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Documentation practice
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Learning objectives
Describe the concept documentation
Describe the documentation tool used in the
ICU
Explain the type of information that is
appropriate for documentation
Explain the purpose of documentation Discuss the case study on documentation
given and lessons that can be learnt.
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Description and definition
Documentation is a vital component of safe,ethical and effective nursing practice.
provide registered nurses with professional
accountability in record keeping Nursing documentation provides an account
of the judgment and critical thinking used in
the nursing process (i.e., assessment,diagnosis, planning, intervention andevaluation).
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Cont
Accurate, timely documentation reflects careprovided; meets professional, legislative andagency standards; promotes enhanced nursing
care; and facilitates communication, betweennurses and other healthcare providers.
nursing documentation must be bothcomprehensive and flexible enough to obtain
critical data, maintain quality and continuity ofcare, track client outcomes, and reflect currentstandards.
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Cont.
Documentation also reflects the application ofnursing knowledge, skills and judgment,establishes accountability, and conveys the
unique contribution of nursing to health care. The current trend toward interdisciplinary
documentation is intended to eliminateduplication, enhance efficient use of time, andenrich client outcomes through teamcollaboration
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Cont
Registered nurses are legally and ethically
required to practice nursing in accordance with
the Registered Nurses Act and the code of
Ethics for Registered Nurses. According to the Standards, a nurse is expected
to record andmaintain documentation that is
clear, timely, accurate, reflective of observations,
permanent, legible and chronological
Nurses need to be familiar with agencies
policies, standards and protocols.
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Documentation refers to written or
electronically generated information about a
client, describing the care or services provided
to that client (e.g., charting, recording, nurses
notes, or progress notes).
In other words, documentation is an accurate
account of events that have occurred andwhen they occurred.
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Cont
Individual Clients
Nursing documentation for individual clients
provides a clear picture of the status of a
client, the actions of the clients nurse, the
clients health outcomes, and information
about or from the clients family.
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Nursing documentation for an individual client, shoulddescribe:
an assessment of the clients health status
a care plan or health plan reflecting the needs and goals of
the client nursing interventions carried out
the impact of these interventions on client outcomes
any proposed or needed changes to the care plan
information reported to a physician or other healthcare
provider and, when applicable, that providers response
advocacy undertaken by the nurse on behalf of the Client .
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Documentation in ICU
The intensive care nurse has to be highly
skilled today due to technological advances
and complex care of the critically ill patients.
Also the documentation and care required are
complex and time consuming
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The current process of documentation in theintensive care unit involves one chart withmany areas:
Vital signs respiratory observation ,neurological
observation stool chart ,pain chart,nursing
management chart ,daily fluidbalance,problem sheet ,ECG collection,biochemistry/haematology
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Cont.
This flow chart should fulfil the following criteria:-
decrease the amount of time required for
charting by: -
avoiding unnecessary repetition of patient data,
condensing patient observations onto one main chart;
be relatively easy for all nursing and medical staff
to use decrease the amount of paper required for
charting;
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Cont
be cost effective and compatible with
ecological principles.
allow more time for patient care at the
bedside
provide accurate documentation of patient
care for medico-legal reasons, to fulfil hospital
requirements and to facilitate continuity of
care.
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Purposes of Documentation
Communications and Continuity of Care
Quality Improvement and Risk Management
Risk management is a system used to identify,
assess, and reduce, where appropriate, risks toclients, visitors, staff, and organizational assets.
Risk management entails good documentation,
and client health records may be used for audits,ethical and disciplinary reviews, accreditation
surveys, legislated inspections and board
reviews, and ongoing risk management analysis
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Purposes cont..
Professional Accountability
Registered nurses are expected to follow the
Standards for Nursing Practice and Code of
Ethics for Registered Nurses when
documenting information related to the health
status of clients, related
situations/circumstances, and care provided.
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Cont
Legal Records
In a court of law, a health record serves as the legal record
of care or service provided, and documentation is often usedas evidence in legal proceedings.
Nursing care and the documentation of that care is measured
according to the standard of a reasonable and prudent nursewith similar education and experience in a similar situation.
Consequently, thorough and accurate documentation is one
of the best defenses against legal claims and the bestdefence if a lawsuit actually ensues.
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Cont..
Funding and Resource Management
Documentation is one source of data that can be usedby administration in making funding and resourcemanagement decisions.
Health records are proof of care provided, and third-party insurers sometimes use documented clientoutcomes for the approval of insurance claims.
Workload measurements, client classification systems,derived as a consequence of client documentation, areused by some agencies to help determine theallocation of staff and/or funding
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Research
Health records serve as a valuable and major source
of data for nursing and health related research
Data obtained from health records are also used inhealth research to assess nursing interventions,
evaluate client outcomes, and determine the
efficiency and effectiveness of care
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What should be documented?
Relevant and client-focusedinformation
environmental factors (e.g., safety, equipment, allergies),self-care, and client education
significant events during a client care episode, clientoutcomes, including a clients response to treatments,teaching or preventive care
discharge assessment data. Discharge documentationshould note whether a client and his/her family hadadequate preparation prior to discharge (e.g., contentand outcome of education sessions).
more comprehensive, in-depth and frequent notationsfor clients who are seriously ill, considered high-risk, orhave complex health problems
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Cont
Collaboration/Communication with Other Healthcare Providers
Nurses collaborate with other healthcare providers in person, bytelephone, meetings or other electronic means. In these situations,record significant communications in the clients health record,noting:
o date and time of the contact
o name(s) of the people involved in the collaboration
o information provided to or by healthcare providers
o responses from healthcare providers
o orders/interventions resulting from the collaboration
o the agreed upon plan of action
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Cont
Medication Administration
actual times medications are administered
names of medications
routes medications administered
sites of medication administration (when
appropriate)
dosage administered nurses signature/designation.
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Cont..
Verbal Orders
Giving and receiving verbal orders is
considered a high risk activity and should be
carried out only in situations in which it is
deemed to be in a clients best interest.
However, any miscommunication or lack of
communication could lead to negative
implications for the client.
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Cont
Telephone orders should be co-signed by the
physician involved at the first availableopportunity or within the time frame indicated in
the policy Errors in recording telephone orders can occur,
and there is always the question of who madethe error: the physician in the ordering or the
nurse in recording. Despite these concerns, thereare times when telephone orders may be thenext best option for the client.
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