HLTENN036 Documentation and Open Disclosure PDF

HLTENN036-APPLY COMMUNICATION SKILLS IN NURSING PRACTICE LESSON 3 : DOCUMENTATION AND OPEN DISCLOSURE REWRITTEN BY TWINKLE MASHRUWALA RMIT Classification: Trusted Objectives Purpose of documentation in nursing Understanding Legal and Ethical aspect of documentation in nursing. Principle and guidelin...

HLTENN036-APPLY COMMUNICATION SKILLS IN NURSING PRACTICE LESSON 3 : DOCUMENTATION AND OPEN DISCLOSURE REWRITTEN BY TWINKLE MASHRUWALA RMIT Classification: Trusted Objectives Purpose of documentation in nursing Understanding Legal and Ethical aspect of documentation in nursing. Principle and guidelines in documentation Potential implications of poor documentation Element of open disclosure framework Gain understanding of 8 principles of open disclosure in health care So, what do you think we should include when we are documenting? RMIT Classification: Trusted Purpose of documentation Nursing documentation is essential for good clinical communication. Appropriate documentation provides an accurate reflection of nursing assessments, changes in clinical state, care provided and pertinent patient information to support the multidisciplinary team to deliver great care. Documentation provides evidence of care and is an important professional and medico-legal requirement of nursing practice. Nursing documentation is aligned with the ‘nursing process’ and reflects the principles of assessment, planning, implementation and evaluation. Nursing care is continuous and nursing documentation should reflect this. RMIT Classification: Trusted Nursing Documentation Appropriate documentation promotes: a high standard of care continuity of care improved communication an accurate description of the care provided goal setting and evaluation of care early detection of problems and changes in health status evidence of care provided. COMPREHENSIVE AND COMPLETE COLLABORATIVE AND CLIENT CENTRED Professional health care documentation should be: 1. Clear, concise and accurate 2. Contemporaneous with the events recorded in chronological order. Written as event occurs 3. Complete and Confidential 4. Patient-centered 5. Must be actual work of nurses including patient education and psychosocial support 6. Fulfil legal requirements If it isn’t documented it didn’t happen! CONFIDENTIAL Documentation MUST include these elements! RMIT Classification: Trusted Documentation - What counts? Documentation refers to all forms of information recorded in professional capacity: written, printed and electronic health records audio and video tapes, emails, faxes, images, observation charts checklists communication books shift management reports incident reports anecdotal notes Demonstrates clinician's accountability for the service they provided and a record of professional practice RMIT University©2017 School of Vocational Engineering, Health & Sciences RMIT Classification: Trusted Documentation Identification on every page / screen 1. Unique identifier (eg. Unique Patient Identifier, Medical Record Number). 2. Patient / client’s family name and given name/s. 3. Date of birth (or gestational age / age if date of birth is estimated). 4. Sex. RMIT Classification: Trusted Standards for Documentation Documentation in health care records must comply with the following: 1. Be clear and accurate. 2. Legible and in English. 3. Use approved abbreviations and symbols. 4. Written in dark ink that is readily reproducible, legible, and difficult to erase and write over for paper-based records. 5. Time of entry (using a 24-hour clock – hhmm). 6. Date of entry (using ddmmyy or ddmmyyyy). 7. Signed by the author and include their printed name and designation. In a computerised system, this will require the use of an appropriate identification system eg. electronic signature. RMIT Classification: Trusted Standards for Documentation Documentation in health care records must comply with the following: 7. Entries by students involved in the care and treatment of a patient / client must be cosigned by the student’s supervising clinician. 8. Entries by different professional groups are integrated ie. there are not separate sections for each professional group. 9. Be accurate statements of clinical interactions between the patient / client and their significant others, and the health service relating to assessment; diagnosis; care planning; management / care / treatment/ services provided and response / outcomes; professional advice sought and provided; observation/s taken and results. 10. Be sufficiently clear, structured and detailed to enable other members of the health care team to assume care of the patient / client or to provide ongoing service at any time. 11. Written in an objective way and not include demeaning or derogatory remarks. RMIT Classification: Trusted Standards for Documentation Documentation in health care records must comply with the following: 12. Made at the time of an event or as soon as possible afterwards. The time of writing must be distinguished from the time of an incident, event or observation being reported. 13. Sequential - where lines are left between entries they must be ruled across to indicate they are not left for later entries and to reflect the sequential and contemporaneous nature of all entries. Be relevant to that patient/client. 14. Written in error - all errors are must be appropriately corrected RMIT Classification: Trusted How to correct documentation error Written in error - all errors are must be appropriately corrected No alteration and correction of records is to render information in the records illegible. An original incorrect entry must remain readable ie. do not overwrite incorrect entries, do not use correction fluid. An accepted method of correction is to draw a line through the incorrect entry or ‘strikethrough’ text in electronic records; document “written in error”, followed by the author’s printed name, signature, designation and date / time of correction. For electronic records the history of audited changes must be retained and the replacement note linked to the note flagged as “written in error”. This provides the viewer with both the RMIT Classification: Trusted Example of Nursing Notes 22/12/2021 Date and time. Written in Chronological order Clear, concise and accurate details about patient Name & Designation RMIT Classification: Trusted Correcting Error in Documentation Do not obliterate the incorrect entry Strikethrough – make sure that entry is still readable Make correct entry Enter date, time and initial it You can only work your own entry and not someone else Do not write over. Progress Notes: 150 ‘error’ 11/06/21 13:10 MT 11/06/21 Nursing AM – Pt vomited 250 mls this morning. Doctor notified, pt given anti-nausea 13:00 given with good effect. RIB today. Going for U/S abdo @1500 – to remain NBM. RMIT Classification: Trusted Documentation – Frequency How often should you document? Daily/Every shift or as per organizational policy At a time of any significant change in patient condition. RMIT Classification: Trusted What should be Documented ? Document everything: Observations taken Results of any pathology Nursing assessment and care provided Patient’s response to therapy and treatment Any unusual incidents or cancelled treatments Safety precautions you took to protect the patient Any professional advice sought or given Any reservations you have about a doctor’s orders Leaving blanks or omitting documentation could have disastrous results in a lawsuit If it isn’t documented it didn’t happen! RMIT University©2017 School of Vocational Engineering, Health & Sciences RMIT Classification: Trusted Nursing documentation – Legal Point of View The importance of accurate documentation: Being inaccurate diminishes the strength of your case. Errors in documentation are viewed as sloppiness on the part of the registered person. If you have poor handwriting print in block letters, as the documentation needs to be readable. Do not document entries that are obvious or irrelevant, i.e.: “call bell within reach, verbalizes no complaints” when the patient is in a comatose state! Altering documents after the fact is considered fraud and will subject the institution and you to civil and criminal penalties. RMIT University©2017 School of Vocational Engineering, Health & Sciences RMIT Classification: Trusted Nursing documentation – Legal Point of View Understanding legal requirements of nursing documentation: The nursing documents are considered to be the most reliable source of information to determine what happened. If you document properly, your chances of winning a lawsuit are better. Proper documenting means that you do not alter or go back and correct documentation. Remember the proper method is to draw a line through improper or incorrect charting and place the word “error” immediately after the entry with your initials. If it isn’t documented, it didn’t happen! RMIT University©2017 School of Vocational Engineering, Health & Sciences RMIT Classification: Trusted Open Disclosure Framework The framework is designed to enable health service organisations and clinicians to communicate openly with patients when health care does not go to plan. o Adverse event and patient harm can and do occur Definition of harm by WHO: “Impairment of structure or function of the body and/ or any deleterious effect arising there from, including disease, injury, suffering, disability and death. Harm may be physical, social or psychological.” Open disclosure is the provision of an open and consistent approach to communication with patients/residents following an adverse event. Can you think of some examples that can lead to patient harm? RMIT University©2017 School of Vocational Engineering, Health & Sciences RMIT Classification: Trusted Open Disclosure Framework Open Disclosure is mandated in the NSQHS Standards 1 – Clinical Governance. and is part of accreditation process. Endorsed by Australian Health Ministers as well as many professional organization such as ACN, Royal Australians College of Physician etc. Open disclosure is: A patient and consumers right A core professional requirement and institutional obligation A normal part of an episode of care should the unexpected occur, and critical element of clinical communications An attribute of high-quality health service organisations and important part of the heath care quality improvement. RMIT University©2017 School of Vocational Engineering, Health & Sciences RMIT Classification: Trusted Open Disclosure – Elements Open disclosure should include following elements: o An apology or expression of regret o Factual explanation of what happened o Opportunity for the patient, their family and carers to relate their experience o Discussion of any potential consequences of the adverse event o Steps taken to manage and to prevent an event from recurring Open disclosure does not assign blame RMIT Classification: Trusted Open Disclosure – 8 Guiding principles 1. 2. 3. 4. 5. 6. 7. 8. Open and timely Communication Acknowledgement Apology or expression of regret Supporting and meeting the needs and expectation pf patients, their family and carers Supporting and meeting the needs and expectation of those providing health care Integrated clinical risk management and systems improvement Good governance Confidentially RMIT Classification: Trusted Open Disclosure – 8 Guiding principles 1. Open and timely Communication o If things go wrong, the patient, their family and carers should be provided with information about what happened in a timely, open and honest manner. o The open disclosure process is fluid and will often involve the provision of ongoing information. 2. Acknowledgement o All adverse events should be notified to the consumer as soon as possible. o Health service organisations should acknowledge when an adverse event has occurred and initiate open disclosure. RMIT Classification: Trusted Open Disclosure – 8 Guiding principles 3. Apology or expression of regret o Should receive an apology or expression of regret for any harm that resulted from the adverse event. o “I am sorry” or “we are sorry” should be included. 4. Supporting and meeting the needs and expectation pf patients, their family and carers. The patient, their family and carers can expect to be: o Fully informed of the facts surrounding an adverse event and its consequences o Treated with empathy, respect and consideration o Supported in a manner appropriate to their needs. RMIT Classification: Trusted Open Disclosure – 8 Guiding principles 5. Staff rights and responsibilities o Acknowledging their role in adverse events and conveying an apology or expression of regret. o Participating in open disclosure training and education as required. o Supported in open disclosure processes as required. 6. Integrated clinical risk management and systems improvement o Adverse events should be reviewed and investigated o Findings of review should focus on improvement of system of care and their effectiveness o Finding should in incorporated into quality improvement activity RMIT Classification: Trusted Open Disclosure – 8 Guiding principles 7. Good Governance o Involves system of accountability through a health service organization’s senior management, executive or governing body to ensure that appropriate changes are implemented, and their effectiveness is reviewed. o Should include internal performance monitoring and reporting. 8. Confidentiality o Any policies and procedure should be developed by health service organizations with full consideration for patient and clinician privacy and confidentiality. RMIT Classification: Trusted Detecting and Assessing incidents Open disclosure formally begins with the recognition that the patient has suffered harm during treatment or care. Detecting incident through variety of mechanisms Providing prompt clinical care to the patient to prevent further harm Assess the incident severity of harm and level of response Initiate a response – ranging form lower to higher level Notify relevant personnel and authorities Ensure privacy and confidentiality of everyone involved. RMIT Classification: Trusted Criteria for Determining Level of Response RMIT Classification: Trusted Open Disclosure Example Watch following video where open disclosure is done in a professional manner (06:23min). https://www.youtube.com/watch?v=b7VHNgGHbqA Video also highlights importance of documentation in a timely manner. RMIT University©2017 School of Vocational Engineering, Health & Sciences RMIT Classification: Trusted In-class Activity – 25 mins Divide Class into 4 groups to complete open disclosure activity. o Provide case study This activity has 4 case scenario and questioning pertaining to open disclosure. Please discussion amongst your group each case scenario as well as answer the questions regarding open disclosure. RMIT Classification: Trusted Confidentiality and Privacy Confidentiality refers to "specifically to restrictions upon private information revealed in confidence, with an understanding that the information will not be disclosed to others" Privacy refers to "ownership of one’s own body or information about one’s self" Nurses must not disclose any information obtained during their care Nurses, midwives and carers as health care providers are heavily regulated by a range of different legislation, codes and guidelines. These include: 1. 2. 3. 4. Health Records Act 2001 (Vic); Health Practitioner Regulation National Law 2009 (National Law); Code of conduct for nurses/ NMBA Code of conduct for midwives; Individual health facility policies. RMIT Classification: Trusted Confidentiality and Privacy For under-age person – parents or appointed guardian is allowed to access to the health information If someone has appointed guardian – person can have access to information. RMIT Classification: Trusted Critical Thinking Case Scenario from Tabbners (2.7) Shaun is a 22-year-old male on the ward. He tested positive for HIV. He reveals that he is homosexual and in the past was in multiple relationships with older male partners. His family is not aware of his homosexuality, and he does not want them to know about his HIV diagnosis. He thinks his family will not be supportive if they know about his sexual identify and his HIV diagnosis. What do you do or say if the family ask about his health and test results when they visit? RMIT Classification: Trusted Critical Thinking Case Scenario from Tabbners (2.8) You are arriving at work and are in a crowded elevator. The conversation in the elevator revolves around a well-known celebrity who was admitted during the night following a motor vehicle accident. How has this person’s right to confidentiality been breached? What would you do in this situation? RMIT Classification: Trusted References Australian Commission on Safety and Quality in Health Care. Open Disclosure Framework – Better communication, a better way to care. 2014. Retrieved online: https://www.safetyandquality.gov.au/sites/default/files/migrated/Australian-Open-Disclosure-FrameworkFeb-2014.pdf Berman, A., Kozier, B., and Erb, G. (2015). Kozier and Erb’s Fundamentals of Nursing Vol 3. (3rd Ed.). Pearson Australia, Melbourne, Australia. Dempsey, J., and French, J. (2009) Fundamentals of Nursing and Midwifery A person-centred approach to care. Lippincott Williams & Wilkins Pty Ltd, Broadway, NSW. Funnel, R., Koutoukidis, G., and Lawrence, K. (2005). Tabbners Nursing Care (4th Ed.). Elsevier Churchill Livingstone, Sydney, Australia. Koutoukidis, G., Stainton, K., & Hughson, J. (2013). Tabbner’s Nursing Care Theory and Practice (6th ed.). Chatswood, Australia: Elsevier. World Health Organization. The International Classification for Patient Safety WHO, 2009.