Week 5: Documentation 1 Flashcards
What are the 6 purposes of patient records?
- Communication and care planning
- Legal documentation
- Education
- Funding and resource management
- Research
- Quality review (auditing and monitoring)
What is documentation?
A nursing action that produces a written account of pertinent patient data, nursing clinical decisions, and interventions, and patient responses in a health record.
“Anything written or electronically generated that describes the status of a patient or the care or service given to the patient”
How do pt records serve the purpose of ‘communication & care planning’?
- all HCT members communicate its needs, progress, care, tx, and education (starts on admission and ends on discharge)
- this ensures
consistency and
continuity of care
- this ensures
- reflects the nursing process (ADPIE)
- provides baseline data
How do pt records serve the purpose of ‘legal documentation’?
- demonstrates accountability for practice
- best defense against legal claims
- need to document: assessments, care, pt. responses, instructions, referrals, etc.
- CARE NOT DOCUMENTED = CARE NOT GIVEN
How do pt records serve the purpose of ‘education’?
- provides uniqueness of each pt (for education for students, staff, etc)
- get to learn about illness and patterns of behavior
- enables students to see patterns & types of care provided/needed
How do pt records serve the purpose of ‘funding & resource management’?
- chart/record shows how health care resources have been used
- level of acuity of pt indicates the type and amount of resources required (eg. hours of nursing care, qualifications of HCP)
How do pt records serve the purpose of ‘research’?
- data for statistical purposes (e.g rate of infection post-C-section, rate of recovery post appendectomy)
- analysis of data for research purposes (e.g rates of depression in residential care)
How do pt records serve the purpose of ‘quality review (auditing)?
- evaluation of the quality and appropriateness of care
- audit charts (multidisciplinary)
- deficiencies are shared with the care team so new policies or practices can be introduced
What are the six guidelines for quality documentation?
- factual information
- accurate
- complete
- current
- organized
- complies with standards
‘Factual information’ is a guideline for quality documentation and entails:
- descriptive, objective data
- avoids: “appears, seems, apparently”
- notes subjective data as exact as possible (e.g pt states “I passed a clot the size of a toonie”)
‘Accuracy’ is a guideline for quality documentation and entails:
- accurate specific times, amounts, sizes, description & responses
- acceptable abbreviations & symbols (1st use always spelled out)
- clear & concise w/ accurate spelling
- initials and status after each timed charting entry
- knows how to chart and error & late entry
‘Complete charting’ is a guideline for quality documentation and entails:
- comprehensive
- paints a clear picture of pt status, care provided to pt or pt. response
‘Being current’ is a guideline for quality documentation and entails:
- timely entries (@ time of occurrence or asap)
- bedside computers for charting are a bonus (@ARH)
What things should be documented immediately (being current - part of quality documentation guidelines)?
- vital signs
- administration of meds
- treatments
- prep for tests/surgery
- change in staus & associated treatments
- admission, discharge, birth, death
‘Being organized’ is a guideline for quality documentation and entails:
- DARP (data, action, response, plan) focus charting
