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    Documentation 1

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    Waaberrin
    The document defines nursing documentation and discusses its purposes and principles. Documentation is defined as anything written or electronic that describes a client's status and care. Its main purposes are communication and continuity of care, quality improvement, risk management, establishing professional accountability, and legal reasons. Principles of documentation include being factual, accurate, complete, timely, concise, legible, and maintaining confidentiality. The roles of nurses in documentation include medication administration, verbal/telephone orders, collaboration, care plans, admissions/discharges, education, and incident reports. Do's include charting at the time of care and don'ts include charting ahead of time or altering records.

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    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd

    Documentation 1

    Uploaded by

    Waaberrin
    127 views26 pages
    The document defines nursing documentation and discusses its purposes and principles. Documentation is defined as anything written or electronic that describes a client's status and care. Its main purposes are communication and continuity of care, quality improvement, risk management, establishing professional accountability, and legal reasons. Principles of documentation include being factual, accurate, complete, timely, concise, legible, and maintaining confidentiality. The roles of nurses in documentation include medication administration, verbal/telephone orders, collaboration, care plans, admissions/discharges, education, and incident reports. Do's include charting at the time of care and don'ts include charting ahead of time or altering records.

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    Documentation 1

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    The document defines nursing documentation and discusses its purposes and principles. Documentation is defined as anything written or electronic that describes a client's status and care. Its main purposes are communication and continuity of care, quality improvement, risk management, establishing professional accountability, and legal reasons. Principles of documentation include being factual, accurate, complete, timely, concise, legible, and maintaining confidentiality. The roles of nurses in documentation include medication administration, verbal/telephone orders, collaboration, care plans, admissions/discharges, education, and incident reports. Do's include charting at the time of care and don'ts include charting ahead of time or altering records.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    127 views26 pages

    Documentation 1

    Uploaded by

    Waaberrin
    The document defines nursing documentation and discusses its purposes and principles. Documentation is defined as anything written or electronic that describes a client's status and care. Its main purposes are communication and continuity of care, quality improvement, risk management, establishing professional accountability, and legal reasons. Principles of documentation include being factual, accurate, complete, timely, concise, legible, and maintaining confidentiality. The roles of nurses in documentation include medication administration, verbal/telephone orders, collaboration, care plans, admissions/discharges, education, and incident reports. Do's include charting at the time of care and don'ts include charting ahead of time or altering records.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    of 26

    DOCUMENTATION

    DEFINITION
    Documentation in Nursing Practice is
    anything written or electronically
    generated that describes the status
    of client on the care or services given
    to that client ( Potter and Perry,
    2010)

    PURPOSES
    Communication and Continuity of Care
    all health care team members should have
    access to information upon which to plan and
    evaluate their interventions.
    all health care team members require accurate
    information about clients to ensure the
    development of an organized comprehensive care
    plan.
    The risk of inaccurate or incomplete
    documentation is: care that is fragmented, tasks
    that are repeated and therapies which could be
    delayed or omitted.

    Quality Improvement/Assurance and Risk


    Management
    Clear, complete and accurate nursing
    documentation facilitates quality
    improvement initiatives and risk management
    analysis for clients, staff and organizations.
    Through chart audits and performance
    reviews documentation is used to evaluate
    quality of services and appropriateness of
    care

    Establishes Professional
    Accountability
    Documentation is a valuable method of
    demonstrating that nursing knowledge,
    judgment and skills have been applied
    within a nurse-client relationship in
    accordance with the code of ethics for
    nurses.

    Legal Reasons
    The clients record is a legal document and can
    be used as evidence in a court of law or in a
    professional conduct proceeding.
    Documentation should provide a chronological
    record of events in client care and delivery of
    services.
    Courts may use the health record to
    reconstruct events, establish time and dates,
    refresh ones memory and to substantiate
    and/or resolve conflicts in testimony

    Expanding the Science of Nursing


    Health records serve as a valuable and major
    source of data for nursing and health related
    research.
    Data obtained from health records is also used in
    health research to assess nursing interventions,
    evaluate client outcomes, and determine the
    efficiency and effectiveness of care. The type of
    research made possible through the information
    in health records can enable nurses to further
    improve nursing practice.

    Principles in Documentation

    Factual
    Accurate
    Complete
    Timely
    Concise
    Legible
    Confidentiality

    FACTUAL
    Descriptive objective information
    about what the nurse sees, hears,
    feels, smells and think
    Includes objective signs of problems
    Subjective data is documented in
    clients exact words within quotation
    marks

    ACCURATE
    Use of exact measurement
    establishes accuracy
    e.g. Intake of 400ml of water then
    writing adequate amount of water

    COMPLETE
    Condition change
    Patients responses especially unusual, undesired or
    ineffective response.
    Communication with patient family
    Entries in all spaces on all relevant assessment form.
    Use N/A or other designation per policy for items that
    do apply to your patient.
    Do not leave blank

    TIMELY
    Document date & time of each recording
    Record time in conventional manner (e.g. 9:00am
    to 6:00pm or according to the 24 hours clock)
    Avoid recording in advance (this practice is illegal
    falsification of the records contributes to errors
    and confusion and threatens patient safety.

    CONSICE
    Recording need to be brief as well as
    complete to save time and communication

    LEGIBLE
    Using black pen, clear enough to be
    read, readable particularly handwriting
    Any mistakes occur while recording draw
    a line through it and write above or next
    to original entry with your initial or name.

    CONFIDENTIALITY
    Technology does not change clients rights
    to privacy of health information. Whether
    documentation is paper-based, electronic or
    in any other format, maintaining
    confidentiality of all information in a health
    record is essential, and relates to access,
    storage, retrieval and transmission of a
    clients information.

    Role of the nurse in documentation?


    Medication Administration
    Every hospitals should have specific policies and
    procedures related to documentation of medication
    administration. The general requirements for this type of
    documentation include: ( 10 rights should be followed)
    Date
    Actual time medications are administrated
    Names of medications
    Routes of medications
    Sites of administration when appropriate
    Dosage administered
    Nurses signature/designation

    Verbal Orders and Telephone Orders


    The expectation is that authorized prescribers will write
    medication orders whenever possible. However, registered
    nurses can accept verbal medication orders from authorized
    prescribers (either face-to-face or by telephone) when it is in the
    best interest of a client and there are no reasonable alternatives.
    Situations in which verbal orders would be considered acceptable
    include:
    urgent or emergency situations when it is impractical for a
    prescriber to interrupt client care and write the medication order
    when a prescriber is not present and direction is urgently required
    by a registered nurse to provide appropriate client care.

    Collaboration with other Health Care Professionals


    There is a current trend toward interdisciplinary practice. This
    way of documenting is intended to eliminate duplication,
    enhance efficient use of time and enrich client outcomes through
    team collaboration. Collaborative documentation enables
    healthcare professionals of all disciplines to share the same
    documentation tools. Examples of such tools are clinical
    pathways which reflect interdisciplinary care and integrated,
    interdisciplinary patient progress notes

    Collaboration with multidisciplinary team


    There is a current trend toward
    interdisciplinary practice. This way of
    documenting is intended to eliminate
    duplication, enhance efficient use of
    time and enrich client outcomes
    through team collaboration.
    Collaborative documentation enables
    healthcare professionals of all
    disciplines to share the same
    documentation.

    Plan of Care
    Effective client-focused documentation should
    also include a plan of care.

    Admission, Transfer, Transport and Discharge


    Information
    Accurate and concise documentation on
    admission, transfer, transport and discharge
    provides baseline data for subsequent care and
    follow up. Nursing documentation should reflect
    information on the clients status at discharge, any
    instructions provided (verbal and written),
    arrangements for follow-up care and evidence of the
    clients understanding, and family involvement as
    appropriate.

    Client Education
    The following aspects of client education
    should be documented in the health record:
    both formal (planned) and informal
    (unplanned) teaching
    materials used to educate
    method of teaching (written, visual, verbal,
    auditory and instructional aids)
    involvement of patient and/or family
    evaluation of teaching objectives with
    validation of client comprehension and learning
    any follow up required.

    All Aspects of the Nursing Process


    nursing process demonstrates that an RN has fulfilled her/his duty of care.
    unique contribution of nursing to the care of clients.
    any information that is clinically significant should be documented.

    To determine what is essential to document, for each episode of


    care or service the health record should contain:
    a clear, concise statement of client status (including: physical,
    psychological, spiritual)
    relevant assessment data (include client/family comments as appropriate)
    all on-going monitoring and communications
    the care/service provided (all interventions, including advocacy, counseling,
    consultation and teaching)
    an evaluation of outcomes, including the clients response and plans for
    follow up
    discharge planning.

    Failure to document evaluation is a common deficiency in charting.

    Incident Reports
    An incident is an event which is not consistent
    with the routine operations of the unit or of
    client care (Perry and Potter, 2010). Examples of
    incidents include patient falls, medication errors,
    needle stick injuries, or any circumstances that
    places clients or staff at risk of injury. Incidents
    are generally recorded in two places, in the
    clients medical record and in an incident report,
    which is separate from the chart.

    Do's and Don'ts of Nursing Documentation

    Do's
    Check that you have the correct file before you begin
    writing.
    Make sure your documentation reflects the nursing
    process.
    Write legibly.
    Chart the time you gave a medication, the
    administration route, and the patient's response.
    Chart precautions or preventive measures used, such as
    bed rails.
    Record each phone call to a physician, including the
    exact time, message, and response.

    23

    Do's..
    Chart patient care at the time you provide it.
    If you remember an important point after
    you've completed your documentation, chart
    the information with a notation that it's a
    "late entry." Include the date and time of the
    late entry.
    Document often enough to tell the whole
    story.
    24

    Don'ts
    Don't chart a symptom, such as "c/o pain," without also
    charting what you did about it.

    Don't alter a patient's record - this is a criminal offense.


    Don't use shorthand or abbreviations that aren't widely
    accepted.

    Don't write imprecise descriptions, such as "a large


    amount."

    25

    Don't
    Don't chart what someone else said, heard, felt,
    or smelled unless the information is critical. In
    that case, use quotations and attribute the remarks
    appropriately.

    Don't chart care ahead of time - something may


    happen and you may be unable to actually give
    the care you've charted. Charting care that you
    haven't done is considered fraud.
    26

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