Documentation Basics Flashcards
Appropriate documentation practices related to nursing foot care
Per standards of practice:
timely and accurate reports of relevant observations, and outcomes
Appropriate documentation practices related to nursing foot care
If working for an employer
Document foot care according to the facility policy and procedures
Appropriate documentation practices related to nursing foot care
– describe the principles of foot care documentation practices
C NAN C AEI
Clearly present the client’s current health status, including:
- Nursing assessment findings
– description of any foot pathologies noted - A health care plan based on the client’s needs
- Nursing interventions implemented
– type of foot care to be provided
– client education
– referrals - Client response to interventions
- Advocacy undertaken on behalf of the client
- Evaluation and modification of the care plan (ongoing)
- Information reported to other health care provider
What is the first step in the assessment process?
health history interview
Appropriate documentation practices related to nursing foot care
– demonstrate the ability to document a health history
What is the purpose of the health history interview?
- Gather data from client
- Understand the client’s perspective
- Build a trusting relationship and rapport
- Assess understanding of foot health, foot conditions and preventative care
Appropriate documentation practices related to nursing foot care
– demonstrate the ability to document a health history
Approrpriate health information will ALWAYS include…
(health history interview components)
AABCCD GROAN
Advanced directives ADL functional assessment Biographical details (name, address, phone, DOB) Current acute or chronic conditions Current meds (incl herbal/natural) Doctor (family physician)
General health history of all body systems
resp, cardiac, digestion, endocrine, EENT, neuro, musc/skel, psych, surgery
Reasons for seeking foot care
Other members of the health care team
Allergies
Next of kin
Health history interview mnemonic
AABCCD GROAN
Appropriate documentation practices related to nursing foot care
– demonstrate the ability to document a health history
Other important components of the health history to consider are:
PCCCHHH
Personal habits (smoking, alcohol intake)
Communication needs (language)
Cultural practices that might impact care of the foot
Current and past occupations
Health maintenance practices
History information source (client, family)
History of falls
Other important components of health history to consider mnemonic
PCCCHHH
What should the nurse do about any symptoms the client brings forward during the health history interview?
They should be further investigated.
When does observation begin?
Observation begins as soon as the client enters the room.
The complete hx may involve a lengthy intervx during the initial visit.
During subsequent visits the foot care nurse must set aside time to?
Every visit will include?
This involves? CINGS
Verify that the data previously collected and documented is still valid.
Every visit will include a more focused assessment of the lower limb.
This involves gathering both subjective and objective data regarding: Circulatory Integument Nervous General observation Structure and function
4.1 Employ the Code of Ethics in nursing foot care practice
– describe confidentiality and its application to nursing foot care
Health information is personal and sensitive and its confidentiality must be protected so that individuals are not afraid to seek health care or to disclose sensitive information to health professionals.
When gathering personal health information, the foot care nurse must know how to appropriately store, transport, share and destroy this data. Client records must be stored in a safe, confidential place and kept for ten years. After ten years of no activity, client records can be shredded or incinerated.
4.1 Employ the Code of Ethics in nursing foot care practice
– describe aspects of informed consent and its application to nursing foot care
4Cs AB
Capacity to make an informed decision
Care procedures must be explained
Coercion cannot be present
Clear understanding of the risks vs benefits of the foot care procedures.
An interpreter must be used if the client and the nurse do not communicate using the same language.
Best practice guidelines = client should be able to rephrase what has been discussed during the informed consent process.
4.2 Examine the Personal Health Information Act as it relates to nursing foot care practise
– describe the Personal Health Information Act
The Personal Health Information Act is a Manitoba law that protects the privacy of all personal health information that can identify an individual patient or client (Government of Manitoba, 2017).
