Week 6: Communication, Documentation, Reporting

Define documentation

Any written or electronically generated information about a client that describes the care or services provided to that client, and is an essential part of nursing practice

List the types of records

-Database (assessment information)

-Problem list

-Care Plans

-Progress notes (i.e. narrative records)

-Care maps/critical pathways

-Flow sheets

-Graphic records

-Kardex

-Electronic Health Records

What are the three standards for documentation?

-Standard 1: Accountability (Documenting the needed info)

-Standard 2: Communication and safe provision of care

-Standard 3: Security (Keeping documents safe)

What type of information must documentations include?

-All assessments, plan, interventions, evaluation

-Issues, concerns, outcomes, preferred goals

-Patient responses, relevant information

-Adverse event or outcome

-Complete and compliant with standards

-Instructions, patient/family teaching

-Communication with other care providers

What documentation guidelines need to be followed?

-Record all facts, accurately, thoroughly, and completely

-Correct errors promptly

-Include subjective data and objective data

-Chart contemporaneously

-Always protect your passwords, and follow electronic charting guidelines

-Ensure correct spelling and wording and use only approved abbreviations

When documenting how should patient words be indicated?

In quotations (" ")

Who should you chart for?

Chart only for yourself, unless in an emergency situation

What should you avoid when charting?

Avoid generalizations, be accurate and objective

What identification details are required for the individual charting when using paper records?

Always begin with date, time (24 hr clock), and end with your name and designation

What should you do if you notice a blank space after completing your charting?

Never leave blank spaces, if theres a blank space strikes though the area

Which color ink is recommended for paper charting?

Permanent black ink

Should you pre chart patient care?

Never pre chart, chart promptly after an event has occurred and always indicate the exact time you're actually charting

When paper charting what should you ensure to make sure the information is legible?

Ensure all handwriting is legible

List the types of narrative documentation

-SOAP

-PIE

-DAR

What does SOAP stand for?

S: Subjective

O: Objective

A: Assessment

P: Plan

What does PIE stand for?

P: Problem

I: Intervention

E: Evaluation

What does DAR stand for?

D: Data

A: Action

R: Response

What are the advantages of electronic records

-Captures longitudinal information on the patients health

-Continuous access to authorized users at any time

-Can link to information resources such as medication information

-AHS phasing in Connect Care

What is the health information act (HIA)?

The provincial legislation including expectations for the collection, use, disclosure and security of health information

Who does the health information act (HIA) protect?

Protects the privacy and confidentiality of individuals and their health information

When would you need to make a HIA report?

Mandatory reporting when there is inappropriate access, disclosure or loss of individually identifying health information

What does the agency do when a HIA report is made?

Once reported the agency must do a risk of harm assessment to the individual who is the subject of the breach. Agencies may be required to notify the individual(s) of the reported incident

What patient information are you allowed to access?

Only access patient information relevant to your practice

How can you handle and protect patient information?

Handle it in a secure manner and dispose of it correctly

Gathering information must be done without what?

Must be done without photocopying, printing, or photographing

All identifiable patient information must not __________

Leave the unit

What does safe, effective clinical care depend on?

Reliable, flawless communication between caregivers

What has been frequently identified as a major contributor in sentinel or critical events?

Miscommunication

List the reason for communication breakdown

-Different communication styles

-High level of activity

-Frequent interruptions

-Complex healthcare environment

-Stress

-No standardization in organizing essential information

What is SBAR?

A standard communication tool used to communicate critical situational information between healthcare providers

What does SBAR stand for?

S: Situation (Major concern)

B: Background (Pertinent information, and events leading up to the situation)

A: Assessment (What do I think is the problem? Assessment of the situation)

R: Recommendation (What I recommend needs to be done)

SBAR is used as a ________ model

Situational briefing

What section of SBAR does this cover: I am calling about patient Paul Todd. The main problem is pain, edema, warmth and redness to his right lower leg. He has no allergies.

Situation

3 multiple choice options

What section of SBAR does this cover: Vital signs are stable. He has pain in his calf, rating it at 7/10, and his posterior right calf is red, warm, and edematous, skin is intact. He was given acetaminophen in 1420, which was ineffective for pain.

Background

3 multiple choice options

What section of SBAR does this cover: I am very worried about his situation and think the problem is a possible DVT in his right leg.

Assessment

3 multiple choice options

What section of SBAR does this cover: I think Paul needs to be seen right away. Are there any other tests you wish to order.

Recommendation

3 multiple choice options

What are the guidelines surrounding social media

As regulated health professionals, nurses need to understand their professional and ethical obligation to protect the public and maintain conduct that reflects trustworthiness and integrity, including their online presence

For nurses that use social media, what do they need to ensure?

-Does not breach confidentiality

-Has no derogatory comments

-Credits thoughts and work of others

-Only post authorized content

-Careful regarding personal views

-Information is evidence based so do not give health advice online

Nurses need to ensure their social media _______/_______ free

Client, patient