NSE 101 Week 9 Students - Documentation PDF

Documentation © Communicatio n Course What is Documentation? Paper and electronic Points of Consideration keeping Information and communication technologies (ICT) The client chart / ICT is an umbr...

Documentation © Communicatio n Course What is Documentation? Paper and electronic Points of Consideration keeping Information and communication technologies (ICT) The client chart / ICT is an umbrella term used to describe the technology-based tools that nurses use health record in the clinical environment, including the The nursing process client’s electronic record. Documentation can be facilitated by using ICT; these digital technologies allow “the electronic capture, processing, storage, and exchange of information” (Gagnon et al., 2012, p.241). (Lapum et al., 2020) Reasons for Documentation Legal obligation College of Nurses of Ontario Documentation Practice Standard Points of Communication, continuity of care, Considerati and clinical judgment on Client safety Documentati Quality improvement on and Violence Funding Research Population and clinical health insights (Lapum et al., 2020)  Documentation Components Flow or graphic sheets Admission sheet Kardex or summary Progress notes / sheet interdisciplinary notes Nursing care plans Referrals and Operative procedures consultations Diagnostic, laboratory Discharge plans/summaries and therapeutic orders Critical incident reports Medication administration record – Workload measurement the MAR tools (Lapum et al., 2020) Progress note - example Date Time Discipli Notes (year/mm/dd ne ) 2020/10/01 1405 Nursing Reason for seeking care “itchy red rash on left ankle and foot.” ------ Client thinks it might be poison ivy as they were camping last week. They tried an ointment from home, does not recall name, but it has not helped……… NOTE: AFTER A FULL NOTE, YOU MUST SIGN YOUR FULL NAME AND DESIGNATION Vital sign graphic sheet - example Electronic Documentation Systems Electronic Documentation Systems Electronic medical records and electronic health records Benefits Points of Consideration - The Status of EHR The status of EHR deployment, maturity, and Real-time data use varies among organizations, provinces and Seamless care territories. It is important to note that EHRs are not simple replacements of paper records; Interprofessional EHRs change workflow significantly when communication compared to paper records (i.e. how nurses work, document, and manage information). Analysis EHR vendors Structured and unstructured data elements (Lapum et al., 2020) Principles of Documentation What are the indicators for the standard statements of CNO Documentation Practice Standard? Communication “Nurses ensure documentation presents an accurate, clear, and comprehensive picture of the client’s needs, the nurse’s interventions and the client’s outcomes” (p.6). Accountability “Nurses are accountable for ensuring their documentation of client care is accurate, timely, and complete” (p.7). Security “Nurses safeguard client health information by maintaining confidentiality and acting in accordance with information retention and destruction policies and procedures that are consistent with the standard(s) and legislation” (p. 8). (CNO 2019 as cited in Lapum et al., Privacy, Confidentiality and Security Privacy rights of personal information and person’s Points of Consideration right to access information Who Owns the Client Record? Clients have the right to access their own The Personal Health personal health information. In 1992, the Supreme Court of Canada, indicated that Protection Act (PHIPA, 2004) although the institution or physician owns the legislates collection, use, physical client record, the client owns what’s inside of it and has the right to receive a full copy and disclosure of personal of the record, except in certain situations where the likelihood of this act would cause harm to the health information by client (as cited by Canadian Medical Protective health information Association, n.d.a, 2019). custodians – YOU Disclosure exceptions (As cited in Lapum et al., 2020) Methods of Documentation Charting by exception Narrative Nursing process focused on issue/concern/problem Data action response (DAR) Assessment plan intervention evaluation (APIE) Subjective objective assessment plan intervention or evaluation (SOAPIE) (Lapum et al., 2020) The Future of Documentation Role of the client Points of Consideration As a healthcare professional, it is Data literacy important that you are aware of the biases inherent with artificial intelligence (AI) EHR documentation (Canadian Medical Protective Association [CMPA], n.d.b). AI is programmed by a person, and each one of has inherent biases. If the program is created with a bias, it becomes systematized into the algorithm. It is recommended that AI is considered as a clinical aid to supplement, but not replace your own clinical judgment (CMPA, n.d.b). (Lapum et al., 2020) Keypoints Documentation includes paper and/or electronic record keeping of a client’s health state and their care. Nurses are legally obligated to complete accurate, timely, and comprehensive documentation. In Ontario, nurses must adhere to the College of Nurses of Ontario practice standard related to documentation. PHIPA is an important provincial legislation that nurses are obligated to comply with. (Lapum et al., 2020)