DOCUMENTATION

DOCUMENTATIONDEFINITIONDocumentation in Nursing Practice is anything written or electronically generated that describes the status of client on the care or services given to that client ( Potter and Perry, 2010)

PURPOSESCommunication and Continuity of Care all health care team members should have access to information upon which to plan and evaluate their interventions.all health care team members require accurate information about clients to ensure the development of an organized comprehensive care plan. The risk of inaccurate or incomplete documentation is: care that is fragmented, tasks that are repeated and therapies which could be delayed or omitted.Quality Improvement/Assurance and Risk Management Clear, complete and accurate nursing documentation facilitates quality improvement initiatives and risk management analysis for clients, staff and organizations. Through chart audits and performance reviews documentation is used to evaluate quality of services and appropriateness of care

Establishes Professional AccountabilityDocumentation is a valuable method of demonstrating that nursing knowledge, judgment and skills have been applied within a nurse-client relationship in accordance with the code of ethics for nurses.Legal ReasonsThe clients record is a legal document and can be used as evidence in a court of law or in a professional conduct proceeding.Documentation should provide a chronological record of events in client care and delivery of services.Courts may use the health record to reconstruct events, establish time and dates, refresh ones memory and to substantiate and/or resolve conflicts in testimony

Expanding the Science of Nursing Health records serve as a valuable and major source of data for nursing and health related research.Data obtained from health records is also used in health research to assess nursing interventions, evaluate client outcomes, and determine the efficiency and effectiveness of care. The type of research made possible through the information in health records can enable nurses to further improve nursing practice.Principles in DocumentationFactualAccurate CompleteTimelyConciseLegibleConfidentiality

FACTUALDescriptive objective information about what the nurse sees, hears, feels, smells and thinkIncludes objective signs of problemsSubjective data is documented in clients exact words within quotation marks

ACCURATE

Use of exact measurement establishes accuracy e.g. Intake of 400ml of water then writing adequate amount of water

COMPLETE

Condition change

Patients responses especially unusual, undesired or ineffective response.

Communication with patient family

Entries in all spaces on all relevant assessment form. Use N/A or other designation per policy for items that do apply to your patient.

Do not leave blank

TIMELY

Document date & time of each recording

Record time in conventional manner (e.g. 9:00am to 6:00pm or according to the 24 hours clock) Avoid recording in advance (this practice is illegal falsification of the records contributes to errors and confusion and threatens patient safety.

CONSICERecording need to be brief as well as complete to save time and communication

LEGIBLE

Using black pen, clear enough to be read, readable particularly handwriting Any mistakes occur while recording draw a line through it and write above or next to original entry with your initial or name.

CONFIDENTIALITY

Technology does not change clients rights to privacy of health information. Whether documentation is paper-based, electronic or in any other format, maintaining confidentiality of all information in a health record is essential, and relates to access, storage, retrieval and transmission of a clients information. Medication AdministrationEvery hospitals should have specific policies and procedures related to documentation of medication administration. The general requirements for this type of documentation include: ( 10 rights should be followed) Date Actual time medications are administrated Names of medications Routes of medications Sites of administration when appropriate Dosage administered Nurses signature/designationRole of the nurse in documentation? Verbal Orders and Telephone OrdersThe expectation is that authorized prescribers will write medication orders whenever possible. However, registered nurses can accept verbal medication orders from authorized prescribers (either face-to-face or by telephone) when it is in the best interest of a client and there are no reasonable alternatives. Situations in which verbal orders would be considered acceptable include: urgent or emergency situations when it is impractical for a prescriber to interrupt client care and write the medication order when a prescriber is not present and direction is urgently required by a registered nurse to provide appropriate client care. Collaboration with other Health Care ProfessionalsThere is a current trend toward interdisciplinary practice. This way of documenting is intended to eliminate duplication, enhance efficient use of time and enrich client outcomes through team collaboration. Collaborative documentation enables healthcare professionals of all disciplines to share the same documentation tools. Examples of such tools are clinical pathways which reflect interdisciplinary care and integrated, interdisciplinary patient progress notesCollaboration with multi-disciplinary teamThere is a current trend toward interdisciplinary practice. This way of documenting is intended to eliminate duplication, enhance efficient use of time and enrich client outcomes through team collaboration. Collaborative documentation enables healthcare professionals of all disciplines to share the same documentation.

Plan of CareEffective client-focused documentation should also include a plan of care.

Admission, Transfer, Transport and Discharge Information Accurate and concise documentation on admission, transfer, transport and discharge provides baseline data for subsequent care and follow up. Nursing documentation should reflect information on the clients status at discharge, any instructions provided (verbal and written), arrangements for follow-up care and evidence of the clients understanding, and family involvement as appropriate.Client Education The following aspects of client education should be documented in the health record: both formal (planned) and informal (unplanned) teaching materials used to educate method of teaching (written, visual, verbal, auditory and instructional aids) involvement of patient and/or family evaluation of teaching objectives with validation of client comprehension and learning any follow up required.

All Aspects of the Nursing Processnursing process demonstrates that an RN has fulfilled her/his duty of care. unique contribution of nursing to the care of clients. any information that is clinically significant should be documented. To determine what is essential to document, for each episode of care or service the health record should contain:a clear, concise statement of client status (including: physical, psychological, spiritual) relevant assessment data (include client/family comments as appropriate) all on-going monitoring and communications the care/service provided (all interventions, including advocacy, counseling, consultation and teaching) an evaluation of outcomes, including the clients response and plans for follow updischarge planning.Failure to document evaluation is a common deficiency in charting. Incident ReportsAn incident is an event which is not consistent with the routine operations of the unit or of client care (Perry and Potter, 2010). Examples of incidents include patient falls, medication errors, needle stick injuries, or any circumstances that places clients or staff at risk of injury. Incidents are generally recorded in two places, in the clients medical record and in an incident report, which is separate from the chart.

Do's and Don'ts of Nursing Documentation

Do's Check that you have the correct file before you begin writing. Make sure your documentation reflects the nursing process. Write legibly. Chart the time you gave a medication, the administration route, and the patient's response. Chart precautions or preventive measures used, such as bed rails. Record each phone call to a physician, including the exact time, message, and response.

23Do's.. Chart patient care at the time you provide it.

If you remember an important point after you've completed your documentation, chart the information with a notation that it's a "late entry." Include the date and time of the late entry. Document often enough to tell the whole story.

24Don'ts Don't chart a symptom, such as "c/o pain," without also charting what you did about it. Don't alter a patient's record - this is a criminal offense.Don't use shorthand or abbreviations that aren't widely accepted.Don't write imprecise descriptions, such as "a large amount."

25Don'tDon't chart what someone else said, heard, felt, or smelled unless the information is critical. In that case, use quotations and attribute the remarks appropriately. Don't chart care ahead of time - something may happen and you may be unable to actually give the care you've charted. Charting care that you haven't done is considered fraud. 26