documentation bsp oct, 2010

8/8/2019 Documentation BSP Oct, 2010

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CNE - BSP October, 2010 1


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GOAL of SKMC

In preparation for the JCIA audit visit scheduled early December 2010,

SKMC nursing department aims at



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Goal of BSP

In light of SKMC preparation for the JCIA audit visit on December 2010,

we aim to



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Objectives of BSP Action Plan



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Current Focus

1. Nursing Admission Assessment (NAAF)

2. Nursing Care Plan APIE

3. Ongoing Assessment



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Standard Time Frame


Document When to Fill Remarks

1. NAAF On AdmissionRegardless of shift Day

or Night

2.APIE

Car Plan

On Admission

For all patients on morning shift

For any identified problem after then

EE

to be done on each

endorsement HAND

IN & Hand OVER oneach shift

3.Ongoing

AssessmentEvery shift for all patients Physical + MHA


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Day ShiftResponsibilities


3. Write a complete Care Plan using the APIE format.

ForALL patients, whetherNEWLY ADMITTED orEXISTING Patients in the unit.

2. Perform Physical + Mental Health Assessment (MHA).

For allEXISTING Patients in the unit.

1. Write a Complete NAAF

For allNEWLY ADMITTED Patients during day shift.


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Night ShiftResponsibilities


2. Write a complete Care Plan using the APIE format.

For allNEWLY ADMITTED Patients during Night Shift, and

For anyNEWLY identified DIAGNOSES/PROBLEMS.

1. Write a Complete NAAF

For allNEWLY ADMITTED Patients during Night Shift.

3. Document E ofthe APIE on bothHANDING IN and

HANDING OVER.

ForALL patients, whetherNEWLY ADMITTED orEXISTING Patients in the unit.


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General Guidelines


2. Assign each problem a NUMBER in a chronological order.

1. Use only oneSK progress note to documentthe APIE and

the carethatYOU renderto your patient during the shift.

3. Enter whateverhappens during the shiftin a chronological

order.

4. ritethe ATE and TIME ofeachentry.

5. SAFE and SIGN OFF eachentry.


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General Guidelines


6. Ifthe patient develops another problem during the Shift

that was not captured in theinitial APIE, writethe new

problem with a chronological number assigned to it.

7. Never use ABBREVIA IONS.

8. The night staff will do thePHYSICAL and MH assessment

and comparetheiridentified problems withthe ones

identified in the APIE ofthe day shift.


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General Guidelines


6. Iftheidentified problem(s) is/arealready captured in the

day shift APIE, only write an evaluation ofthe numbered

problem(s).

7. Ifthe problem identified is notyet captured in an APIE

during the day shift, write a complete APIE forthe new

problem and numberit chronologically.

8. Should a patient be admitted on night shift, the nurse will

beresponsible for writing a complete APIE for problems

identified on admission.


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documentation bsp oct, 2010

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