chart
A document that may consist of a single form or a number of forms compiled to provide a complete record of patient care
documentation
any written or electronically generated information about a client that describes the care or service provided to that patient
what are the 4 min reasons for documentation?
- vital for safe, ethical, and effective nursing practice
- reflects knowledge, skills and judgments
- reflects patient’s perspectives
- promotes accountability, quality care, communication, nursing’s contribution to health care
why is documentation necessary? (5)
- Legal and professional
- Helps coordinate care
- Prevents repetition
- Promotes accuracy in care
- Allows for efficient use of time
what are the consequences of poor documentation?
- may not be continuity and consistent care
- Omission or duplication of treatments
- Inappropriate care decisions
- Inability to evaluate effectiveness of care /treatments
- Inability to respond appropriately to changes in patient’s health status
how is communication a tool?
helps us make good care decisions between all health care providers
how does documentation promote quality improvement and risk management?
- Evaluate effectiveness of our nursing care plan interventions
- Promotes patient safety
how does documentation promote professional accountability
-Reflects our professional judgment, assessment, coordination of care, decisions, actions and evaluation
how does documentation provide liability protection?
- Our charting can be used as evidence in a court of law
- Our charting needs to be specific, clear, and outlines the patient’s response to treatment/interventions
how does documentation expand the science of nursing?
- Source of data for nursing and health research
- Identifies the impact of nursing interventions, evaluates patient outcomes and identifies gaps or concerns in the provision of care
how can documentation improve funding and resource management?
Administrators can use documentation to support requests for additional funding and to help manage current resources
how does documentation promote education?
Opportunity to teach and learn
what are the regulatory bodies for documentation?
- PIPEDA
- HIPA
- CNA Code of Ethics
- CNPS
- SRNA
who should document the care?
if there are 2 people giving care, the person with first hand knowledge should document it.
-you saw it or you did it, YOU DOCUMENT IT
third party documentation. when is it acceptable, when it is not?
acceptable when:
- Designated recorder (ex- OR)
- Auxiliary or external personnel (unregulated care providers may not be able to document)
- Client or family
- Students (can document but may require co-sign)
- Co-signing and countersigning entries (ex- narc waste)
how should we doccument?
- need date, time, signature, designation
- clear, concise, unbiased, accurate
- do not label, argue, complain, or criticize
- objective (if using subjective need quotations)
- precise descriptions
- avoid using vague phrases and the words “appears, seems, and apparently” as well as slang
- don’t need to use complete sentences (a, also, is, are, were, the can probably be omitted)
who should we not use “appears, seems, or apparently?”
suggests that the nurse doesnt know the facts
what information is provided with the mater signature sheet?
- record of caregivers
- printed name, signature, initials, designation, date
- available on each individual chart
what information do we document?
all aspects of the nursing process (assessment to evaluation)
- has the intervention worked?
- anything clinically significant (the abnormal)
- all information that will allow for seamless delivery of safe competent care between shifts.
besides care, what else is documented?
admissions, transfers, transport, and discharge information
what is included in discharge documentation?
- Patient status at discharge
- Instructions provided to the patient (both written and verbal)
- Preparing patient for any transitions (what to expect in the course of recovery)
- Arrangements for follow-up (appointments made or need to be made)
- Ensuring that the patient understands teaching and, if appropriate, family’s involvement
beyond the basics, what does documentation allow for?
communication between all health care providers
-client education (what was taught, how they comprehended the information, information handouts, outstanding learning needs)
why is it important to document risk taking behaviours?
- regardless of teaching , patients have their right to make their own decisions
what should nurses do if pt’s go against medical advice?
- when patients choose to go against medical advice and have been informed of associated risks you MUST document what was taught, the associated risks for their behaviour and our recommendations
- fill out incident report
