9. Documentation, Recording and Reporting.pptx

Documentation, Communication, Recording and Reporting in Health care is verry crutial.pptx

1. By Ame Mehadi (BScN, MSc in EMCCN, HDP) DOCUMENTATION, REPORTING AND RECORDING 1

2. Communications and Documentation By Ame Mehadi (BScN, MSc in EMCCN, HDP) 2

3. Documentation, recording & reporting [1 hr.] Purpose of documentation Types of report Patient parameters recording guideline Guidelines for reporting client data Confidentiality of records 3

4. Learning outcomes After this session, students will be able to: Understand and apply the principles of documentation and communication that align with legal and ethical aspects of the emergency and critical care process. Demonstrate effective communication in Emergency Department settings. Identify effective communications strategies in the ED. Identify the needs of special populations who require emergency care and develop appropriate plans of care that are culturally and demographically relevant. Apply therapeutic communication in patient care Demonstrate clear, sensitive and effective communication skills in interactions with individuals, families, communities staff, local health department staff, peers and faculty Document information’s according to principles of proper recording and documentation 4

5. RECORD KEEPING What is documentation/record keeping? Purpose of documentation/record keeping? Principles of documentation/record keeping? Main characteristics of documentation/record keeping? Validity of documents/records Documentation/record keeping responsibility Documentation/record keeping & medico–legal issues

6. RECORD KEEPING Definitions Documentation is written communication Medical records are a method of communication for healthcare team members and are required to be an integrated, sequential and contemporaneous record of events, where possible. Chart is a written record of history, examination, tests, diagnosis, and prognosis response to therapy. Written communication is as important in the health care arena as both verbal and non-verbal communication. Maintaining clear, concise but comprehensive client care records is absolutely essential both in terms of: providing continuity of client care of a high standard and meeting legislative requirements . Remember, in a court of law it is assumed that if the care was not documented then it didn’t happen.

7. Nursing documentation, record keeping and written communication INTRODUCTION Accurate record keeping and careful documentation is an essential part of nursing practice. ‘Good record keeping helps to protect the welfare of patients and clients’ – which of course is a fundamental aim for nurses everywhere. (The Nursing and Midwifery Council (NMC 2002)) It is equally important that you can also communicate by letter and e-mail with other health and social care professionals, to ensure that they understand exactly what you mean.

8. NURSING DOCUMENTATION AND RECORD KEEPING High quality record keeping will help to give skilled and safe care Nurses have a legal and professional duty of care Nurses record keeping and documentation should demonstrate: a full description of assessment and the care planned and given relevant information about patient/client at any given time and what done in response to their needs that you have understood and fulfilled your duty of care, that you have taken all reasonable steps to care for the patient/client and that any of your actions or things you failed to do have not compromised their safety in any way ‘a record of any arrangement you have made for the continuing care of a patient or client’.

9. NURSING DOCUMENTATION AND RECORD KEEPING Investigations into complaints about care will look at and use the patient/client documents and records as evidence, so high quality record keeping is essential. A court of law will tend to assume that if care has not been recorded then it has not been given.

10. Documentation You will see lots of different charts, forms and documentation. Every hospital, care home and community nursing service will have the same basic ones, but with small variations that work best locally. The common documents that you will use include some of the following. 10

11. Documentation Nursing assessment sheet The nursing assessment sheet contains the patient’s biographical details (e.g. name and age), the reason for admission, the nursing needs and problems identified for the care plan, medication, allergies and medical history. Nursing care plan The documents of the care plan will have space for: Patient/client needs and problems. 11

12. Documentation Sometimes , nursing Dx s will be documented but these are not used as frequently as in North America. Planning to set care priorities and goals. Goal-setting should follow the SMART system, i.e. the goal will be specific, measurable, achievable and realistic, and time-oriented. For exam- ple , a SMART goal would be that ‘ Mr Lee will be able to drink 1.5 L of fluid by 22.00 hours’. Some goals, such as reducing anxiety, are not easily measured and it is usual to ask patients to describe how they feel about a problem that was causing anxiety. The care/nursing interventions needed to achieve the goals. An evaluation of progress and the review date. This might include evaluation notes, continuation sheets and discharge plans. In some care areas you might record progress using a Kardex system along with the care plan. Reassessing patient/client needs and changing the care plan as needed. 12

13. Documentation Vital signs The basic chart is used to record temperature, pulse, respiration and possibly blood pressure. Sometimes the patient’s blood pressure is recorded on a separate chart. Basic charts may also have space to record urinalysis, weight, bowel action and the 24-hour totals for fluid intake and output. More complex charts, such as neurological observation charts, are used for recording vital signs plus other specific observations, which include the Glasgow Coma Scale score for level of consciousness, pupil size and reaction to light, and limb movement Fluid balance chart This is often called a ‘fluid intake and output chart’ or sometimes just ‘fluid chart’. It is used to record all fluid intake and fluid out- put over a 24-hour period. The amounts may be totalled and the balance calculated at 24.00 hours (midnight), or at 06.00 or 08.00 hours. Sometimes the amounts are totalled twice in every 24 hours (i.e. every 12 hours). Fluid intake includes oral, nasogastric, via a gastrostomy feeding tube, and infusions given intra- venously, subcutaneously and rectally. Fluid output from urine, vomit, aspirate from a nasogastric tube, diarrhoea , fluid from a stoma or wound drain are all recorded. 13

14. Documentation Medicine/drug chart It is important to become familiar with the medicine/drug-related documents used in area of practice. A basic medication record will contain the patient’s biographical information, weight, history of allergies and previous adverse drug reactions. There will be separate areas on the chart for different types of drug orders. These include: drugs to be given once only at a specified time, such as a sedative before an invasive procedure drugs to be given immediately as a single dose and only once, such as adrenalin (epinephrine) in an emergency drugs to be given when required, such as laxatives or analgesics (pain killers) drugs given regularly, such as a 7-day course of an antibiotic or a drug taken for longer periods (e.g. a diuretic or a drug to prevent seizures). 14

15. Documentation All drugs will include the dose, route, frequency (with times), start date and sometimes a finish date. There is space for the signature of the nurse giving the drug and, in some cases, the witness. It is vital to record when you give a drug. This is done at the time so that all staff know that it has been given, and do not repeat the dose. Likewise, if you cannot give the drug for some reason (e.g. patient is in another department or their physical condition contraindicates giving the drug), make sure that this fact is recorded on the medicine/drug chart and the doctor is informed if necessary. Remember that in some situations you will need to record in the nursing notes when you give patients a drug (e.g. if you give analgesic drugs (pain killers)). 15

16. Documentation Informed consent Responsibility for making sure that the person or the parents of a chil d hav e al l th e info r matio n neede d fo r the m t o giv e info r med written consent rests with the health practitioner (usually a doctor or nurse ) who is undertaking the procedure or operation. This info r mation will include : info r mation about the procedure/operation the benefits and likely results the risks of the procedure/operation the other treatments that could be used instead that the patient/parent can consult another health practitioner that the patient/parent can change their mind. 16

17. Documentation Incident/accident form Any non-routine incident or accident involving a patient/client, relative, visitor or member of staff must be recorded by the nurse who witnesses (sees) the incident or finds the patient/client after the incident happened? Incidents include falls, drug errors, a visitor fainting or a patient attacking a member of staff in any way. An incident/accident form should be completed as soon as possible after the event. Careful documentation of incidents is important for clinical governance continuous quality improvement, learning from mistakes and managing risk, etc. and in case of a complaint or legal action 17

18. Documentation The following points provide some guidance for documentation of incidents be concise, accurate and objective record what you saw and describe the care you gave, who else was involved and the person’s condition do not try to guess or explain what happened (e.g. you should record that side rails were not in place, but you should not write that this was the reason the patient fell out of bed) record the actions taken by other nurses and doctors at the time do not blame individuals in the report always record the full facts. 18

19. Guidelines for documentation & record keeping The basic guidelines for good practice in documentation and record keeping apply equally to written records and to computer-held records. Patient and client records should:  be based on fact, correct and consistent be written as soon as possible after an event has happened to provide current (up to date) information about the care and condition of the patient or client ‘be written clearly and in such a way that the text cannot be erased’ (rubbed out or obliterated) be written in such a way that any alterations or additions are dated, timed and signed, so that the original entry is still clear ‘be accurately dated, timed and signed, with the signature printed alongside the first entry’

20. Guidelines for documentation & record keeping Patient and client records should:  ‘not include abbreviations, jargon, meaningless phrases, irrelevant speculation and offensive subjective statements’ ‘be readable on any photocopies. ‘be written, wherever possible, with the involvement of the patient, client or their carer ’ ‘be written in terms that the patient or client can understand’ ‘be consecutive’ (uninterrupted) ‘Identify problems that have arisen and the action taken to rectify’ (correct or put right) them ‘Provide clear evidence of the care planned, the decisions made, the care delivered and the information shared’.

21. Documentation documentation and management of health care records are maintained consistent with common law, legislation, ethical and current best practice requirements . In ED, you will assess and treat patients and families from all walks of life. It is important to treat these patients with: Respect, Privacy and Dignity It is also worth bearing in mind that medico–legal cases frequently arise where patients have suffered trauma or complications from medical and surgical treatment, and that your record-keeping might therefore be scrutinized in the future.

22. RECORD KEEPING Method of keeping medical records Electronically or ‘on line’ With the advent of information technology , computerized information systems are being increasingly used to record , store and evaluate information pertaining to clients. These are proving very useful in terms of easier and speedier access to information both within and across care env’ts , for example dep’t to dep’t , hospital & community. In many units, the patient’s charts, pathology results, X-rays and prescription charts are now kept electronically or ‘on line’. Whatever method is used in your area, however, it is important that you familiarize yourself with the systems and ensure that you do not breach client confidentiality.

23. What to record Daily examination & progress notes. the condition of the patient and the treatment given. Interventions & procedures. Complications of procedures, which must be recorded accurately & honestly. The content and outcome of discussion with the patient’s relatives, so that other staff do not give conflicting advice or opinions. each interaction b/n the nurse & the patient and/or significant others Complications do occur, and providing you have followed correct procedures, they do not imply negligence. (Failure to record them or act appropriately upon them does!)

24. What to record Results of important investigations. The patient’s chart is often used to record: blood gases, biochemistry, hematology and microbiology results. Important positive and negative findings, those which carry either diagnostic or prognostic significance, or which directly affect management, should be transcribed This is a legal document and therefore the results do not need to be routinely copied into the medical notes.

25. Any change in a patient’s condition should be documented clearly and a senior member of nursing and medical staff notified if the patient is deteriorating, unsafe or there is a significant change in their condition.

26. Documentation requirements Client records should be: factual , consistent & accurate clear , legible & readable following photocopying accurate, clear and succinct. easily accessible able to be understood written as soon as possible after the event and, if possible, with the involvement of the client written in a manner that cannot be erased timed, dated & signed with name printed by the side & indicating your role, e.g. PA Hilton (PA Hilton, Staff Nurse) devoid of abbreviations, jargon or meaningless phrases such as ‘ Bed bath given ’ written in a language understandable by the client

27. Documentation requirements Client records should: not contain any subjective, offensive statements or irrelevant speculation identify client problems and steps taken to rectify them provide evidence of the care that has been planned and delivered include information that has been shared with others include evidence of evaluation of the efficacy of care delivery.

28. Purpose of Patients Chart Continuity of care For diagnosis or treatment of a patient while in the hospital (find after discharge) if patient returns for treatment in the future time. Legislative purpose For maintaining accurate data on matters demanded by courts. Research purpose For providing material for research Education purpose For serving an information in the education of health personnel (medical students, interns, nurses, dieticians, etc.) Vital statistics Promoting public health action 28

29. General Rules for Charting Spelling Make certain you spell correctly Accuracy Records must be correct all ways, be honest Completeness No omission, avoid unnecessary words or statement Exactness Do not use a word you are not sure of 29

30. General Rules … Objective information Record what you see avoid saying (condition better) Legibility Print/write plainly and distinctively as possible Neatness No wrinkles, proper speaking of items Place all abbreviation, and at end of statement Composition/arrangement

31. General Rules … Chart carefully consult if in doubt avoid using of chemical formulas Sentences need to be complete and clear, avoid repetition Don’t overwrite Don’t leave empty spaces in between Time of charting Specific time and date Colour of ink Black or blue (red for transfusion, days of surgery, body temperature) It should be recorded on the graphic sheet All orders should be written and signed. Verbal or telephone orders should be taken only in emergency verbal orders & should be written in the order sheet and signed on the next visit.

32. Orders of Assembling Patients Chart It may vary from one hospital to others Vital sign sheet (graphics) Order sheet Physician’s progress notes Nurses notes sheet Intake and output recording sheet Laboratory and other diagnostic reports History sheet Personal and social data

33. Good communication with and by staff leads to increased shared information and clear advice.

34. RECORD … The frequency of entries is generally determined by local policies should be complemented by sound professional judgement . Occasionally, because of the pressure of work in the ICU, it may not be possible to make full notes at the time, for example when admitting and resuscitating a very unstable patient. It is crucial, however, that notes are written at the earliest opportunity, and the fact that they have been written retrospectively should be recorded. All entries in the medical records must include date, time, name (printed) designation (i.e. ICU resident/specialist registrar/nurse) and signature.

35. MEDICAL RECORDS The nature of intensive care Occasionally, because of the pressure of work in the ICU, it may not be possible to make full notes at the time, for example when admitting and resuscitating a very unstable patient. many different individuals are involved in the care of the patient . At the same time, the patient’s condition may change rapidly , requiring frequent changes in therapy . If everyone is to keep up with the patient’s progress, accurate, contemporaneous note-keeping is essential.

36. MEDICAL RECORDS recording the content & outcome of discussion with the patient’s relatives, prevent other staff do not give conflicting advice or opinions. recording in the medical notes what has been said to the family ensures continuity and prevents misunderstandings. leads to increased shared information and clear advice.

37. CONFIDENTIALITY The patient’s medical condition and treatment are matters of confidentiality. While it is generally accepted in intensive care that relatives should be kept informed of what is going on, you must respect the patient’s wishes and confidentiality at all times. Therefore: Make sure you know to whom you are talking before giving out any information. Avoid discussing a patient’s condition on the telephone. You do not know who is on the other end of the line. The press have been known to telephone and not admit who they are. If a relative lives too far away to make it to the hospital, offer to telephone them back on a previously agreed number.

38. RECORD … To fully aware of clients’ rights , familiarizing oneself with documents is worthwhile. to access clients’ records for research purposes, written approval must be obtained from local research ethics committee. The use of client records to supplement summative assignments or other course work is considered a direct breach of client confidentiality and should be avoided

39. CONFIDENTIALITY Occasionally patients may request that information is not given to one or more of their relatives. This should be respected. If difficulties ensue, discuss with senior staff. Never make any comment to journalists . Refer them to your hospital press liaison officer or your consultant . Occasionally the police may request information about a patient or request a blood test. Remember that your first duty is to the patient , no matter what he or she is alleged to have done. If in doubt, refer them to your consultant.

40. TALKING TO RELATIVES Discussions with relatives should generally take place in a quiet room away from the patient’s bedside , unless the patient is awake enough to take an active part in such communications. Do not talk ‘ over ’ the patient , who may be aware of the surroundings and able to hear, but unable to communicate back. (Hearing is said to be the last sensory modality to be lost with sedative drugs.) Do not talk standing in the corridor ; use a side room away from other families. Avoid talking to very large groups of relatives . Speak to key members of the family and encourage them to explain things to other relatives.

41. TALKING TO RELATIVES Adjust the explanation of events to the level of understanding of the relatives, and avoid medical jargon and abbreviations. Be honest and not overly optimistic about the ability of intensive care to turn around desperate situations. There are inherent uncertainties about the outcome of any particular disease, and it is best to be cautious rather than attempting to quote probabilities of survival.

42. TALKING TO RELATIVES It is often useful to explain that intensive care offers a level of support that ‘ buys time ’ for the patient’s body to recover, but may do little to ‘ cure ’ the patient. Rather, recovery depends largely on the physiological and immunological reserve of the patient. Do not criticize other medical or nursing colleagues ’ management of the patient. Remember that hindsight is a wonderful thing. Difficult questions or decisions should be referred to senior colleagues or the referring teams. Do not let family members push you into making statements that are not true. This is particularly important concerning prognosis. Don’t agree with statements like ‘ He is going to be all right isn’t he , Doctor ’ if it is not true.

43. TALKING TO RELATIVES Record in the medical notes what has been said to the family. This ensures continuity and prevents misunderstandings. Accept that relatives will not always absorb bad news the first time they hear it. Time and repeated explanations may be required. Bear in mind that relatives may also be selective about which particular items of your information they choose to retain. Complex psychological issues come into play here, and it is important not to be judgmental . Remember also that different cultural groups respond in different ways to bad news.

44. Patients or relatives and friends of patients are not allowed to read the chart, when necessary but can have access if allowed by patient

45. Questions 45 ?

46. Thanks 46

47. REFERENCES Nursing and Midwifery Council (NMC) 2002 Guidelines for records and record keeping. NMC, London. Hoban V 2003 How to ... handle a handover. Nursing Times 99(9):54–55. 47