Documentation
Page 2: Learning outcomes
Discuss the importance of documentation and reporting
Identify the purposes of a healthcare record
Discuss and apply guidelines for effective documentation and reporting
Discuss legal guidelines for recording client care
Describe different methods of record keeping
Discuss the advantages of standardized documentation forms
Identify critical elements of a client's discharge plan
Describe handover reporting tools
Page 3: Documentation
Legal requirement of NCNZ
Documentation protects the welfare of patients
Promotes high standards of clinical care
Ensures continuity of care
Facilitates better communication and distribution of information between multi-disciplinary members
Provides an accurate account of treatment, care planning, and delivery
Enables the early detection of problems
Requirements apply to paper and electronic records
Access organization policies on documentation
Requirements should adhere to The Privacy Commissioner, Health Information Privacy Code 1994 and HDC Code of Health and Disability Services Consumers' Rights (2014)
Page 4: Effective communication
Ensures continuity of care
Hand-over reports
Verbal handovers
Page 5: Dos and Don'ts for change-of-shift reports
Dos:
Provide essential background information about the client
Identify client's nursing diagnosis or healthcare problems and their related causes
Describe objective measurements or observations about the client's condition and response to health problem
Share significant information about family members as it relates to the client's problems
Continuously review ongoing discharge plans
Relay significant changes in the way therapies are given
Describe instructions given in the teaching plan and the client's response
Evaluate results of nursing or medical care measures
Be clear about priorities to which oncoming staff must attend
Don'ts:
Review all routine care procedures or tasks
Review all biographical information already available on file
Use critical comments about client's behavior
Make assumptions about relationships between family members
Engage in idle gossip
Describe basic steps of a procedure
Explain detailed content unless staff members ask for clarification
Simply describe results as 'good' or 'poor'; be specific
Force oncoming staff to guess what to do first
Page 6: Clinical Example
Mrs. Staples, an 89-year-old woman, presents to the Emergency Department with a fractured neck of femur after a fall at home
Mrs. Staples lives alone with her dog and cat
Her daughter Debbie assists with shopping and getting to appointments
Mrs. Staples has become forgetful and may need frequent reminding about her animals
The ED nurse advises the doctor of Mrs. Staples' poor memory
Reports this to the ward nurse when Mrs. Staples is admitted to the surgical ward
At hand-over, the night-shift ward nurse is told that Mrs. Staples has been increasingly upset about her animals
Her daughter has not been contactable
Mrs. Staples falls trying to get out of bed and becomes upset and agitated
The nurse tries to reassure Mrs. Staples and gives analgesia
Mrs. Staples remains upset and agitated
No information about social arrangements for this patient is found in the progress notes
Mrs. Staples has sustained a left-sided Colles' fracture as a result of her fall
Page 7: Fundamental elements of records
What would you expect to see in the patient's file?
Page 8: Guidelines for documentation and reporting
5 important guidelines
Page 9: Frameworks - Focus charting
D: Data
Subjective/objective information as evidence of patient's condition
A: Action
Completed or planned nursing interventions based on the nurse's assessment of the patient
R: Response
Evaluation of the interventions provided
Page 10: SOAP/SOAPIER Charting
S: Subjective data
O: Objective data
A: Assessment
P: Plan
I: Intervention
E: Evaluation
R: Revision
Page 11: Narrative charting
Method where nursing interventions and the impact of the interventions are documented in chronological order
Information is recorded without a framework, does not necessarily include a rationale or evaluation for an action or task
Page 12: Clinical Example
The nurse positions Mr. Page in a semi-Fowler's position
Encourages increased fluid intake
Gives paracetamol 1 g PO as ordered for fever
One hour later, the client is resting in bed
Vital signs are within normal range
The client states he has been able to sleep
His fluid intake has been 200 mL of water
Page 13: Reporting
Change-of-shift reporting
Telephone reports
Telephone orders
Transfer reports
Incident reports
Page 14: Examples of criteria for reporting and recording
Assessment
Subjective data
Objective data
Nursing interventions and evaluation
Medication administration
Client teaching
Discharge planning
Page 15: Key Concepts
The health/medical record is a legal document
Requires information describing the care delivered to a client
All information gathered by examination, observation, conversation, or treatment is confidential
Multidisciplinary communication is essential within the healthcare team
Accurate record-keeping requires objective interpretation of data
Precise measurements, correct spelling, and proper use of abbreviations
Nurse's signature on an entry designates accountability for the contents
Any change in a client's condition warrants immediate documentation
Problem-oriented medical records are organized by the client's healthcare problems
SOAPIE, PIE, DAR charting, or systems-based approaches organize progress notes
Critical/clinical pathways document methods for better client outcomes
Long-term care documentation is multidisciplinary
Change-of-shift report maintains continuity of care
Use of tools and frameworks can improve handovers and reports
Rounds allow nurses to assess, evaluate progress, and determine interventions
Support client participation and decision-making
Telephone communication of care information or orders needs verification
Incident reports objectively describe events inconsistent with routine care of