, pain assessment, functional status, nutritional status, and any relevant psychosocial factors.
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Nursing Care Plan:
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Collaborate with the healthcare team to develop an individualized nursing care plan.
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Document the patient’s goals, expected outcomes, nursing interventions, and evaluation criteria.
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Medication Administration:
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Verify medication orders against the patient’s medical record and any allergies or contraindications.
- Document the medication name, dosage, route, frequency, and time of administration.
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Monitor patient’s response to medications and report any adverse reactions.
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Patient Education:
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Provide patient education on medications, treatments, procedures, and discharge instructions.
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Document the content of the patient education provided and the patient’s understanding.
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Progress Notes:
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Write comprehensive progress notes that summarize the patient’s clinical status, response to treatment, and any changes in condition.
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Note any changes in the patient’s … Read full answer
Source: https://hireabo.com/job/2_0_25/Medical-Surgical%20Nurse