Patient Documentation Guideline V4 PDF

GUIDELINE TO THE COMPLETION OF PATIENT DOCUMENTATION Documentation Guideline MCSA.Clincial Training.V4 TABLE OF CONTENTS General Information............................................................................................................................................... 3 Purpose............................................................................................................................................................................... 3 Applicability......................................................................................................................................................................... 3 Policy Statement................................................................................................................................................................. 3 Critical Elements In Documentation.................................................................................................................................... 4 Completion: General Assessment Record (N0953)....................................................................................................... 6 Completion: Waterlow Pressure Sore Risk Assessment (N3297)............................................................................... 20 Completion: Venous Thrombo-Embolism (Vte) Risk Assessment (N3297)................................................................. 24 Completion: Signature Sheet (N3373)......................................................................................................................... 29 Completion: Adult Early Warning Observation Record (N3182).................................................................................. 30 Completion: Patient Care Plan Basic Needs (N0909)................................................................................................. 38 Completion: Specific Patient Care Plan (N1012)......................................................................................................... 44 Completion: Fluid Balance Record (N0949)................................................................................................................ 46 Completion: Peri-Operative Record (N0997)............................................................................................................... 51 Completion: Post-Operative Patient Care Plan (N1000).............................................................................................. 54 Completion: Implementation Record (N1009).............................................................................................................. 58 Completion: Prescription Chart (P1002)...................................................................................................................... 60 Completion: Prescription Booklet (P3246)................................................................................................................... 65 Responsibilities............................................................................................................................................................ 85 Associated Documents and Records........................................................................................................................... 85 History and Version Control......................................................................................................................................... 87 Approval and Sign-Off................................................................................................................................................. 87 Guideline to Completion of Patient Documentation v 4 Effective date: 01.01.2025 Mediclinic Training and Development GENERAL INFORMATION PURPOSE The purpose of this document is to guide users in the completion of adult patient nursing and clinical records. It can be used as a reference to ensure patient documentation is completed correctly and consistently in all clinical facilities. Accurate and comprehensive recording is essential to:  Provide a description of the patient’s condition, treatment plan, care interventions and the patient’s reaction to care.  Ensure effective communication between the members of the patient care teams  Support investigations, e.g. following adverse events, legal enquiries and complaints  Inform medial aid authorisation and billing of patient admission and treatment  Provide information for accurate clinical coding, which impacts on statistics, funding and strategic decisions. APPLICABILITY This policy applies to nursing practitioners and users who record information in adult patient nursing and clinical records. POLICY STATEMENT All nursing practitioners and employees involved in clinical care must comply with the legal requirements set specific to clinical records and standards related to record keeping. Essential elements in quality nursing documentation include:  Patient records should reflect the nursing care rendered; the patient’s reaction to nursing care and treatment, and the communication with the multi-disciplinary team members.  All categories of nurses are responsible and accountable for the recording of all nursing interventions and other events.  Only Mediclinic approved patient records may be used.  Use the blank areas on the document to give more information about abnormalities.  Mediclinic makes use of circling options in assessment documents. No ticks (√) or crosses (×) to indicate choices.  Do not repeat information you have recorded on the flow records (e.g. fluid balance record), except in case of an abnormality. The following must be recorded: o the specific abnormality o the person whom the abnormality was reported to o the relevant nursing interventions Guideline to Completion of Patient Documentation v 4 Effective date: 01.01.2025 Mediclinic Training and Development  All patient documentation must reflect a complete picture of the entire period of hospitalisation in a legal and valid manner.  All diagnoses, including the admission and discharge diagnoses should be recorded.  All secondary conditions and comorbidities treated during the hospitalisation should be documented.  All complications, both medical and surgical should be documented  Nursing documentation must be patient-centered  Contain the actual work of nurses – including the education and psychosocial support  Reflect the objective clinical judgment of the nurse  Be presented in a logical and sequential manner  Written contemporaneously, or as events occur  Record variances in patient care provided  All documentation must comply to legal requirements CRITICAL ELEMENTS IN DOCUMENTATION TERM Description Legible All handwriting must be neat and legible for all to read. Only Mediclinic approved stationary may be used. Accurate Only accurate facts regarding what happened, what was done about it and the consequences should be recorded. Concise Recording must be the point whilst retaining clarity. Credible The actual facts must be documented continuously. Actions may be recorded only after it was carried out. Chronological Entries must follow chronologically with regard to time and occurrence. Late entries must be recorded under the last entry, referring to the time of the previous incident. Times written on records should reflect the actual time the action happen e.g. 08:20. Permanent Recording is carried out in permanent black ink, unless hospital policy/ unit specific requirements stipulates otherwise. Pencil and pens, of which the writing fades or is erasable, are not permitted. Free of Erasures A line should be drawn through the incorrect entry and the nurse should initial next to it. No correctional fluid/tape (Tipex) or stickers over the error are allowed. Differentiation Entries should be differentiated from each other by writing each on a new line. Entries by different nurses must be distinguishable. Identifiable Each patient record must be identified with the correct patient sticker or the patient’s initials and surname, hospital number, date of birth and treating medical practitioner. A new patient sticker may not be placed over Guideline to Completion of Patient Documentation v 4 Effective date: 01.01.2025 Mediclinic Training and Development TERM Description a previous patient’s sticker. When the patient moves from one unit to another, the new unit must be indicated on the records. Identifiable Each entry must be accompanied by an identifiable signature and rank. signatures and i.e. signature accompanied by printed name. Initial on relevant records as ranks indicated on signature page (employee number or agency number). If a signature is not identifiable, the nurse must print his/her name under the signature or where applicable. Initials may only be used where indicated. Only Mediclinic recognised abbreviations of rank/designation may be used. Guideline to Completion of Patient Documentation v 4 Effective date: 01.01.2025 Mediclinic Training and Development COMPLETION: GENERAL ASSESSMENT RECORD (N0953) GENERAL INFORMATION  The document is divided into different sections and can be used for a patient in an admission center and direct admission into the nursing unit.  In most instances during patient assessment, only the appropriate word or statement must be circled.  Fill in extra information where applicable in the open spaces next to the words.  The record will be identified by only one patient sticker on the front page.  The assessment must be completed as soon as possible after admission.  If the admission center nurse identifies a special need during the assessment, e.g. a language requirement, an interpreter must be organised and arranged prior to admission to the hospital. WELCOME AND ORIENTATION  Warmly welcome the patient to your nursing unit. They are anxious and in an unknown environment.  Identify the document with patient sticker, or record title, initials &surname, date of birth, folder number and treating doctor.  Socio-cultural needs to be assessed.  Determine the patient’s language preference/home language. If the patient’s first language is not one that you can speak, determine a communal language e.g. English/Afrikaans. Determine special needs regarding communication (deaf, hard of hearing, hearing aid).  Determine if the patient has any cultural or religious beliefs that may impact on nursing care or recovery and make a note thereof and record the religion at the open space.  Introduce yourself to the patient and introduce the patient to the other patients in the room (if they would like to be introduced). Guideline to Completion of Patient Documentation v 4 Effective date: 01.01.2025 Mediclinic Training and Development  Write down who accompanied the patient into your nursing unit and obtain their contact details, or the next-of-kin’s contact details, should consent or more information be needed pertaining to the patient or their condition.  Find the Online Clinical Assessment (OCA) forms in the patient’s admin folder (about 35% of surgical admissions would have completed the forms). If there are OCA forms:  Thank the patient for completing/submitting the form.  Verify the clinical information on the form.  Add or change the information on the form.  Sign and date each form as proof that the information was verified by the nurse.  File the OCA forms adjacent to the General Assessment form in the patient file.  The grey areas on the assessment forms, remind the nurse that related information will be available on the OCA form (if and OCA was submitted).  Ask the patient if they have any medication or food-related allergies and record in allergies block. Or put a red sticker in the block provided and record the known allergies. Should the patient have no allergies, record ‘no known allergies’ in the space provided or put a green ‘no known allergies’ sticker in the block provided.  Admission from another healthcare facility: Only complete when one of these is applicable. If not applicable, write N/A next to the block.  The admission diagnosis as stated on the admission form, received from reception or admission center. Please note that a procedure, e.g. appendectomy, is not a diagnosis. Determine the reason for the procedure from the patient or treating doctor.  Remember a full signature and personnel number are needed on the Signature Sheet. CLINICAL ASSESSMENT  A clinical assessment takes place when the patient’s history (subjective data/symptoms), a quick systematic physical examination and basic tests (objective data/signs) are obtained and performed.  The following history is collected:  Current  Medical  Surgical  Travel  Family  The physical examination and tests are systems-related, but more in-depth examinations regarding specific systems will be needed, depending on the history obtained.  To be able to assess the patient sufficiently, there is a need for certain verbal and non- verbal skills and one must be able to perform a physical examination that includes inspection, percussion, palpation and auscultation. The use of all senses is essential e.g. sight, smell, hearing and touch. Guideline to Completion of Patient Documentation v 4 Effective date: 01.01.2025 Mediclinic Training and Development  More detailed information can be written in the open spaces next to the data that needs circling to indicate problems. The more detail written here the less needs to be written in the Implementation record.  As it is not always possible to immediately do a clinical assessment. The time of welcoming and orientation may differ from the time of the clinical assessment. MEDICAL AND SURGICAL HISTORY Current Complaint  This addresses the reason why the patient is admitted to hospital or why the patient is seeking help. Listen to what the patient explains and write a short summary in medical terminology. If the patient is admitted for an operation or procedure, determine the reason for the operation (this reason is the admission diagnosis).  Onset is when this problem started.  Signs are the problems that you can see/hear/feel in your patient e.g. cyanosis, crepitation.  Symptoms are all the problems the patient is complaining about e.g. nausea, pain, burning sensation (things the patient needs to tell you about).  Progress of symptoms addresses whether/ how the symptoms have progressed, is it getting worse or better.  Duration indicates for how long the patient have experienced these signs and symptoms.  Aggravating factors are worsening the problem. Report on actions / treatments that make the condition / signs and symptoms worse and not only make the pain worse. Guideline to Completion of Patient Documentation v 4 Effective date: 01.01.2025 Mediclinic Training and Development  Alleviating factors relieve/improve the problem. Report on actions and treatments that improve or make the condition / signs and symptoms better for this specific patient. Medical History and Co-Morbidities  Circle the identified co-morbidity or write next to ‘other’ if the co-morbidity is not stated on the list. Surgical History  Ask the patient to provide you with a surgical history.  It is important to note the name of the procedure, the date it was performed (if the patient cannot remember, just a month or year will suffice) and note any complications experienced during and after the surgery. This includes complications/ reactions due to anesthetics. Previous Hospitalisation  Indicate the date and duration of the patient’s previous hospitalisation. Previous Resistant Organism  Indicate whether the patient has a known previous resistant organism, this will help the medical practitioner in prescribing medication that is effective, and the IPC-manager to suggest effective infection control measures. Recent Travel History  Indicate the date and place the patient travelled to that is not situated in South Africa. Also indicate if the patient visited and area within South Africa that have known risk factors/ conditions e.g. areas with known Malaria outbreaks. Family History  All medical conditions in the immediate family are noted here, including of parents, grandparents and siblings.  Also note any conditions that are hereditary or if the person has a known risk factor for a hereditary condition.  Pain: Report on the pain level that the patient verbalises after the explanation of the pain scoring system. Report on the pain score; the duration (length of time) that the patient has been experiencing the pain; the site of pain (location); and the characteristics (e.g. stabbing, sharp, throbbing, dull, burning) of the pain. Pain should also be indicated on the Adult Early Warning Observation Record (N3182). Guideline to Completion of Patient Documentation v 4 Effective date: 01.01.2025 Mediclinic Training and Development VALUABLES AND BELONGINGS  Record what happened to patient’s belongings.  Doctor’s prescriptions ̶ circle the documents or results brought along to the hospital.  Circle the numbers describing the patient’s possessions, valuables or medication they are admitted with.  In the last three rows of this section use the corresponding number of the items circled to indicate what the patient kept at own risk, locked away or sent home.  The patient or person receiving the items must sign that they take responsibility for the indicated items. HABITS  It is advisable not to voice a judgmental opinion or give health education regarding bad habits during the assessment. You are still in the process of building a trust relationship with your patient.  Ask the patient how they experience their appetite. If the appetite is poor, indicate the reason e.g. metallic taste in mouth, nausea, painful swallowing.  Smoking “stopped” indicates a period longer than one week and not stopped since that morning. If the patient is still smoking, circle ‘yes’ and indicate how much they smoke a day.  Alcohol – assume that all patients will drink some alcohol and ask them when last they had an alcoholic beverage and what beverage they prefer. This way you may receive more honest answers. Guideline to Completion of Patient Documentation v 4 Effective date: 01.01.2025 Mediclinic Training and Development  Determine your patient’s sleeping patterns and indicate if your patient has a problem falling asleep or waking up frequently during the night. This will help you determine if you need to request sedatives for your patient or where in the unit you might place your patient if beds are open. MOBILITY  Mobility is the way your patient enters the unit. Circle the appropriate support, if any, your patient required on admission. EMOTIONAL STATUS  Emotional status determines the patient’s emotion during the admission process. It is not something you need to ask the patient, but something you need to assess by watching the patient’s reactions and body language. Ensure that you understand the meaning of each of the words used to describe the emotions. SENSES  Senses address only visual and auditory problems. Should you determine that taste or sensation is a problem you should report it in the implementation record. PROTHESIS  Prosthesis indicates anything artificial in the human body.  The most common one (dentures) is listed, but it is your responsibility to determine if your patient has more e.g. hip replacement, shoulder replacement, pacemaker, breast implants, artificial limbs or eye.  Prosthesis has nursing implications e.g. no injections may be given on the side of a joint replacement. SEPTIC FOCI  A foci or infection causing bacteremia or toxemia due to the absorption of toxins and bacteria, e.g. lesions, blisters, abrasions on the skin and mucous membrane of the mouth.  Indicate site and describe the appearance of the septic foci next to the circled ‘yes’. Guideline to Completion of Patient Documentation v 4 Effective date: 01.01.2025 Mediclinic Training and Development  Remember to complete a Wound Assessment form (N1541) if the patient has septic foci and notify the Infection Prevention and Control Manager of your hospital. SKIN  Skin ̶ Indicate the skin condition here.  Look out for signs of abuse and bruises on your geriatric patients, women and children specifically. You may only pick this up while doing a visual skin inspection.  Ulcers are a discontinuity of the skin or break in the skin that stops it from continuing its normal function.  Necrosis is where the skin/tissue is already in a stage of dying and presents as a dark coloured or black area, which may or may not be hard to touch.  Remember to complete a Wound Assessment form (N1541) if the patient has septic foci or other skin lesions and notify the IPC Manager of your hospital.  Be careful not to rely on the patient’s verbal response only, but on your observations.  Waterlow scale – This will be discussed in detail, fill in the score the patient obtained after completion of the Waterlow scale. NERVOUS SYSTEM Verbal  Listen to what your patient is saying and determine if they are orientated. You can also ask questions to determine perception of time, place and person. Muscular Strength  This test requires that you test either arms or legs simultaneously.  Ask the patient to push your hands up / down with his or her hands / legs.  Note if muscular strength is diminished or absent.  Be careful if you ask the patient to ‘push away’ when testing the muscle strength in the legs, patient may cause you injury when they ‘kick’ you away.  You also need to indicate if hemi-, para- or quadriplegia is present, or if muscular strength is diminished. Guideline to Completion of Patient Documentation v 4 Effective date: 01.01.2025 Mediclinic Training and Development Sensation  Sensation on the skin needs to be assessed especially with the diabetic patient as they often suffer from neuropathy.  Touch the feet of the patient on e.g. left lateral side and ask patient to tell you where you touch them.  Do not use any needles or potential harmful objects to perform this test. Pain  Report on the pain level that the patient verbalises after the explanation of the pain scoring system. Report on the pain score; the duration (length of time) that the patient has been experiencing the pain; the site of pain (location); and the characteristics (e.g. stabbing, sharp, throbbing, dull, burning) of the pain.  Pain should also be indicated on the Adult Early Warning Observation Record (N3182). CARDIOVASCULAR SYSTEM Vital Signs  Complete the data obtained when you performed the baseline vital signs.  Write N/A in the open spaces if the value is not needed, do not leave any open spaces. Heart Rhythm  This is not something picked up by the electronic blood pressure machines e.g. Dynamap®.  You must obtain this information when your fingers are on the pulse of your patient, and you count the heart rate and respiration.  You must feel if the pulse beats with a regular or an irregular rhythm.  Also assess the quality (bouncing or fluttering) of the pulse. Skin  The skin is usually the first organ to receive less blood if the vital organs need blood for oxygen or nutrients.  Flushed skin may indicate infection or pyrexia.  Pale clammy, cold skin might indicate poor circulation. Guideline to Completion of Patient Documentation v 4 Effective date: 01.01.2025 Mediclinic Training and Development  Oedema relates to poor peripheral venous return, over-hydration, a capillary leak or right sided heart failure.  Cyanosis indicates a lack of oxygen. Skin Turgor  This is a test to determine the hydration status of the patient.  The best area to determine this is on the breastbone of the patient by lightly pinching the skin between your forefinger and thumb. Lift the skin gently and see how long it takes to go back to the normal skin position.  Remember that turgor will reduce with age but that these patients fall into a vulnerable group for dehydration. Capillary Refill  This is to test peripheral blood flow.  Slower time indicates poor perfusion to the peripheries.  This test is done by pressing down with the pad of your thumb on the fingernail of your patient for one second until it blanches and then releasing the pressure.  The normal reperfusion should occur within 3 seconds and the colour of the fingernail should return to normal. Pedal Pulses  This is the pulse palpable on the foot.  The pedal pulses of all patients going for surgery below the umbilicus, orthopaedic surgery of the lower extremities and cardiac patients should be assessed. RESPIRATORY SYSTEM Vital Signs  Complete when you performed the baseline vital signs. Guideline to Completion of Patient Documentation v 4 Effective date: 01.01.2025 Mediclinic Training and Development  Write N/A in the open spaces if the value is not needed, do not leave any open spaces. Respiratory Pattern  On visual inspection of the patient, you will note if the respiratory pattern is regular or irregular.  You will assess this while holding the patient’s wrist for a pulse count.  You also need to assess if the respiration attempts are shallow or deep.  Other patterns may also be noted and recorded in the Implementation Record. Dyspnea  Visual inspection for difficult or laboured breathing; if shortness of breath is present. Could be a sign of respiratory, neurological or cardiac problems.  If yes is circled, provide more detailed information on what you observe. Cyanosis  Visual inspection of skin that indicates a bluish discoloration of the skin is a late indicator of hypoxia.  Central cyanosis is visible in and around the mouth while peripheral cyanosis is visible on the fingertips and toes.  If yes is circled, provide more detailed information on what you observe. Oxygen Therapy  Indicates method of oxygen administration.  Remember if you admit the patient breathing room air who might need oxygen, your first nursing action will be to administer oxygen and then to record the reasons why in the Implementation Record.  Patients admitted with oxygen masks in place are usually admitted via the emergency centre, theatre, ambulance or from another institution or unit.  If oxygen mask or nasal cannula is circled, provide the % of oxygen administered and/or the flow rate and record on the Adult early warning observation record (the type of oxygen delivered e.g. NC/ FM) and the implementation record (the % of oxygen delivered). Chronic Respiratory Condition  Indicate whether the patient have a chronic respiratory condition e.g. COPD, emphysema.  If yes is circled, then write down the name of the condition next to the yes. Cough  Results from irritation (infections, environmental) of mucous membranes.  If yes is circled, indicate whether the cough is productive, unproductive and whether haemoptysis is present.  Indicate next to the chosen option more details, e.g. how long this is present or when is it worse (morning/ evening). Guideline to Completion of Patient Documentation v 4 Effective date: 01.01.2025 Mediclinic Training and Development Fever > (more than) 2 WEEKS  Indicate a simple yes or no. Night Sweats  Indicate a simple yes or no.  This may be an indication of tuberculosis. Ask when the night sweats started. Uexplained Weight Loss  Indicate a simple yes or no. Tb treatment  Indicate whether the patient is currently on TB treatment, circle yes or no.  Indicate whether the patient had previous TB treatment and indicate the duration of treatment. GASTRO-INTESTINAL SYSTEM Weight and Height  During the assessment phase, the patient is weighed and measured.  The body-mass index (BMI) is then calculated, make use of the formula or chart to determine the patient’s BMI. Fluctuation In Weight  Might be related to diabetes, fluid loss or fluid excess, altered nutrition or other reasons.  If yes is circled, indicate whether it was an increase or decrease in weight. Food Tolerance  Indigestion and upper abdominal discomfort are the causes of numerous gastro-intestinal problems.  Ask the patient for any food intolerances known or whether food ingestion causes nausea and/or vomiting. Guideline to Completion of Patient Documentation v 4 Effective date: 01.01.2025 Mediclinic Training and Development  Dysphagia is difficulty in swallowing and is usually related to cerebro-vascular incidents, oral and oesophageal infections e.g. tonsillitis or other neurological system abnormalities.  Your patient may also be nil per mouth for planned surgery. Diet  Ask the patient if they follow a specific diet at home and indicate in the space next to ‘Home Diet’ (e.g. diabetic, vegetarian, high roughage, low carbs, halal, kosher)..  Enquire when the last oral intake occurred, as some patients may have missed meals due to the admission procedure and investigations.  It will be good client service if you can offer such a patient a meal even if it is after scheduled mealtimes. Stools  This section must always be completed with your patient’s perception of a ‘normal stool’.  You need to indicate what the patient considers as ‘regular stools’.  Some may consider a stool once a day and others one in three days as normal, indicate the information next to ‘frequency’.  The patient should indicate if they experience their stools as loose or constipated.  Determine if the patient is incontinent of faeces as that would increase the risk for skin breakdown. Jaundice  Jaundice is the yellow discoloration of skin or sclera of the eyes and may indicate an abnormality or infection of the liver.  If yes is circled, indicate any medication and duration of jaundice. Stoma  A stoma is a surgical opening of the small or large intestines on the abdomen.  If yes is circled, indicate the type of stoma e.g. colostomy or ileostomy. ENDOCRINE AND RENAL SYSTEM Endocrine  A blood glucose test should be performed for patients at any risk of hypo/hyper glycaemia. Guideline to Completion of Patient Documentation v 4 Effective date: 01.01.2025 Mediclinic Training and Development Urine  A urine test must also be performed and recorded.  The date and time the urine test was performed must be recorded. Add the signature of the person who performed the urine test.  Where no values are needed or if urine test is not needed, write N/A in the open spaces. Urinary pattern  Common problems associated with voiding include frequency and urgency; other abnormalities include dysuria, retention or incontinence.  Nocturia is excessive urination at night that may indicate diabetes, kidney disease or medication related effects, e.g. diuretic use.  If urgency or retention was circled, more detail must be provided in the space. REPRODUCTIVE SYSTEM Discharge  A vaginal or penile discharge should be reported.  If ‘yes’ was circled, provide more details regarding the discharge. Swelling  Ask the patient or examine for penile swelling, valvular or perineal swelling. Contraception  Ask the patient (if of child-bearing age) if she uses contraception.  If ‘yes’ is circled, provide the name or type of contraceptive.  If this is not applicable, circle ‘N/A’. Pregnant  Numerous medications and treatments are contra-indicated during pregnancy.  It is also important to record the mother’s blood group as some women will need anti-D immunoglobulin (deliveries, miscarriages or abortions).  If this is not applicable, circle ‘N/A’. Guideline to Completion of Patient Documentation v 4 Effective date: 01.01.2025 Mediclinic Training and Development Menstruation  For hygiene purposes and to ensure comfort.  This will also help to prevent septic shock if a tampon is left in situ by accident or after surgery.  If this is not applicable, circle ‘N/A’. FALL RISK ASSESSMENT  No formal assessment document to complete for fall risk.  Only circle applicable options. Any element circled indicate that the patient is at high risk of falling, and additional precautions are required.  All patients are treated as patients at risk of falling.  Please refer to the MCSA policy: Prevention of slips, trips and falls on Intranet. COMPLETION  Staff member who performed the observations & point of care tests, record their initial and surname, as well as the date and time it was done  The nurse who performed the assessment record their initial and surname and sign underneath. Guideline to Completion of Patient Documentation v 4 Effective date: 01.01.2025 Mediclinic Training and Development COMPLETION: WATERLOW PRESSURE SORE RISK ASSESSMENT (N3297) GENERAL INFORMATION  Remember you are assessing the patient’s risk of developing a pressure sore during the hospital stay.  Please refer to the MCSA policy on Intranet: Risk assessment scales and prevention of pressure injury.pdf.  You are allowed to use more than one score or category.  Record the date in the first row of blue blocks every time you do an assessment  The time is recorded in the second row of blue blocks, where the ‘:’ sign is, time is indicated as 09:00 or 23:00. CATEGORIES BUILD/ WEIGHT FOR HEIGHT  Consult the General Assessment document for BMI score. if no BMI score was calculated you must weigh and measure the patient then calculate the BMI score.  It is essential to measure and weigh the patient accurately and not to use what the patients says.  An obese patient is at greater risk of complications and staff working with the obese patients are at risk for back injuries.  Once you know the patient’s BMI you can indicate if the patient is average weight, obese or below average. Guideline to Completion of Patient Documentation v 4 Effective date: 01.01.2025 Mediclinic Training and Development SKIN TYPE & VISUAL RISK AREAS  More than one option for skin type & visual risk areas may be applicable to your patient.  All applicable options must be indicated. GENDER & AGE  Write down the number under the score next to the applicable gender and age of the patient.  There should always be two scores in this area, one for the gender and one for the age group. APPETITE  Indicate by writing the applicable number in the scoring column. CONTINENCE  Indicate by writing the applicable number in the scoring column. Guideline to Completion of Patient Documentation v 4 Effective date: 01.01.2025 Mediclinic Training and Development MOBILITY  ‘Bed bound’ includes patients in traction; not yet mobilised post-surgery; CVA or brain surgery. Chair bound patients are patients sitting up in a chair for most of the time e.g. paraplegic patients. TISSUE MALNUTRITION  Terminal cachexia is tissue wasting. It means that tissue/cells do not receive or receive little nutrition – this is common in patients with cancer, HIV/Aids or patients with Tuberculosis.  With single organ failure it is advisable to circle the organ involved.  Peripheral vascular disease includes: Reynard’s disease, deep vein thrombosis (DVT), diabetic ulcers, vein grafts taken from legs in patients who have undergone coronary artery bypass surgery (CABG).  To determine if anaemia is present you need to look at the patient’s haemoglobin (Hb) or full blood count results.  This information is not always present on admission, but should the results become available it should be taken into consideration and the patient should be re-assessed. NEUROLOGICAL DEFICIT  This indicates that the patient has lost some ability to feel or to move muscles.  Indicate what caused your patient to have this deficit.  The patient could be scored for more than one aspect e.g. diabetic and cerebro vascular incident.  Diabetes: Score uncontrolled type 1 diabetes = 6 or type 2 diabetes = 4. Guideline to Completion of Patient Documentation v 4 Effective date: 01.01.2025 Mediclinic Training and Development MAJOR SURGERY OR TRAUMA  The type of surgery should be indicated, if applicable  Major surgery should be indicated for 48 hours post-surgery as the patient remains in one position and was lying still and in one position in theatre (while operated on).  This means that the patient cannot move, and pressure increases. MEDICATION  Cytotoxic drugs are all the cancer-related treatment drugs.  High Dose Steroids, includes Solu Cortef, Cortisone, and Prednisone.  Anti-inflammatory drugs include Voltaren, Myprodol, Ibuprofen, and Rayzon SCORE CALCULATION  Add up all the points to get a final score.  The final score is indicated in the block ‘Total’.  The nurse who calculated the score initials in the ‘initial’ block  Depending on the score, you mark the patient as:  At risk when score is higher than 10  High risk when score is higher than 15  Very high risk if score is higher than 20 Guideline to Completion of Patient Documentation v 4 Effective date: 01.01.2025 Mediclinic Training and Development COMPLETION: VENOUS THROMBO-EMBOLISM (VTE) RISK ASSESSMENT (N3297) GENERAL INFORMATION  The VTE assessment describes the patient’s risk for developing a thrombosis which can lead to a life-threatening pulmonary embolism. Proactive precautionary measures, based on the score, must be taken. DATE & TIME  Record the date in the first row of blue blocks every time you do an assessment..  The time is recorded in the second row of blue blocks, where the ‘:’ sign is, time is indicated as 09:00 or 23:00. CRITERIA  Use the patient’s history (the subjective data) taken during the initial assessment, and the objective data obtained during the physical examination and bedside tests of the patient, to complete this document. Guideline to Completion of Patient Documentation v 4 Effective date: 01.01.2025 Mediclinic Training and Development  Don’t repeat questions already asked during the general assessment.  Write the applicable score (number) in the column underneath the time and date; do not circle the numbers in the blue column. They only indicate the score that needs to be used.  Use the calculated BMI score.  During the physical examination, assess whether the patient currently has swollen legs or varicose veins.  A medical patient is on bed rest when the medical practitioner requests it as part of the treatment plan (the patient can mobilise ̶ but may not ̶ for medical reasons).  Is the patient booked for minor surgery (any surgery lasting less than 45 minutes e.g. tonsillectomy, extraction of teeth). Surgery is ALWAYS invasive!  Has the patient had any of the following conditions during the past month up to and including the day of admission?  Congestive heart failure  Sepsis – e.g. after abdominal wound/ trauma or generalised septicaemia.  Pneumonia  Age is a risk factor for VTE from the age of 41 upwards. It does not mean younger patients can’t also develop a VTE.  Note that there are three different age groups on the document.  Look for the patient’s age on the patient information sticker and write the applicable score, relating to the patient’s age group, in the correct block.  Major surgery – This is any surgery that is planned for the current hospital stay, which normally lasts for longer than 45 minutes.  Laparoscopic surgery – Surgery that is performed using a scope.  Confined to bed >72 hours – this patient is not allowed to, or is not able to, leave the bed for a period more than 72 hours.  An arthroscopy is a procedure where an arthroscope is used to visualise the interior of any joint.  Malignancy – Cancer the patient currently has.  Immobilising plaster cast / bandage / moon boot ̶ reduces the normal movement of the leg.  Central venous access (e.g. CVP, Port or dialysis catheter) – where the line itself can result in thrombi being formed. Guideline to Completion of Patient Documentation v 4 Effective date: 01.01.2025 Mediclinic Training and Development  History of deep venous thrombosis/ pulmonary embolism, obtained from history during the assessment interview (no time limitation).  Family history of thrombosis – did a parent, grandparent, sibling (brother or sister) or child (blood relative) have a thrombosis? Thrombosis is the formation of an intravascular clots - could be cardiac, cerebral, pulmonary or other.  Clotting disorders – Including platelet disorders, haemophilia, arterial or venous thrombotic disease, thrombophilia (a tendency for thrombi to occur), and Factor V Leiden Thrombophilia.  When the patient is booked for a total hip / knee replacement only hip / knee replacement is marked i.e. you cannot score for major surgery and for the replacement procedure.  Using of oral contraceptive or hormone replacement is a risk for development of deep vein thrombosis.  Is the patient pregnant?  Has she had a baby in the month prior to admission? (Post-partum)  Be sensitive when asking the following questions:  Does the patient have a history of an unexplained stillborn child (Medical practitioner unable to explain why it happened), has she had more than 3 spontaneous abortions (miscarriages) ̶ a reliable indication of clotting disease.  Or did she give birth to a premature baby with toxaemia of pregnancy ̶ a condition during pregnancy due to a metabolic disturbance causing hypertension, oedema and albuminuria (albumin in urine) or eclampsia (convulsions).  Or did she give birth to a growth retarded infant (a baby smaller than expected for the term of pregnancy). Guideline to Completion of Patient Documentation v 4 Effective date: 01.01.2025 Mediclinic Training and Development  Add up all the points to get a final score.  The final score is indicated in the block ‘Total’.  The nurse who calculated the score initials in the ‘initial’ block  Place the VTE sticker on the prescription chart and circle the patient’s risk result.  This emphasises the patient’s VTE risk and prompts the medical practitioner to prescribe prophylactic measures. THE PROPHYLAXIS (PREVENTION) OF VENOUS THROMBO-EMBOLISMS IS AS FOLLOWS: NON-PHARMACOLOGICAL PREVENTION  Patient education regarding the possible formation of thrombi because of bed rest.  Patients must get up and start walking as soon as their condition and medical practitioner’s prescription allow.  Passive and isometric exercises during bed rest (where applicable and correct exercises according to medical practitioner’s prescription).  Intermittent pneumatic compression devices (medical practitioner’s prescription) to be applied.  Graded compression (TED) stockings (medical practitioner’s prescription) applied correctly. PHARMACOLOGICAL PREVENTION  The medical practitioner must be informed of the patient’s risk for embolism and the medical practitioner will determine the appropriateness of an anticoagulant. POSSIBLE CONTRAINDICATIONS (REASONS TO AVOID) TO ANTICOAGULANT THERAPY (MEDICATION THAT DECREASES / PREVENTS CLOTTING OF BLOOD):  If the patient is bleeding actively.  If they have a history of heparin-induced (caused by heparin) thrombocytopenia.  Has a low platelet count (a reduction of platelets in the blood ̶ platelets are essential for blood clotting).  Is using oral anticoagulants or platelet inhibitors e.g. Warfarin, Aspirin, Ecotrin, Pradaxa or Xarelto. Also consider natural remedies e.g. Procydin and Ginko Biloba.  It is very important to ask the patient what medication they use at home and to record everything they use on the prescription chart in the applicable area. Guideline to Completion of Patient Documentation v 4 Effective date: 01.01.2025 Mediclinic Training and Development POSSIBLE CONTRA-INDICATIONS TO AN INTERMITTENT PNEUMATIC COMPRESSION DEVICE:  Severe peripheral arterial disease e.g. arteriosclerosis, atherosclerosis (a disease causing thickening or hardening of the arteries), poor circulation, or leg cramps from poor circulation.  Congestive heart failure: The inability of the heart to meet the body’s blood requirements due to a problem with the structure or function of the heart, resulting in congestion and over distension of certain veins and organs with blood, and retention of water and salt.  Acute or superficial deep venous thrombosis. Any blood clot (or other deposit) in the vascular system, but especially in the lower extremities. Guideline to Completion of Patient Documentation v 4 Effective date: 01.01.2025 Mediclinic Training and Development COMPLETION: SIGNATURE SHEET (N3373) GENERAL INFORMATION  This document needs to be completed once only by all members of the multidisciplinary team who record in the patient file during that patient’s hospital stay.  Each patient will have their own Signature Sheet in their patient file.  Employee number / or agency number must be included.  Initials and surname to be printed clearly.  Rank must be noted.  Initial as you would on all patient records. Guideline to Completion of Patient Documentation v 4 Effective date: 01.01.2025 Mediclinic Training and Development COMPLETION: ADULT EARLY WARNING OBSERVATION RECORD (N3182) GENERAL INFORMATION  The purpose of the Early Warning Observation Record is to:  Assist the nurse in identifying adult patients who are at risk of deterioration.  Guide nurse practitioners with regards to appropriate interventions that should be taken and / or considered.  Assist the professional nurse to effectively communicating the patient’s condition to the medical practitioner.  Document the actual time that observations were done.  The Implementation Record must reflect any abnormalities identified; the appropriate nursing interventions taken, including specifics around communication with the medical practitioner.  The Patient Care Plan must be updated accordingly. Frequency of monitoring should be adapted according to the patient’s condition.  Initial at the bottom when recording was done.  You will note that this observation record uses 3 colour zones. The aim of these colour zones is to guide you in interpreting the values of observations obtained. o White zone: Normal Values contained in this range but may vary due to patient’s baseline data. o Orange zone: Out of normal reference range. Closer monitoring required, notify the Professional Registered Nurse and document in Implementation Record. o Red zone: Patient is at HIGH risk of decompensating or has started decompensating. Guideline to Completion of Patient Documentation v 4 Effective date: 01.01.2025 Mediclinic Training and Development  The Algorithm that has been designed must be placed in the patient folder (included in the file divider pack) and referred to for quick guidance.  The maximum time interval for observations of adult patients, is 4-hourly. The observation intervals may be adjusted according to the patient’s condition; nursing prescriptions or medical practitioner’s prescriptions. See relevant policies on ‘Minimum frequency of vital sign monitoring’. Guideline to Completion of Patient Documentation v 4 Effective date: 01.01.2025 Mediclinic Training and Development  Vital signs can be abnormal (due to the patient’s specific condition); but when the vitals fall into the orange / red zone – it becomes essential to report this abnormality. The colours serve as a warning that the patient may be deteriorating.  Reference values may be adjusted for the patient’s underlying condition by the Medical Practitioner: e.g. Respiratory rate < 30/min is normal for this patient due to his underlying condition.  At the top right corner, fill in the year and month in the open spaces.  Date – this is the day of that specific month you perform the vital signs e.g. – 12 or 27.  The time is filled in e.g. 09:00, 16:12, or 23:37. RESPIRATORY RATE  The respiratory rate is one of the most sensitive indicators of deterioration.  Record the actual respiratory rate in the applicable block e.g. respiratory rate of 16bpm will be recorded in the block 12-24. SATURATION  Record the actual saturation value in the block. OXYGEN THERAPY Guideline to Completion of Patient Documentation v 4 Effective date: 01.01.2025 Mediclinic Training and Development  The legend in the bottom right corner provides you with acceptable abbreviations to use when recording the type of oxygen therapy the patient is receiving.  Record this is the open space in the block.  In the space provided, record the l/min oxygen is delivered.  If no oxygen therapy is provided, record ‘RA’ in the block. BLOOD PRESSURE  NB: Note that this is a warning system designed to assess the Systolic Blood Pressure.  Blood pressure is defined as the pressure that the blood exerts on the arterial wall and the pressure of the arterial wall on the blood.  Systolic pressure indicates the peak pressure exerted during left ventricular contraction and ejection of blood through the aortic valve.  Both systolic and diastolic blood pressure readings must be recorded however, only the systolic value will be assessed by the colour zones.  Systolic and diastolic pressures are both indicated by drawing a line between the two dots that indicate the systolic and diastolic pressure.  The recording on the graphs must display the results (and trend) of the vital sign measurements accurately. It should not be necessary to write the actual values down.’ Guideline to Completion of Patient Documentation v 4 Effective date: 01.01.2025 Mediclinic Training and Development PULSE RATE  A normal adult pulse rate is within the range of 60 ̶ 100 beats per minute.  When palpated, (felt), the pulse or beat should be strong and regular.  Measure for 30 seconds and multiply by 2.  The recording on the graphs must display the results (and trend) of the vital sign measurements accurately. It should not be necessary to write the actual values down.’ TEMPERATURE  The recording on the graphs must display the results (and trend) of the vital sign measurements accurately. It should not be necessary to write the actual values down.’  Reasons for a pyrexia include:  Inflammatory response  Sepsis  Drug or transfusion reaction  Reasons for hypothermia include:  Intra-operative cooling Guideline to Completion of Patient Documentation v 4 Effective date: 01.01.2025 Mediclinic Training and Development  Cold environment / inappropriate exposure  Sepsis PAIN INTENSITY  Pain is a subjective sign, i.e. the patient (and not the nurse) decides whether or not they have pain.  Pain may indicate a problem, especially if it is new or unexpected and cannot be relieved with normal dosages of analgesia.  Pain may be due to pressure on nerve endings, e.g. a haematoma has developed.  It could also indicate ischemia (poor blood supply/perfusion) to an area.  Pain stimulates the sympathetic response, i.e. raising heart rate, increased blood pressure, increase in respiratory rate.  It may however stimulate a parasympathetic response or vagal response with the opposite effect, i.e. drop in blood pressure and heart rate.  Record the value by making a dot in the block next to the corresponding value.  The recording on the graphs must display the results (and trend) of the vital sign measurements accurately. It should not be necessary to write the actual values down.’ LEVEL OF CONSCIOUSNESS  Use the legend to record the patient’s level of consciousness.  Record only the letter identified (as per legend) in each block. Guideline to Completion of Patient Documentation v 4 Effective date: 01.01.2025 Mediclinic Training and Development BLEEDING/ HAEMOGLOBIN  Use the legend to record whether there is bleeding or not.  If not applicable, write N/A next to bleeding.  In the same block, under bleeding, record the patient’s haemoglobin level if done.  If not applicable, write N/A next to Hb. BOWEL ACTION  Use the legend to record whether the patient passed a stool or not.  If not applicable, write N/A next to bowel action. URINE TEST  Urine must be tested on admission (or soonest thereafter) and form part of the physical assessment of a patient.  Patients that need more frequent urine analysis include:  Patient who are catheterised  Diabetics  Patients with renal problems Guideline to Completion of Patient Documentation v 4 Effective date: 01.01.2025 Mediclinic Training and Development  Planned abdominal surgery  Urinary tract infections  Dehydrated  Receiving TPN  ‘Nil per mouth’  Receiving blood  Blood product transfusion  Pregnant patients presenting with pre-eclampsia Guideline to Completion of Patient Documentation v 4 Effective date: 01.01.2025 Mediclinic Training and Development COMPLETION: PATIENT CARE PLAN BASIC NEEDS (N0909) GENERAL INFORMATION  Each basic needs care plan should be activated in the morning after assessment of the patient and the night nursing team must review the plan after their handover assessment.  The nurse practitioner who performs this action must sign the document.  A nursing prescription is activated with a √ and deactivated with a line drawn though the √. HYGIENE  The year and month must be completed in the space provided.  In the blocks next to the month, record the day of the month, e.g. 5,6 or 7.  One document can be used for 7 executive days.  Hygiene includes nursing prescriptions on bathing, oral hygiene, hair and nail care.  Tick the applicable option(s). Guideline to Completion of Patient Documentation v 4 Effective date: 01.01.2025 Mediclinic Training and Development  Additional instructions, e.g. the preferred time or frequency, can be added in the open spaces provided.  Independent: The patient is self-sufficient and can do the care activity for themselves.  Assist patient: This patient can do the care activity themselves, but need some e.g. needs help to get out of bed to mobilise to the toilet.  Full wash patient: The patient is unable to perform this task themselves and is dependent on nurses to perform basic care tasks. NUTRITION  Tick the applicable option(s).  If the patient is on a special diet which is not listed, the diet must be added in the open space. ELIMINATION Guideline to Completion of Patient Documentation v 4 Effective date: 01.01.2025 Mediclinic Training and Development  Tick the applicable option(s).  Circle the applicable option at urinal/ bedpan and sheath/ catheter. ACTIVITIES  Tick the applicable option(s).  Additional instructions must be added in the open spaces provided, e.g. preferred times or frequencies.  Example: Sit out in chair bd. for an hour at 10h00 and 15h00. COMFORT, REST AND SLEEP  Tick the applicable option(s).  Additional instructions must be added in the open spaces provided.  Example: Provide pressure care 6-hourly. Add on the open line: ‘Turn patient 2 hourly.’  Ensure privacy – This includes curtains that are drawn, doors that are closed to ensure that other medical team members as well as visitors do not walk in during procedures or while the patient is busy with private issues. Guideline to Completion of Patient Documentation v 4 Effective date: 01.01.2025 Mediclinic Training and Development SAFETY  Tick the applicable option(s).  Check that the patient is identified and that the identification band (ID) is still legible.  The ID band should provide the following information: Patient title, initials and surname, hospital number, treating medical practitioner and nursing unit (as per MCSA policy: ‘Identification of patients’).  The bed should be at a safe height for the patient to get in and out of bed, should they mobilise.  Bed rails may be required with some patients. Check if they are in place (if necessary).  Bed brakes should always be on to prevent patient falls and back injuries.  Check that the nurse call system is functional and that it is within easy reach of the patient.  The patient’s locker should be clean and within the patient’s reach. LEARNING  Tick the applicable option(s).  Additional instructions can be added in the open spaces provided.  Health education is directed to the patient/family/community to improve; maintain and safeguard health. Guideline to Completion of Patient Documentation v 4 Effective date: 01.01.2025 Mediclinic Training and Development  It is an active process aimed to change people’s attitude and influence their actions regarding their own health.  Health education and information should address medication, diet and lifestyle, wound care, abnormal signs and symptoms, emergencies that could develop, and preventative measures if applicable to that patient.  The nurse should start with health education soonest after admission and throughout the patient’s stay and not only on discharge.  It is Mediclinic policy and a patient’s right to know what care (treatment) they are receiving and to consent to this treatment. A patient has the right to refuse treatment.  Should you perform any procedure, you need to explain to the patient what you plan to do, how it is done, what they may experience; and what the implications are (should they refuse). Give alternatives (should there be any). SPIRITUAL  Tick the applicable option(s).  Additional instructions can be added in the open spaces provided.  Support patient emotionally – Allow patient to verbalise fears, emotions and feelings. The nurses’ role is to listen attentively and empathetically and refer to the appropriate team members.  Support family emotionally – Allow the family to verbalise fears, emotions and feelings. The nurses’ role is to listen attentively and empathetically and to refer to the appropriate team members. COMPLETION Guideline to Completion of Patient Documentation v 4 Effective date: 01.01.2025 Mediclinic Training and Development  The nurse who completed the basic needs care plan, must record the date, time, their initials and surname and initial in the space provided.  The care plan must be discussed with the patient after it was completed the first time. the patient then signs in the space provided.  The nurse who discussed the care plan with the patient, signs next to the patient at the signature: nurse space. Guideline to Completion of Patient Documentation v 4 Effective date: 01.01.2025 Mediclinic Training and Development COMPLETION: SPECIFIC PATIENT CARE PLAN (N1012) GENERAL INFORMATION  A patient care plan provides written, detailed instructions on activities nurses should implement to help a patient reach expected outcomes.  Nursing prescriptions are based on the nursing diagnosis made after the assessment phase.  The nursing prescriptions should always start with a verb, and be specific, measurable, attainable, realistic and time bound.  SMART principles should be reflected in every prescription:  S = Specific  M = Measurable  A = Attainable  R = Realistic  T = Time bound  Examples of SMART nursing prescription are: o Weigh patient daily at 6:00. o Sit out in chair daily at 10:00 and 15:00 for 1 hour each.  The patient’s initial care planning for the day should be done by the nurse practitioner assessing the patient.  The RN/PN/GN may add or cancel some nursing actions should the patient’s condition change (improve or deteriorate).  A nursing prescription is activated with a √ and deactivated with a line drawn though the √.  The expected outcome for the patient should be written along the same line as the nursing prescription. Guideline to Completion of Patient Documentation v 4 Effective date: 01.01.2025 Mediclinic Training and Development o Expected outcomes are range statements on the plan of what must be achieved before patient discharge e.g. mobilise 10 steps.  Indicate the frequency that the nursing action should take place e.g. 4 hourly / daily / 06h00; and initial the prescription.  Nursing interventions that must be taken into consideration include: wound care, nasogastric/ gastrostomy feeds, obtaining of specimens, administering oxygen, taking an ECG, suctioning, changing an intercostal drainage bottle, analysing urine, performing skin-, bowel preparation for surgery, etc. Guideline to Completion of Patient Documentation v 4 Effective date: 01.01.2025 Mediclinic Training and Development COMPLETION: FLUID BALANCE RECORD (N0949) GENERAL INFORMATION  Fluid balance indicates the harmony between fluid taken in and fluid excreted.  This is also referred to as intake and output monitoring.  Identify the patient record by applying a patient sticker.  Date the page – one page per 24 hours.  Document the actual time the nursing action is taking place. INTRAVENOUS INTAKE  Intake refers to oral fluid and intravenous fluid intake ̶ tube feedings, intravenous fluids, blood product administration, flushes and medication volume intake. Guideline to Completion of Patient Documentation v 4 Effective date: 01.01.2025 Mediclinic Training and Development  Ensure that only fluids are recorded ̶ this is not a ‘feeding’ record. (Food intake should be recorded on the Implementation record, if required).  Intake and output are measured in millilitres.  It is not necessary to write ‘ml’ after each entry. This is already indicated in the headings.  Frequency of monitoring should be adapted according to the patient’s needs.  When an intravenous fluid bag is hung, note the type of solution.  Any additives to the intravenous solution must be recorded (e.g. vitamins, antibiotics).  Volume started, this is the volume in the bag, e.g. 1000, 50, 100.l  IV check ̶ Intravenous site checked.  No signs of redness, swelling, back flow, line patent & secure.  The infusion site shows no signs of phlebitis.  The site is covered with transparent plaster that secure cannula.  The infusion is running at the correct infusion rate.  Assess IV check in line with legend (√) provided at bottom of page.  Continuous monitoring of intake: o Complete the record when the volume infused is completed, e.g. if the fluid is started at 09:15, infused over 1 hour, the completed time should be recorded at 10:15. o Add the volume i.e. 150 to the previous running total to calculate the new running total.  Intermittent monitoring of intake:  These infusion bags should have a time tape and intravenous fluid volume intake should be recorded at a regular interval to prevent dehydration or accidental over hydration. It is recommended to have at least a dial-a-flow on these patients.  No patient’s intravenous fluid should run free. It should be controlled to complete within a specific time frame and the patient should be monitored to prevent complications.  At 06:00 each day the patient’s fluid should be carried over to the next fluid balance record. The volume carried over is the volume left in the intravenous fluid bag. This also means that at 06:00 the fluid that has been completed should reflect as the last entry on the record and should be totalled to calculate the patient’s fluid balance for 24 hours. Guideline to Completion of Patient Documentation v 4 Effective date: 01.01.2025 Mediclinic Training and Development ORAL / TUBE INTAKE  Document the actual time that the nursing action takes place or when the patient drank the fluid.  Oral / Nasogastric / gastrostomy fluid volume: o Specify type of oral fluid or nasogastric feed, e.g. Tea – 50ml or Ensure – 100ml. o Enter the volume the patient received.  Running total is the total volume of fluid that the patient has received up to that specific time. It is calculated by adding the totals of the volumes completed. Guideline to Completion of Patient Documentation v 4 Effective date: 01.01.2025 Mediclinic Training and Development OUTPUT  Output refers to urinary-, tube drainage (nasogastric, ileostomy, chest tubes, and surgical drains), wound drainage, bleeding, diarrhoea or liquid stools and vomiting.  Specify the type of output in the different columns, e.g. urine – 50ml, vomitus – 100ml.  If the patient has more than one portovac or drain mark the portovac / drain with an A or B and record it under the correct drain/portovac. Guideline to Completion of Patient Documentation v 4 Effective date: 01.01.2025 Mediclinic Training and Development DETERMINE FLUID BALANCE  Add the totals for intake and the totals for output to determine fluid balance.  Evaluate the intake versus output during the 24 hours.  Consult the basic nursing procedure: Monitor fluid intake and output for formulas pertaining to intake and output. Guideline to Completion of Patient Documentation v 4 Effective date: 01.01.2025 Mediclinic Training and Development COMPLETION: PERI-OPERATIVE RECORD (N0997)  Identify the document by placing a patient sticker in the space provided.  Record patient allergies by either:  Writing ‘no known allergies’ in black pen or placing the green ‘no known allergies’ sticker in the space provided.  Or if a patient has allergies write the name of the allergy/ allergies in red pen or place a red sticker in the space provided and write the name of the allergy/ allergies in black pen on the red sticker.  ‘Consent confirmation’ implies checking of the evidence of consent (obtained by the doctor) with the booked procedure and the patient’s version of the expected procedure.  This is to confirm that the doctor obtained informed consent from the patient and that the patient understands what was explained.  Before the patient receives any pre-medication the ‘consent confirmation’ should be completed with the patient.  The first line, the nurse writes what the patient consented to. The patient explains in their own words what the doctor is going to do.  The second line the nurse writes the procedure as stated on the theatre list.  On the third line, the nurse evaluates whether the evidence of consent form, the explanation the patient gave and the booked procedure correlate, circle ‘yes’ or ‘no’. If ‘no’, indicate the actions taken to correct the mistake e.g. doctor informed to come and explain/clarify the procedure to the patient. Guideline to Completion of Patient Documentation v 4 Effective date: 01.01.2025 Mediclinic Training and Development  Check that the surgical site is marked, if the site is not marked provide for not marking the site and sign at the end of the line.  Explain to the patient that a medical representative might be present in the theatre, to assist the surgeon with equipment or prostheses required for the operation (relevant to specific procedures).  If recordings are ever made in your hospital, explain to the patient that, in rare cases, a film recording of an operation might be made for training purposes. This is relevant to specific hospitals and specific doctors and procedures only. Filming of procedures is mostly not relevant. If not relevant, write N/A (not applicable) in this line.  Obtain the signature as proof of consent from the patient, for presence of a representative and filming of the procedure.  Should the patient not agree to a medical representative being present during the procedure, or the filming of the procedure for training purposes, and if such consent is required, the doctor and scrub nurse should be informed of the patient’s refusal.  On the last line, the nurse lists all the patient risk factors.  This document reflects the nursing process that includes the diagnosis, plan, implementation and evaluation.  Activate (√) the nursing prescriptions applicable to the patient.  Circle additional options in the nursing prescription column that are relevant to the patient, e.g. shave or clipped, the type of preparation to be performed.  Circle the actions in the implementation column when those have been performed.  If no antibiotic prophylaxis administered, mark the n.a. option. If indicated yes next to the prophylaxis antibiotics administered, correlate with the prescription chart for type and dosage administered.  Before the patient leaves the unit, a professional nurse will check that all nursing actions were performed (Unit check).  During the handover to theatre, the nursing unit nurse and theatre nurse must perform the theatre check. Guideline to Completion of Patient Documentation v 4 Effective date: 01.01.2025 Mediclinic Training and Development  The vital observations should be performed during the theatre preparation.  Should any urine abnormalities be found record adjacent to the ‘yes’.  The n.a. option on menstruation should be used for children, males and women who have had a hysterectomy or are post-menopausal.  Pedal pulses should be tested for all surgery below the umbilicus, as well as patients with diabetes and peripheral vascular problems.  Make up should be removed to allow observation of saturation and skin colour.  Jewellery (includes all body piercings) as well as hair pins should be removed as this may cause burns to the patient during the use of the diathermy.  If jewellery cannot be removed, it should be covered with a plaster that the patient is not allergic to.  Bladder must be emptied before the administration of pre-medication.  The person who performed the pre-operative check should sign and date the document.  Handover is signed off in theatre by the nurse who accompanied the patient to theatre and the theatre nurse who received the patient.  The actual time that the patient is handed over should be reflected in’ the ‘time’ space. Guideline to Completion of Patient Documentation v 4 Effective date: 01.01.2025 Mediclinic Training and Development COMPLETION: POST-OPERATIVE PATIENT CARE PLAN (N1000)  Identify the document by placing the patient sticker in the space provided.  Write the surgical intervention as displayed on the intra-operative record.  Problem/ expected outcomes. POTENTIAL SHOCK  Fill in the expected parameters for the listed vital signs (expected outcomes) and the frequency of when vital signs should be done (nursing prescriptions).  Tick/activate the applicable nursing prescriptions.  Initial each nursing action activated and add the time. PAIN  Add the expected outcome for pain e.g. 0 ̶ 2 / 10.  Tick/activate applicable nursing prescriptions.  Add any additional pain relief measures.  Initial each nursing prescription and add the time. Guideline to Completion of Patient Documentation v 4 Effective date: 01.01.2025 Mediclinic Training and Development POTENTIAL WOUND INFECTION  Add the parameters for this patient’s temperature.  Add information in open spaces to individualise the care plan.  Tick/activate applicable nursing prescriptions.  Initial each prescription and add the time. POTENTIAL URINARY INFECTION  Tick/activate applicable nursing prescriptions.  Add the frequencies of actions.  Add nursing prescriptions on the open lines as needed.  Initial each prescription and add the time. POTENTIAL URINARY RETENTION/ DECREASED URINARY OUTPUT  Insert the minimum urinary output in ml/hour for this patient (expected outcome).  Urinary catheter emptied & volume recorded.  Record volume on the fluid balance record (N0949).  Add the frequencies/detail of actions.  Add nursing prescriptions on the open lines as needed.  Initial each prescription and add the time. Guideline to Completion of Patient Documentation v 4 Effective date: 01.01.2025 Mediclinic Training and Development POTENTIAL PHLEBITIS / INFILTRATION  Add information in open spaces to individualise the care plan.  Tick/activate applicable nursing prescriptions.  Initial each prescription and add the time. POTENTIAL RESPIRATORY COMPLICATIONS  Insert the expected O2 saturation for this patient.  Add information in open spaces to individualise the care plan.  Tick/activate applicable nursing prescriptions.  Initial each prescription and add the time. POTENTIAL NAUSEA  Add information in open spaces to individualise the care plan.  Tick/activate applicable nursing prescriptions.  Initial each prescription and add the time. POTENTIAL CIRCULATORY DEFICIENCY  Ensure patient is in an anatomical position where head, back and buttocks are in line. Remove or add pillows to support patient positioning and ensure comfort.  Patient must be pulled up in bed when they have slipped down.  Support arms / knees if needed. Guideline to Completion of Patient Documentation v 4 Effective date: 01.01.2025 Mediclinic Training and Development  Ensure linen is loose over the toes to prevent unnecessary pressure and limit limb mobility. No crumbs in bed.  Bed linen is crease free and dry.  Remove unnecessary bed equipment to ensure comfort.  Add information in open spaces to individualise the care plan.  Tick/activate applicable nursing prescriptions.  Initial each prescription and add the time. Guideline to Completion of Patient Documentation v 4 Effective date: 01.01.2025 Mediclinic Training and Development COMPLETION OF THE IMPLEMENTATION RECORD (N1009)  The Implementation Record should be used to record care activities.  The pages should be numbered chronologically.  Indicate the actual time that the nursing care is rendered in the allocated time blocks.  For a late entry, write the time the entry is made in the ‘time’ space. Indicate the time of the intervention in the ‘Patient interventions and progress’ space. E.g. Time of entry: 10:00 At 9:15, the patient was found on the floor in the bathroom….  Indicate if a Patient care plan was adjusted or discussed with the patient.  Patient round done: This action means that a nurse practitioner has visited the patient to ensure comfort and quality care. This includes nurses performing basic needs care rounds (fixing rounds), care rounds or rounds by the nursing management to ensure quality patient care.  The Implementation record is used whenever extra information needs recording.  The implementation record is also used to evaluate actual and potential problems and the effectiveness of nursing care by assessing if expected outcomes were reached.  Any procedures performed, e.g. wound care, nasogastric tube or catheter inserted, must be recorded in full on the implementation record. Any actions, observations or detail not recorded on another flow chart, must be captured on the Implementation record, e.g. the site where an intramuscular or subcutaneous injection was administered. Additionally, any abnormalities or problems noted must also be recorded on the implementation record, followed by the actions to address the abnormality or problem. Mediclinic follows a problem orientated documentation approach.  Procedures & Problems must include the following: o Signs & symptoms noted Guideline to Completion of Patient Documentation v 4 Effective date: 01.01.2025 Mediclinic Training and Development o Actions performed o Person informed about problem and actions o Infection control and safety actions performed  There is no need to duplicate medication administration entries, except when the medication was given to address a sign/symptom, which required an assessment (e.g. pain, anxiety, high blood pressure reading) or the actual site of administration needs to be recorded, e.g. IMI given in left rectus femoris, or SC injection given in left umbilical area.  Other entries that must be reflected in this record include visits by doctors, movement of patients e.g. to radiology and back from radiology or to doctors’ rooms. Guideline to Completion of Patient Documentation v 4 Effective date: 01.01.2025 Mediclinic Training and Development COMPLETION: PRESCRIPTION CHART (P1002) GENERAL INFORMATION  The prescription chart must be used according to MCSA Policy: Prescriptions from Medical Practitioners.  Important: The Pharmacist may only dispense medication from an original prescription chart – no photocopies are allowed.  Several prescription charts / booklets are available and adopted to suit the specific unit/discipline’s requirements.  Identify the document with a patient sticker.  Circle the comorbidities of the patient.  Medical diagnosis of the patient should be inserted.  Weight and height of the patient should be inserted.  Record patient allergies by either: o Writing ‘no known allergies’ in black pen or placing the green ‘no known allergies’ sticker in the space provided. o Or if a patient has an allergy write the name of the allergy/ allergies in red pen or place a red sticker in the space provided and write the name of the allergy/ allergies in black pen on the red sticker. o Write the ward name and bed number in the blocks provided. Ensure the correct ward name and bed number is always reflected, to ensure medication is delivered to the right nursing unit. o Insert the chart number, e.g. 1 of 1 or 1 of 2. Guideline to Completion of Patient Documentation v 4 Effective date: 01.01.2025 Mediclinic Training and Development PHARMACY ORDER FORM  This part of the prescription chart is used to order medication form the pharmacy.  Insert the year and month.  In the blocks above ‘Qty’ and ‘Para’ insert the day of the month, e.g. 5 or 12.  Under ‘Item’ write the name of the medication to order.  The pharmacy will write the dispensed amount of medication under ‘Qty’ and initial in the next block. Guideline to Completion of Patient Documentation v 4 Effective date: 01.01.2025 Mediclinic Training and Development  ALL medication the patient brought along to hospital must be recorded here.  The medication name and quantity must be recorded in the blocks provided.  The staff member that counts the medication must initial next to each entry.  Also add the medication the patient uses at home that were not brought with to hospital. Write the quantity (Qty) as 0.  If the patient completed an Online Clinical Admission (OCA), find the forms in the administration file and see the medication captured. Verify this with the patient and write on the prescription chart (‘Own Medication’). File the OCA forms in the patient file.  Below the block, add the full signature and initial.  The medical practitioners use the rest of the page to write pre-medication, care instructions and fluid regimes etc.  Only stat medication or telephonic prescriptions may be written on this page, all other medications need to be written on the next page. Guideline to Completion of Patient Documentation v 4 Effective date: 01.01.2025 Mediclinic Training and Development  Identify the document with a patient sticker.  Record patient allergies by either: o Writing ‘no known allergies’ in black pen or placing the green ‘no known allergies’ sticker in the space provided. o Or if a patient has any allergies write the name of the allergy/ allergies in red pen or place a red sticker in the space provided and write the name of the allergy/ allergies in black pen on the red sticker.  Each staff member who administers medication to the patient, must complete the ‘signature’ block at the top.  Take note of the codes under the allergies block. This will assist the staff member to record reasons why the patient did not receive the medication as prescribed.  Record the year and month at the top.  Record the day of the month in the space provided, e.g. 5, 8 or 31.  All prescriptions MUST comply with the following: o Patient sticker on the prescription chart o Name of the medication o The dose to be administered o The route of administration o The frequency/ time of administration o All prescriptions must be signed by the doctor, with date and time when the prescription was written. Guideline to Completion of Patient Documentation v 4 Effective date: 01.01.2025 Mediclinic Training and Development  On administration of medication to the patient, write the time in the block provided.  In the block next to the time, the person administrating the medication must initial.  If the patient did not receive the medication as prescribed, use the codes to record the reason. Guideline to Completion of Patient Documentation v 4 Effective date: 01.01.2025 Mediclinic Training and Development COMPLETION: PRESCRIPTION BOOKLET (P3246) GENERAL INFORMATION  The prescription chart must be used according to MCSA Policy: Prescriptions from Medical Practitioners.  Important: The Pharmacist may only dispense medication from an original prescription chart – no photocopies are allowed.  Several prescription charts / booklets are available and adopted to suit the specific unit/discipline’s requirements. Please note: This specific prescription booklet has not yet been implemented in all clinical units yet the principles of accurate and legal documentation and recording apply universally. Additional training resources may become available to support training on the prescription booklet’s completion.  Identify the document with a patient sticker.  Circle the comorbidities of the patient.  Weight, height and BMI of the patient should be inserted.  Record patient allergies by either: o Writing ‘no known allergies’ in black pen or placing the green ‘no known allergies’ sticker in the space provided. o Or if a patient has an allergy write the name of the allergy/ allergies in red pen or place a red sticker in the space provided and write the name of the allergy/ allergies in black pen on the red sticker.  Write the ward name and bed number in the blocks provided. Ensure the correct ward name and bed number is always reflected, to ensure medication is delivered to the right nursing unit.  Date commenced should be inserted in the space provided. Guideline to Completion of Patient Documentation v 4 Effective date: 01.01.2025 Mediclinic Training and Development  Tick the level of risk from low to highest according to the VTE Waterlow risk assessment.  Medical diagnosis of the patient should be inserted.  All staff members writing in the prescription booklet should record their details in the space provided.  Any medical practitioner prescribing on the prescription booklet should complete the block with the stated details. Guideline to Completion of Patient Documentation v 4 Effective date: 01.01.2025 Mediclinic Training and Development  Only pre-medication and stat/ once-off medication should be prescribed here.  This section is divided into 3 parts: o The first block should be completed by the pharmacy. o The second block should be completed by the prescribing medical practitioner. o The last block should be completed by the nursing staff member that administer the medication, this includes the time and date the medication was administered, followed by their initials. Guideline to Completion of Patient Documentation v 4 Effective date: 01.01.2025 Mediclinic Training and Development  ALL medication the patient brought along to hospital must be recorded here.  The medication name and quantity must be recorded in the blocks provided.  The staff member that counts the medication must initial next to each entry.  Also add the medication the patient uses at home that were not brought with to hospital. Write the quantity (Qty) as 0.  If the patient completed an Online Clinical Admission (OCA), find the forms in the administration file and see the medication captured. Verify this with the patient and write on the prescription chart (‘Own Medication’). File the OCA forms i

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