Download NOC1411_ExecAssist - Ontario Immigration

Registered Nurse
NOC 3152
Essential Skills Focus
Document Use: Level 2
Oral Communication: Level 2
Report Sheet
Registered nurses provide direct nursing care to patients, deliver health education programs
and provide consultative services regarding issues relevant to the practice of nursing. They
are employed in a variety of settings including hospitals, nursing homes, extended care
facilities, rehabilitation centres, doctors’ offices, clinics, community agencies, companies and
private homes, or they may be self-employed.
1. Tasks
Registered nurses record daily activities, times and notes in log books to
maintain permanent records of patient care administered, clinical work
performed, research tasks undertaken and meetings attended.
Task 1
Look at the sample report sheet for Mrs. J. Doe. Highlight the section of the form with
information about the tests and lab work she received.
Document Use
Task 2
Look at the sample report sheet. Highlight the concerns that need to be mentioned to the most
responsible physician (MRP).
Document Use
1
Registered nurses interact with physicians and other health professionals to
exchange information about patients' treatment plans, request tests,
recommend referrals, discuss communication strategies involving the
patients and their families, provide information on test results, obtain
information on medications prescribed to patients, or ask for clarifications of
diagnoses.
Task 3
The most responsible physician, Dr. Able, phones at 10:30 and leaves a message for the RN
requesting results from Mrs. J. Doe’s CAT scan. The RN looks at the report sheet and sees that
the CAT scan was rescheduled. Look at the report sheet to find the reason why. What should the
RN say to the physician? When you are ready, record your answer.
Oral Communication
2
Report Sheet
3
2. Answer Key
Task 1
Look at the sample report sheet for Mrs. J. Doe. Highlight the section of the form with
information about the tests and lab work she received.
Answer
The section of the form with information about the tests and lab work she received:
Essential Skills Focus: Document Use - Level 2
Check page 6 for one way to get this answer.
Task 2
Look at the sample report sheet. Highlight the concerns that need to be mentioned to the most
responsible physician (MRP).
Answer
Concerns that need to be mentioned to most responsible physician (MRP):
• Lab abnormal results e.g. low hemoglobin
• Antibiotic outdated
• Family would like to speak to you
Essential Skills Focus: Document Use - Level 2
Check page 7 for one way to get this answer.
4
Task 3
The most responsible physician, Dr. Able, phones at 10:30 and leaves a message for the RN
requesting results from Mrs. J. Doe’s CAT scan. The RN looks at the report sheet and sees that
the CAT scan was rescheduled. Look at the report sheet to find the reason why. What should
the RN say to the physician? When you are ready, record your answer.
Answer
Answers will vary. Possible answer AUDIO 1:
Hi Dr. Able. This is
(name), RN at critical care unit. You had called asking for the
results for the CAT scan for Mrs. J. Doe. The CAT scan had to be rescheduled because
she was experiencing chest pain around 10:00. The CAT scan has been rescheduled for
14:00 today. Feel free to call back if you have any further questions.
Essential Skills Focus: Oral Communication - Level 2, Document Use - Level 2
Check page 8 for one way to get this answer.
5
3. Answer Steps
Task 1
Look at the sample report sheet for Mrs. J. Doe. Highlight the section of the form with
information about the tests and lab work she received.
Answer
The section of the form with information about the tests and lab work she received:
One way to get this answer...
1. Scan the report sheet using the key words tests and lab work.
2. Locate the words Tests/Labs.
3. Decide the words Tests/Labs indicate the section of the form with information
about tests and lab work received.
4. Highlight the section Tests/Labs.
Skill Focus: Document Use - Level 2
6
Task 2
Look at the sample report sheet. Highlight the concerns that need to be mentioned to the most
responsible physician (MRP).
Answer
Concerns that need to be mentioned to most responsible physician (MRP):
• Lab abnormal results e.g. low hemoglobin
• Antibiotic outdated
• Family would like to speak to you
One way to get this answer...
1. Scan the report sheet using the key words concerns and MRP.
2. Locate the words Concerns for MRP and column below.
3. Identify items listed in the column under Concerns for MRP including: Lab abnormal
results e.g. low hemoglobin, Antibiotic outdated, family would like to speak to you
as concerns.
4. Decide the following are concerns that need to be mentioned to MRP:
• Lab abnormal results e.g. low hemoglobin
• Antibiotic outdated
• Family would like to speak to you
Skill Focus: Document Use - Level 2
7
Task 3
The most responsible physician, Dr. Able, phones at 10:30 and leaves a message for the RN
requesting results from Mrs. J. Doe’s CAT scan. The RN looks at the report sheet and sees that
the CAT scan was rescheduled. Look at the report sheet to find the reason why. What should the
RN say to the physician? When you are ready, record your answer.
Answer
Answers will vary. Possible answer AUDIO 1:
Hi Dr. Able. This is
(name), RN at critical care unit. You had called asking for the
results for the CAT scan for Mrs. J. Doe. The CAT scan had to be rescheduled because
she was experiencing chest pain around 10:00. The CAT scan has been rescheduled for
14:00 today. Feel free to call back if you have any further questions.
One way to get this answer...
1. Identify the information requested: the physician is requesting results of Mrs. J. Doe’s
CAT scan.
2. Scan the report sheet to locate the word CAT scan.
3. Locate the row of the report sheet with the word CAT scan and the time 10:00 and the words
cancelled due to chest pain.
4. Decide that the CAT scan was cancelled because the patient was experiencing
chest pain.
5. Scan the report sheet further to locate the word CAT scan repeated at 14:00 and the word
rescheduled.
6. Decide that the CAT scan has been rescheduled for 14:00.
7. Record message for Dr. Able that includes the following highlighted information:
Hi Dr. Able. This is _______ (name), RN at critical care unit. You had called asking for
the results for the CAT scan for Mrs. J. Doe. The CAT scan had to be rescheduled
because she was experiencing chest pain around 10:00. The CAT scan has been
rescheduled for 14:00 today. Feel free to call back if you have any further questions.
8. Check that the requested information has been covered.
Skill Focus: Oral Communication - Level 2
Additional Skills: Document Use - Level 2
8
Notes for Teachers/Facilitators:
See Medical terms below. The medical terms below may be useful for instructors who may wish to
develop extension activities using these forms.
See College of Nurses of Ontario for information on the education required for RNs
(University) vs. RPNs (two year college) vs. NPs (Masters).
Medical Terms
The following terms and acronyms are used in the Report Sheet.
Dx:
Diagnosis
Hx:
History
CAD:
Coronary Artery Disease
NPO:
nothing by mouth, short for the Latin words ‘nil per os’
Neuro:
Neurological
Resp:
Respiratory
MRP:
Most Responsible Physician
Hg ↓:
low hemoglobin
CVS:
Cardio Vascular System
GI:
Gastro Intestinal
GU:
Genito-urinary
MRSA:
‘super bug’, Methicillin-resistant Staphylococcus aureus
Sputum: phlegm from lung
pt/ot:
physiotherapist/occupational therapist
q 2-4 h:
q = every 2-4 h = two to four hours
I/V:
intravenous
S/C:
subcutaneous injection
NTG:
Nitroglycerine
VS:
vital signs
CAT scan: A computerized axial tomography scan is an x-ray procedure that combines many
x-ray images with the aid of a computer to generate cross-sectional views and, if
needed, three-dimensional images of the internal organs and structures of the
body.
9