Documentation Flashcards
what are the 3 key purposes of documentation according to BCCNM
- communication
- safe & appropriate nursing care
- professional and legal standards
BCCNM professional standards vs. practice standards (documentation)
Professional standards – broad
Practice standards – very specific for documentation
legal issues regarding documentation
Client’s record is a permanent, legal document
May be used to provide evidence in court and/or coroner’s inquests
Nurse must clearly document all nursing care given, that care decisions were based on assessment, and that the nurse continues to monitor, document, and report patient responses
In court, care not documented is care not given
Freedom of Information and Protection of Privacy Act (FOIPPA)
ethical issues regarding documentation
RPN code of ethics
Protects the confidentiality of all information gathered in the context of the professional relationship
Practices within relevant legislation that governs privacy, access, use
documentation principles
- Only document care you personally provided
- Only use agency-approved abbreviations
- Never use pencil, only black ink
- Document ASAP, in chronological order, never prior to giving care
- Follow proper protocol for errors, no erasing or white out is permitted
- Documentation must be clear, concise, factual, objective, timely and legible
- Do not leave any blank spaces or lines
- RPN’s must add their signature and designation in a clear, legible manner
types of charting/nurses notes (narrative)
Narrative – written chronologically in paragraph form in progress notes
types of charting/nurses notes (Problem-Oriented /Charting by Exception - DARP; SOAP(IE))
focuses on documenting only deviations from the norm, narrative format; often seen with checklist flowsheets
what does DARP stand for
D- data
A-action
R- response
P- plan
what does SOAP(IER) stand for
Subjective
Objective
Assessment
Plan
Intervention
Evaluation
Revision
types of charting/nurses notes (Source Oriented Medical Records)
each discipline writes in a separate section of the chart ( history: doctor’s/consult notes, interdisciplinary team: physio, occupational therapist, dietician, social work, nursing: nursing notes)
SOAPIER (example)
S: 2245 patient states, “No” when asked if she has pain. At 2335 patient states, “my left arm hurts”
O: Pain reported as 8/10 on scale of 0 to 10
A: Patient is in pain and needs pain medication
P: Give pain meds as ordered
I: Patient given morphine 2 mg IV at 2340
E: Patient reports pain as 6/10
R: Patient’s continued pain reported to Dr. Jones at 0015.
what is the purpose of incident reports
to document unusual, unanticipated occurrences as a risk management tool. Internal quality control only – standalone report/not in patient’s chart eg. medication errors, falls
