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    Documentation and SBAR Fall21 Student

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    masita
    This document discusses effective communication strategies in healthcare, including SBAR, call-out, check-back, handoff, I PASS the Baton, and CUS. It emphasizes that timely and accurate communication is critical for safe patient care. Key components of patient documentation include being confidential, accurate, concise, objective, organized and timely. Common types of nursing documentation include narrative notes, flow sheets, and plans of care. The SBAR template provides a standard structure for verbal communication between healthcare team members.

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    Documentation and SBAR Fall21 Student

    Uploaded by

    masita
    17 views28 pages
    This document discusses effective communication strategies in healthcare, including SBAR, call-out, check-back, handoff, I PASS the Baton, and CUS. It emphasizes that timely and accurate communication is critical for safe patient care. Key components of patient documentation include being confidential, accurate, concise, objective, organized and timely. Common types of nursing documentation include narrative notes, flow sheets, and plans of care. The SBAR template provides a standard structure for verbal communication between healthcare team members.

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    This document discusses effective communication strategies in healthcare, including SBAR, call-out, check-back, handoff, I PASS the Baton, and CUS. It emphasizes that timely and accurate communication is critical for safe patient care. Key components of patient documentation include being confidential, accurate, concise, objective, organized and timely. Common types of nursing documentation include narrative notes, flow sheets, and plans of care. The SBAR template provides a standard structure for verbal communication between healthcare team members.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    17 views28 pages

    Documentation and SBAR Fall21 Student

    Uploaded by

    masita
    This document discusses effective communication strategies in healthcare, including SBAR, call-out, check-back, handoff, I PASS the Baton, and CUS. It emphasizes that timely and accurate communication is critical for safe patient care. Key components of patient documentation include being confidential, accurate, concise, objective, organized and timely. Common types of nursing documentation include narrative notes, flow sheets, and plans of care. The SBAR template provides a standard structure for verbal communication between healthcare team members.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    of 28

    Documentation and SBAR

    Shannah Lowe DNP, RN, APRN, ACNS-BC, CNRN


    Objectives
    • Develop strategies for effective communication with the
    intediscplanry team using written, verbal, and emerging technology
    methods
    • Describe the importance of timely, accurate communication in
    healthcare
    • Identify critical components for safe patient handoff
    • List key principles of charting
    Communication and • Absent inaccurate or delayed
    Patient Care communication can subject the
    patient to serious risks or delayed
    recovery.​

    • The Joint Commission identified


    critical communication failure as
    one of the most common root
    causes responsible for sentinel
    events.
    Patient record
    • Communication: Clear, accurate, and up-to-date patient documentation is
    a cornerstone for safe care delivery providing flow of information between
    providers of care.​

    • Communicates the plan of care and patient progress to all healthcare team
    members.​

    • Conveys clear picture of patient through different viewpoints and at different times.​

    • Ensures continuity of care and provides data for evaluation and revision or
    continuation of care.
    Principles of Documentation
    • Confidential
    • Accurate
    • Concise and complete
    • Objective
    • Organized and timely
    Universal Computer-Based Patient Record#1
    • Federally initiated goal of having a single health-related electronic
    record for all individuals.
    • Would allow patients to share their complete health information with
    any practitioner, regardless of institutional affiliation or location.
    • Supported by the 2009 Health Information Technology for Economic
    and Clinical Health (HITECH) Act whose goal it is to increase patients’
    access to their own medical records.
    Types of Nursing Entries
    • Kardex
    • Admission Entries
    • Narrative notes
    • Charting by Exception
    • Progress Notes
    • SOAP and SOAPIER notes
    • PIE and APIE notes
    • FOCUS DAR notes
    Types of Nursing Entries
    • Flow sheets: Tables with vertical and horizontal columns allowing for
    documentation of routine assessments and procedures.
    • Plan of care: Contains nursing diagnoses, goals, outcome criteria,
    interventions, and evaluation. Standardized plans of care may be
    used, but must always be individualized.
    • Critical pathways: Multidisciplinary tools that identify expected
    progression of patients toward discharge. Often used for patients
    requiring complex care or for frequently encountered situations.
    Types of Nursing Entries
    • Written Handoff Summary
    • Nursing Discharge Summary
    • Medication Administration Record (MAR)
    • Home Care Documentation
    • Long-Term Care Documentation
    • Incident Report
    Template for Communication
    • SBAR
    • Situation: What is happening at the present time?
    • Background: What are the circumstances leading up to this situation?
    • Assessment: What is the problem?
    • Recommendations: What should be done to correct the problem?
    Reporting to the Primary
    Healthcare Provider/Healthcare Team
    • Telephone communication
    • Verbal Orders
    • Consults
    • Rounding
    • Care Plan Conferences
    • Voice Communication Badges
    TeamSTEPPS
    • An acronym for Team Strategies and Tools to Enhance Performance
    and Patient Safety.

    • A safety curriculum designed to improve patient outcomes by


    cultivating teamwork among healthcare providers.

    • Developed in 2006 by the U.S. Department of Defense (DOD) Patient


    Safety Program and the Agency for Healthcare Research and Quality
    (AHRQ).
    TeamSTEPPS Communication Tools
    and Strategies
    • SBAR
    • Call-out
    • Check-back
    • Handoff
    • I PASS THE BATON
    • CUS (I am concerned; I am uncomfortable; this is a Safety Issue)
    SBAR
    Call out
    Check back
    Handoff
    I PASS the Baton
    CUS
    References
    • Craven, R., Hirnle, C., & Henshaw, C. M. (2021). Craven, Hirnle, &
    Henshaw: Fundamentals of nursing (9th ed.). Wolters Kluwer.
    • TeamSTEPPS 2.0 Video Training Tools. Content last reviewed March
    2014. Agency for Healthcare Research and Quality, Rockville, MD.
    https://www.ahrq.gov/teamstepps/instructor/videos/index.html

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