Documentation and SBAR Technique PDF

Quality of Documentation System Assist. Lecturer : Farida Said  Objectives Define the documentation Illustrate Importance of documentation Explain types of documentation Discuss the methods of documentations Identify Guidelines / principles for writing nurse notes. Discuss nurses respo...

Quality of Documentation System Assist. Lecturer : Farida Said  Objectives Define the documentation Illustrate Importance of documentation Explain types of documentation Discuss the methods of documentations Identify Guidelines / principles for writing nurse notes. Discuss nurses responsibility for record keeping. Apply SBAR tool Out lines Definitions Purposes and importance of documentation Principles for quality documentation  Patient File Quality of Documentation Reporting Types of reporting SBAR SBAR Scenario Definition Documentation : It is defined as written evidence of the interactions between and among health professionals, clients, their families, and health care organizations. OR It is a process of making an entry on a patient record. Purposes and importance of documentation 1- Communication:- It is provides efficient and effective method of sharing. 2- Legal documentation:- It is admissible as evidence in a court of law. 3-Research:- It is Provides valuable health-related data for provides valuable health-related data for research. 4-Planning patient care: It is provides data which the entire health team uses to plan care for the Purposes and importance of documentation 5-Auditing health agencies:- Monitors the quality of care received by the client and the competence of care received by the client and the competence of health care 6-Education: It is Serves as an educational tool for students in health discipline. 7- Financial billing  Principles for quality documentation Factual Accurate Completeness Current Organized Timings  Forms for Recording  Kardex  Flow Sheets Nurses’ Progress Notes Discharge Summary  Kardex The Kardex is used as a reference throughout the shift and during change-of-shift reports. Client data (e.g name, age, admission date, allergy) Medical diagnoses and nursing diagnoses Medical orders, list of medications Activities, diagnostic tests, or specific data on the pt. Provides a concise method of organizing and recording data about a client, making information readily accessible to all members of the health team.  Kardex It is a series of flip cards usually kept in portable file It is a way to ensure continuity of care from one shift to another and from one day to the next. It is a tool for change – of – shift report. It is include the following data: Personal data, Basic needs, Allergies, Diagnostic tests, Medications and intravenous (IV) therapy and blood transfusion Treatments like oxygen therapy, steam inhalation, change of dressings, mechanical ventilation. suctioning, change of dressings.  Reporting Verbal communication of data regarding the client’s health status, needs, treatments, outcomes, and responses Reporting is based on the nursing process.  Types of reports Summary Reports Walking Rounds Incident Reports Telephone Reports and Orders Other report types  Unit Report (statistical report) Date: ------------------- Department: ----------Head nurse: -------------- No. of No. of No. of No. of No. of No. of No. of No. of Deaths Transfers Discharges Admissions critical Patients Absent present patients Staff Staff Function/ Function To Time To Time from Time name / name  Patient Shift Report DATE: ----------------------------------- SHIFT: --------------------- Patient no. : -------------------------- REMARKES DIET SPECIAL ENDORSEMENT INFUSIONS CONNECTIONS DIAGNOSIS PT. NAME BED NO. CRITIC FOLLOW PT FOR AL UP VALUE S No. of admissions: No. of discharges: No. of transfers No. of deaths: No. of critical ill patients: Definition SBAR is a useful and effective communication tool that allows healthcare professionals to share concise and important information in a short amount of time.  SBAR – why it is important to use Improving the exchange of information between nurses and physicians to preventing medical errors and promoting a safe environment. Because information is given in a standardized way, there’s less room for human error. This greatly improves accuracy. When to Use SBAR Conversations with physicians, physical therapists, or other professionals. In-person discussions and phone calls. Shift change When resolving a patient issue. Daily safety briefings. When you’re escalating a concern. When calling an emergency response team  Who Should Use SBAR? SBAR should be used by: Nurses communicating to physicians Nursing assistants communicating with nurses. Physicians to other physicians Residents to attending physicians Nurses to other nurses Nurses to technicians Pharmacy to nurses and/or physicians Administrators to physicians  SBAR broken down SITUATION: State what is happening at the present time that has warranted the SBAR communication. (State your name & unit, what patient you are calling about, & what the problem is) Example: Hello Dr. ______, this is ________, from ____unit. I am calling about __(pt name & room #)___. The patient’s code status is ____. I have just assessed the patient myself. I am concerned about ________________. SBAR broken down BACKGROUND: Explain circumstances leading up to this situation. (State admission diagnosis, date of admission, brief pertinent medical history, and treatment to date) Example: Mrs Taylor is a 69-year-old woman who was admitted from home three days ago with a community-acquired chest infection. She has been on intravenous antibiotics and appeared, until now, to be doing well. She is normally fit and well and independent.  SBAR broken down ASSESSMENT: Indicate what you think the problem is (Provide last vital signs, oxygen if being used, & any changes from prior assessment: vital signs, heart rhythm, pain, wound drainage, neuro changes, etc. Example: I believe the problem is: (state what you believe the problem is, i.e. cardiac, infection, neurologic, respiratory, other). OR: I don’t know what the problem is but the patient is deteriorating. OR: The patient seems to be unstable. SBAR broken down RECOMMENDATION: Express what you believe the patient needs or what order specifically you want i.e. give fluids, order labs, x-ray, have the physician come see the patient, transfer the patient to ICU, ask for a consulting physician to see the patient, etc. Example: I suggest/request/recommend that you __________ (see immediately, transfer the patient to ICU, ask the hospitalist/resident to see the patient now, talk to family about code status, etc.  SBAR Scenario Mr. F. has a history of severe bladder infections and an indwelling catheter. Is temperature is now 38.5 c and his urine is foul-smelling and cloudy. In the past, a high temperature has signalled infection. His catheter was changed two weeks ago. He took Tylenol every four hours through the night. He presents as increasingly more confused.  SBAR Scenario Mrs:X is a 56-year-old woman who was diagnosed with heart failure 4 years ago. She has been admitted to the hospital for shortness of breath (SOB). She states “I was taking a diuretic at home but ran out 2 days ago. She complains of difficulty breathing and has noticed some swelling in her feet that seemed worse than usual. On physical examination, nurse observe that: SBAR Scenario Mrs:X alert and oriented to person, place, and time. For respiratory assessment, she has SOB on exertion; oxygen saturation is 89% on room air. On auscultation, nurse hear fine crackles bilateral in the lower lobes. When assessing her lower extremities, you fine 2+ edema bilaterally. Vital signs are: T.37oC, BP – 130/85mmHg, P – 120/min, R- 35/min.