L5-HLTENN041_Clinical-Documentation_V1_2024_2_.txt

RMIT Classification: Trusted HLTENN041 Apply legal and ethical parameters to nursing practice NURS5420C & NURS5421C Lesson – 5 Clinical documentation RMIT Classification: Trusted SESSION OBJECTIVES By the end of this session, learners will be able to identify the key concepts of legal and ethica...

RMIT Classification: Trusted HLTENN041 Apply legal and ethical parameters to nursing practice NURS5420C & NURS5421C Lesson – 5 Clinical documentation RMIT Classification: Trusted SESSION OBJECTIVES By the end of this session, learners will be able to identify the key concepts of legal and ethical aspects related to documentation and communication in nursing: Complete documentation in accordance with State/Territory legislation and organisational policies and procedures. Monitor and record compliance with legal obligations and requirements. Use and interpret common legal terms associated with nursing practice. Write nursing practice reports according to legal requirements and organisational expectations and requirements. Observe privacy and confidentiality requirements in accordance with legislative requirements and organisational policies and procedures. RMIT University©2017 School of Vocational Engineering, Health & Sciences RMIT Classification: Trusted DOCUMENTATION CASE SCENARIO Nurse White witnessed a care provider dragging Mr Brown along a cement path. The nurse failed to record or report this incident. The nurse dressed the patient’s injuries and noticed bruising on his ankles, buttocks and scalp as she assisted him to change his torn clothing. The nurse failed to document these. Mr Brown’s daughter saw the injuries and heard what happened from another resident and intends to see a lawyer. What are the issues involved in this incident? RMIT Classification: Trusted DOCUMENTATION Health care documentation is a legal requirement. Key legislation include The Health Records Act 2001 (VIC), The Privacy Act 2000 (VIC), Freedom of information Act 1982 (VIC). Purpose of maintaining documentation: 1. Effective communication 2. Patient record 3. Accountability of care 4. Resource allocations 5. Evidence of practice RMIT Classification: Trusted REMEMBER!!!! If it’s not documented in the medical record then it didn’t happen.” Documenting is a critical component to the delivery of healthcare. Failure to document relevant data is itself considered a significant breach and deviation from the standard of care. RMIT Classification: Trusted WHAT SHOULD BE DOCUMENTED? Assessment findings Risks related to care The plan of care for the person Modifications to the care plan Nursing interventions Evaluation of care Reasons for omission of care RMIT Classification: Trusted DOCUMENTATION PRINCIPLES Contemporaneous Chronological Must be relevant, individualised and specific Avoid duplication (Do not double chart) Approved list of abbreviations Approved clinical documents/ templates Retrospective entries Inaccuracy Other health professional’s documentation https://jcu.pressbooks.pub/nursingdocumentation/chapter/principles-of-documentation/ RMIT Classification: Trusted Must report the following at the time of the occurrence Vital signs Medication administration/ refusal Preparation for diagnostic tests or surgery Change in patient status , reported to RN /medical team Admission , transfer , discharge or death of a client Treatment for a sudden change in status Any events that occur out of the ordinary Discussions with patient/ family/ significant other Note: Nursing actions must NOT be recorded before they have been performed. RMIT Classification: Trusted DOCUMENTATION & REPORTS MUST BE: Comprehensive, Factual, Complete, Accurate, Current, Organised, Person –centred, Collaborative and Confidential. TELEPHONE REPORT To document a phone call , the nurse includes: This Photo by Unknown Author is licensed under when the call was made CC BY who made it who was called to whom the information was given what information was received. RMIT Classification: Trusted Screenshot from : https://jcu.pressbooks.pub/nursingdocumentation/chapter/principles-of- documentation/ RMIT Classification: Trusted THE DO’S AND DON’TS OF DOCUMENTATION DO DON’T Record all relevant information Don’t erase what is recorded Record in black or blue ink Don’t leave white space! Clarify orders and treatment Don’t use ambiguous statements Only use (organisation) approved Don’t write in anticipation abbreviations and acronymns Date/time/sign Write legibly Use ‘late entries’ notation (avoid where possible) + patient details + signature Follow organization policies Record telephone calls Co-sign where applicable Use 24-hour clock https://www.ausmed.com/articles/nursing-documentation/ RMIT Classification: Trusted DOCUMENTATION PRINCIPLES Electronic health records Digital identity and time stamps Follow guidelines for structured and unstructured fields Security and passwords Accurate https://jcu.pressbooks.pub/nursingdocumentation/chapter/principles-of-documentation/ RMIT Classification: Trusted DOCUMENTATION OF ADVERSE EVENTS Reporting incidents and clinical near misses Opportunity to change practice and promote safety Victorian Health Incident Management System (VHIMS) (Department of Health, 2017) Victorian Agency for Health Information – Risk Man Victorian Charted of Human Rights and Responsibilities Act 2006 (VIC) – legal obligation to discuss adverse events with the affected patient/ or carer/family. RMIT Classification: Trusted DOCUMENTATION METHODS / FRAMEWORKS SOAPIER Subjective – what the patient verbalises Objective – based on measurable data Assessment - nursing diagnosis Plan – nursing care plan/ desired outcomes Intervention – nursing actions Evaluation – patient outcomes Revision / resolution – modifications needed https://jcu.pressbooks.pub/nursingdocumentation/chapter/documentation-frameworks/ RMIT Classification: Trusted SAMPLE Scenario: 2 days post op (abdominal surgery) Mr. Bright complains of “severe pain” to his abdomen and rates his pain level as an 8 on a scale of 10. He is grimacing. His heart rate is 102. The nurse administers IV morphine sulfate. The nurse evaluates Mr. Bright’s pain after administering the medication. Mr. Bright says his pain has decreased and now rates his pain level as a 2. He is no longer grimacing, and his heart rate is 86. S – Reports “severe” abdominal pain; rates pain as an 8 on a scale of O – Grimaces, heart rate 102 A – Post-operative abdominal pain P – Administer analgesics, as ordered I – Morphine sulfate 4mg IV E – Reports pain decreased; now rates pain as a 2. No longer grimaces, heart rate 86. RMIT Classification: Trusted OTHER DOCUMENTATION METHODS / FRAMEWORKS Charting by exception Narrative Problem focused Systems based documentation view sample https://jcu.pressbooks.pub/nursingdocumentation/back- matter/appendix-1/ https://jcu.pressbooks.pub/nursingdocumentation/chapter/documentation-frameworks/ RMIT Classification: Trusted ACTIVITY 1 Writing Progress Notes Review the scenario and write a progress note. Rationale: this activity is important to have hands on practice writing progress notes addressing all standards of documentation to improve the nursing documentation skills of the students. RMIT Classification: Trusted PRACTICE SCENARIO Mr Brown is admitted post a fall at home (long lie for >4hrs). He was admitted into the general ward for conservative management of his right arm fracture. On commencement of shift, Mr Brown c/o 7/10 in his arm. He was moaning on movement and refused his ADLs. The nurse administered PRN Endone 5mg and regular pain relief medication (Paracetamol 1000mg) as per the medication chart. On further assessment, Mr Brown reported his pain has reduced (pain score 3/10, no longer moaning) and requested for a wash. RMIT Classification: Trusted REFERENCES Documentation standards https://jcu.pressbooks.pub/nursingdocumentation/chapter/principles-of- documentation/ Documentation frameworks https://jcu.pressbooks.pub/nursingdocumentation/chapter/documentation- frameworks/ https://jcu.pressbooks.pub/nursingdocumentation/back-matter/appendix-1/ NSQHS standards- Documentation of information https://www.safetyandquality.gov.au/standards/nsqhs- standards/communicating-safety-standard/documentation-information