Fundamentals of nursing documentation

ROYALTY TELEVISION

1. FUNDAMENTALS OF NURSING DOCUMENTATION 2/23/2021 JONES H.M -MBA/DMS 1

2. Documentation is any written or electronically generated information about a client that describes the care or service provided to that client. DOCUMENTING AND REPORTING 2/23/2021 JONES H.M -MBA/DMS 2

3. Documentation allows nurses and other care providers to communicate about the care provided. Documentation also promotes good nursing care and supports nurses to meet professional and legal standards. Through documentation, nurses communicate their observations, decisions, actions and outcomes of these actions for clients. 2/23/2021 JONES H.M -MBA/DMS 3

4. Documentation is about giving an accurate account of what occurred and when it occurred. Nurses document information pertaining to individual clients or groups of clients. 2/23/2021 JONES H.M -MBA/DMS 4

5. To facilitate communication Through documentation, nurses communicate to other nurses and care providers their assessments about the status of clients, nursing interventions that are carried out and the results of these interventions. Documentation of this information increases the likelihood that the client will receive consistent and informed care or service REASONS FOR DOCUMENTATION 2/23/2021 JONES H.M -MBA/DMS 5

6. Thorough and accurate documentation decreases the potential for miscommunication and errors. 2/23/2021 JONES H.M -MBA/DMS 6

7. To promote good nursing care Documentation encourages nurses to assess client progress and determine which interventions are effective and which are ineffective, and identify and document changes to the plan of care as needed. Documentation can be a valuable source of data for making decisions about funding and resource management as well as facilitating nursing research, 2/23/2021 JONES H.M -MBA/DMS 7

8. all of which have the potential to improve the quality of nursing practice and client care. Individual nurses can use outcome information or information from a critical incident to reflect on their practice and make needed changes based on evidence. 2/23/2021 JONES H.M -MBA/DMS 8

9. To meet professional and legal standards Documentation is a valuable method for demonstrating that, within the nurse-client relationship, the nurse has applied nursing knowledge, skills and judgment according to professional standards. 2/23/2021 JONES H.M -MBA/DMS 9

10. The nurse’s documentation may be used as evidence in legal proceedings such as lawsuits, coroners’ inquests, and disciplinary hearings through professional regulatory bodies. In a court of law, the client’s health record serves as the legal record of the care or service provided. 2/23/2021 JONES H.M -MBA/DMS 10

11. Analysis of the Health Care The information of the files can assist the professionals of the health system to point out the needs of the particular nursing institution, as well as the hospital’s services. 2/23/2021 JONES H.M -MBA/DMS 11

12. Different hospitals have different protocols On: how and who to document on the charts. Storage of records How often documentation should be done. How long the file should be kept in the ward after patient is discharged or dies. HOSPITAL POLICIES AND REGULATIONS 2/23/2021 JONES H.M -MBA/DMS 12

13. LEGAL DOCUMENTATION: Legal documentation refers to lawful written information. The client’s record is a legal document and it is acceptable in court as evidence. For example, the positive laboratory results for high vaginal swab would be used as evidence of rape in the court of law especially in this error of girl child sexual abuse by elderly men. PURPOSE OF CLIENT RECORDS 2/23/2021 JONES H.M -MBA/DMS 13

14. Compensation The documentation also assists the client in obtaining compensation from the public and private insurances. In order to obtain compensation, the file of the patient’s clinical situation should have the right diagnosis. 2/23/2021 JONES H.M -MBA/DMS 14

15. COMMUNICATION The records serve as the vehicle by which different health professionals who interact with clients communicate with each other. For example, knocking off nurses give a hand-over at the end of the shift to the taking over nurses. 2/23/2021 JONES H.M -MBA/DMS 15

16. The knocking-off nurses explain to their colleagues who are taking over the condition of the clients in the wards, what type of care and medication had been administered and what had been advised to be done for the client by the Doctor. 2/23/2021 JONES H.M -MBA/DMS 16

17. EDUCATION Students in health disciplines often use medical records such as case notes as educational tools. 2/23/2021 JONES H.M -MBA/DMS 17

18. CONTINUITY OF CARE It is after going through the past records and reports that hospital staff refer patients to other level of care for continuity of healthy care. For example:  The Healthy post personnel refer pregnant women with a record of previous cesarean section to the first level hospital for continuity of care, that is caesarean section procedure. 2/23/2021 JONES H.M -MBA/DMS 18

19. Accountability Records give an account of what the nurse has been able to do the time they have been on duty. With Records and reports available, it is easy to find out the person responsible for an act on the client because the records and reports bear signatures of the caregiver. The caregiver is made responsible for his/her action especially in times of mal practice or negligence. 2/23/2021 JONES H.M -MBA/DMS 19

20. STATISTICS Statistics refers to a science that obtain facts from figures. Statistical information from the client’s records can help an agency anticipate and plan for people’s future needs. For example, the number of admissions, or births and types of illness can be obtained from the records. This same data can help the hospital to plan the type and quantity medicines to buy, the number of beds to buy, the type of vaccines to stock etc. 2/23/2021 JONES H.M -MBA/DMS 20

21. QUALITY ASSURANCE MONITORING The clients record is used to monitor the care the client is receiving and the competence of the people giving that care. 2/23/2021 JONES H.M -MBA/DMS 21

22. REFERENCE Records and reports could be used as references especially in cases of an epidemic like cholera, dysentery and sexually transmitted diseases. Information from the previous records can be used as a guide in management or to solve the problem at hand. For example, the disease notification records are kept and used as references for future use. 2/23/2021 JONES H.M -MBA/DMS 22

23. PLANNING: Planning involves making preparations for something in advance. The data obtained from the records and reports enable the responsible people to plan health services and to allocate resources. 2/23/2021 JONES H.M -MBA/DMS 23

24. Patient’s file which contains the case notes of the hospital visit/stay. Graphic record which indicate body temperature, pulse respiration, blood pressure(BP),weight etc. Fluid balance sheet/record. Medication records/ Drug charts. Progress notes. Discharge records. TYPES OF RECORDS 2/23/2021 JONES H.M -MBA/DMS 24

25. Progress notes are made based on a practitioner client encounter. One of the most widely recommended methods for documenting a particular client encounter is the Subjective Objective Assessment Plan (SOAP) format. This format is widely used in medical practices for documenting client encounters. FORMATS FOR WRITING PROGRESS REPORTS 2/23/2021 JONES H.M -MBA/DMS 25

26. There are many advantages of using the SOAP format and these include; encouraging comprehensive records. reducing unnecessary documentation. assisting in the organisation of the notes, saving time, and facilitating rapid and easy retrieval of information from the record. 2/23/2021 JONES H.M -MBA/DMS 26

27. Subjective Data (S) Presenting complaint, including the severity and duration of symptoms; Whether this is a new concern or an ongoing/recurring problem; Changes in the client’s progress or health status since the last visit; Past medical history of the client and their family, where relevant to the presenting problem; Salient/important negative responses. 2/23/2021 JONES H.M -MBA/DMS 27

28. Objective Data (O) Relevant vital signs; Physical examination appropriate to the presenting complaint; Positive physical findings; Significant negative physical findings as they relate to the problem. 2/23/2021 JONES H.M -MBA/DMS 28

29. Assessment (A) Patient risk factors, if appropriate; Ongoing/recurring health concerns, if appropriate; Review of medications, if appropriate; Review of laboratory and procedure results, if available; Review of consultation reports, if available; Diagnosis, differential diagnosis, or problem statement in order of probability and reflective of the presenting complaint. 2/23/2021 JONES H.M -MBA/DMS 29

30. Plan (P) Discussion of treatment options; Tests or procedures ordered and explanation of significant complications, if relevant; Consultation requests including the reason for the referral, if relevant; New medications/remedies/supplements ordered and/or medication repeats including 2/23/2021 JONES H.M -MBA/DMS 30

31. dosage, frequency, duration and an explanation of potentially serious adverse effects; Any other patient advice or client education (e.g., diet or exercise instructions, contraceptive advice); Follow-up and future considerations Specific concerns regarding the client including client refusal to comply with your suggestions. 2/23/2021 JONES H.M -MBA/DMS 31

32. Written records should be- Factual, consistent and accurate Should be complete Well organised Written as soon as possible after an event has occurred, providing current information on the care & condition of the patient. Written clearly in such a manner that the text can not be erased Accurately dated, timed and signed with the signature printed alongside the first entry GUIDELINES FOR RECORDING 2/23/2021 JONES H.M -MBA/DMS 32

33. Not include abbreviations, jargon, meaningless phrases, irrelevant speculation or offensive subjective statements Written wherever possible with the involvement of the patient or carer and in terms that the patient can understand Written in pen and not pencil 2/23/2021 JONES H.M -MBA/DMS 33

34. REPORTING Reporting is meant to communicate specific information to a person or a group of people. A report is oral or written or computer based communication intended to convey information to others. A report whether oral or written should be concise, including pertinent information. The purpose is to provide a permanent and accurate record of relevant data. REPORTING AND CONFERRING 2/23/2021 JONES H.M -MBA/DMS 34

35. A report is a legal document. It is required by law to be kept for a period of five (5) years. The report must have correct spellings, particularly on drugs and leave no doubt concerning the information it contains. Only universally accepted abbreviations must be used. It should be signed by the person who has written it. 2/23/2021 JONES H.M -MBA/DMS 35

36. CHANGE OF SHIFT REPORTS This is a report given to all nurses on the next shift. Its purpose is to provide continuity of care for clients by giving new care givers a quick summary of client’s needs and details. The change of shift report should describe each client’s health status and lets the staff on the next shift know what care the client will require. Types of reports 2/23/2021 JONES H.M -MBA/DMS 36

37. A written report is made three times daily, in the morning by the night staff, at midday by morning staff and in the evening by the afternoon staff. 2/23/2021 JONES H.M -MBA/DMS 37

38. Handover reports The nurse taking over the ward must give her undivided attention to her work, and this procedure should be conducted in a quiet manner without unnecessary interruptions. Any mistakes must be corrected and clarifications made there and then. Report should be given from bed to bed starting with the acutely ill patients.   2/23/2021 JONES H.M -MBA/DMS 38

39. All discharges and transfers and to where, if relatives have been notified. All deaths including condition of the client leading up to death time and doctor called if relatives notified. All pre and post-operative clients (at least 48 hours condition on return from theatre, medication ordered and if given or nay treatment ordered. All pre-operative clients for special 2/23/2021 JONES H.M -MBA/DMS 39

40. investigations state preoperative preparations carried out etc. All clients in acute conditions. All clients on blood transfusion or infusion – length of time when commenced, rate of flow etc. 2/23/2021 JONES H.M -MBA/DMS 40

41. The important details to be included in the ward report are: All admissions, name, age time of admission, religion, next of kin, diagnosis if seen by a doctor, any abnormalities and ordered treatment and investigation to be clearly stated. 2/23/2021 JONES H.M -MBA/DMS 41

42. All accurately ill clients e.g. recent head injury, cerebral malaria, intestinal obstruction, meningitis and acute cardiac failure. Clients on special observations or procedures like strong analgesics, 24 hours urine collection etc  NB: Observations of the above clients must be carefully reported, what drugs given, dosage and time, fluid balance stated. 2/23/2021 JONES H.M -MBA/DMS 42

43. The report particularly on very ill and newly admitted should be detailed. No personal comments should be written in the report. A nurse reports what he/she observes not what he/she feels about a client. Remember to sign the report. 2/23/2021 JONES H.M -MBA/DMS 43

44. ADMISSION REPORT On admission, a detailed ward report should be written indicating name, age, sex, time of admission, date of admission, address, religion, next of kin, 2/23/2021 JONES H.M -MBA/DMS 44

45. where client is coming from diagnosis, bed number medication client is getting including dosage and frequency observations done investigations done or to be done general condition of the client indicate whether the client has been seen by the Dr or not 2/23/2021 JONES H.M -MBA/DMS 45

46. Progress report This is a report written on a client who is on the ward. The nurse’s progress notes provide information regarding the progress of a patient towards the establishment of the desirable results. It should indicate the progress the client is making, how the client spent the day, any thing special about the client eg had diarrhoea, vomited, has a fever, etc. The report should also indicate the treatment the client is getting. All observations done should be indicated. 2/23/2021 JONES H.M -MBA/DMS 46

47. Incident Report This is the report of any event that is not consistent with the routine operation of the health care unit or care of the patient, e.g. client falls, client given overdose, needle stick injury, suicidal attempt, nurses fighting on duty, nurse beaten on duty etc. incident report should have a detailed account of how the event or incident happened. 2/23/2021 JONES H.M -MBA/DMS 47

48. Transfer report This is the report which is written when a client is transferred from one unit/ward/hospital to another for specialised care at a different level, e.g. a client being transferred from intensive care unit to a general ward. A transfer report can be given on phone or in person. The following should be included in the report; 2/23/2021 JONES H.M -MBA/DMS 48

49. Client’s name, age, and medical diagnosis Summary of the progress the client has made since admission and the current health status of the client 2/23/2021 JONES H.M -MBA/DMS 49

50. Death report This should include the detail of the client i.e. name, age, date of admission, diagnosis and management the client was receiving. It should include what has been done before death, the treatment which was being given and the resuscitations measures carried out. The time of death and time of certification should be recorded. 2/23/2021 JONES H.M -MBA/DMS 50

51. Discharge report. This report should include all the particulars of the client (name, age, address, diagnosis etc), date of admission, and the medication. Indicate what time the patient was discharged what medication he/she will take home. Also indicate if the client is still on the ward or has gone with the relatives. 2/23/2021 JONES H.M -MBA/DMS 51

52. The report should also include the type of discharge e.g. by the MO in charge or by themselves (LAMA- Leave against medical advice) where the client or relative sign against advice of medical personnel. 2/23/2021 JONES H.M -MBA/DMS 52

53. Health team members consult among themselves to exchange ideas and knowledge. We confer by consultation e.g. writing a consultation form to a particular dept. Making referrals. Case conferences Drs come together and discuss certain conditions e.g Hospital major rounds. CONFERRING 2/23/2021 JONES H.M -MBA/DMS 53

54. Nurses major rounds. Handover time. Departmental meetings. 2/23/2021 JONES H.M -MBA/DMS 54