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Documentation

The process of obtaining organizing and conveying people health information to others in print or electronic

Why do we document

For quality assurance for facilitation between healthcare professionals to communicate patient plan of care to demonstrate accountability to meet legal requirements

Why clinical documentation

communication education research assessment planning auditing legal requirement

Who should document

All healthcare provider Those with firsthand knowledge Signup and view all the answers

How to document

clear, concise,accurate,truthful,patient centered relevant data all ongoing monitoring and communication care nd service provided evaluation of outcome do not document personal judgement Signup and view all the answers

When to document

at the time of event or asoon as possible not later end of shift as per agency policy never document before you do something Signup and view all the answers

Where to document

MAR- Medication administration record CSRS- Clinical safety reporting system Signup and view all the answers

Remember

Documentation is not optional It is a legal document if not documented it never happened Signup and view all the answers

Respect for a client privacy and not divulging information given in confidence

Confidentiality Signup and view all the answers

Circle of care

Ability to share client health information with implied consent only for the purpose of priding care Signup and view all the answers

Documentation styles- Narrative and problem oriented medical report

Narrative- storylike problem oriented medical report-database, problem list,care plan , progress note Signup and view all the answers

SOAPIE

S_subjective data O- objective data A- assessment P- plan of care I- Intervention E-evaluation Signup and view all the answers

PIE

P-Problem I- Intervention E-evaluation Signup and view all the answers

Focus charting FDAR

F-Focus Specific client concerns ( not a diagnosis) D- data both objective and subjective A-Action R-patient response to the care or action Signup and view all the answers

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Narrative notes

Chronological order Coherence and cohesive Signup and view all the answers

Reporting

Verbal or non verbal Signup and view all the answers

Change of shift reporting

SBAR is commonly used can be orally, audio recording,written info or at patient bedside Signup and view all the answers

Do's in change of shift

Essential background info relevant assessment or change chief nursing diagnosis relevant family info Discharge plan priority needs Signup and view all the answers

Change of shift Dont

Writing all the routine care writing all the info of the patient which is already on their chat writing critical comments about patient-patient is too sturbborn describe basic steps of an action Describe result vaguely Leaving incoming nurse to guess what to do next Signup and view all the answers

TO

Telephone order via the phone Signup and view all the answers

VO

Voice order physically Signup and view all the answers

Individual charting

Clearly indicate if the chatting is late only document what you see or do name date time and signature Signup and view all the answers

Advantages of computer information system

Reduced hospital cost nurse job satisfaction compliance with acrreditation standards Dev of common clinical database Signup and view all the answers

Disadvantages of computerized system

Requires strong security measures for privacy Information can be unavailable during breakdown, power outage are expensive and needs to be updated frequently extended training for staff Signup and view all the answers

SBAR

Standardized verbal communication tool,during emergencies Situation- identify yourself, the patient and what is going on Background-Brief history of the client, allergies,diagnosis,vital signs assessment-what you think is wrong-level of consciousness,patient pain level Recommendation/request-your suggestion, propose an action , then wait for physician to tell you what to do Signup and view all the answers