Six

COMMUNICATION, DOCUMENTATION & REPORTING LAB LECTURE NOTES

LAND ACKNOWLEDGEMENT

LAB LECTURE LEARNING OUTCOMES

• Discuss the importance of communication, documentation, and reporting in nursing practice.

• Explore communication challenges associated with patients who have sensory or cognitive deficits.

• Practice communication techniques to effectively communicate with patients experiencing communication challenges.

• Identify the legal and quality guidelines required in documentation in the healthcare setting.

• Discuss the Health Information Act (HIA) and the nurse’s role in relation to it.

COMMUNICATION

Importance of Communication

• “Safe, effective clinical care depends on reliable, flawless communication between caregivers. Miscommunication is frequently identified as being a major contributor in sentinel or critical events.” (AHS, 2010, pp. 3)

How/Ways to Communicate

• Speaking: Direct verbal communication with patients and colleagues.

• Reading: Understanding written documents and literature pertinent to patient care.

• Listening: Actively hearing and processing information provided by others, especially by patients.

• Writing: Documenting patient data, treatment plans, and care notes accurately.

• Non-verbal Signs: Understanding and utilizing body language, facial expressions, and other non-verbal cues.

DOCUMENTATION

Definition of Documentation

• Documentation is defined as “any written or electronically generated information about a client that describes the care or services provided to that client… an essential part of nursing practice.” (Kilgour, K.N. 2020, pg. 649)

Role of Documentation

• “As part of the permanent client care record, clear, accurate, and comprehensive nursing documentation provides evidence that the registrant has met the expected requirements of documentation standards in their role in a particular practice setting.” (CRNA, 2022, pg. 5)

Why Do We Document?

• Outlines the client’s plan of care, interventions, and health services provided.

• Promotes effective communication.

• Enhances safe patient care between caregivers and across shifts.

• Provides continuity of care.

• Serves as a record of critical thinking and judgment.

• Describes the quality of care and standards of practice.

• Acts as a legal document that provides evidence of the care provided. (CRNA, 2022)

Where Do We Document?

• Formal charts: Traditional paper records containing patient information and care history.

• Electronic records: Such as Connect Care, which manage patient data electronically.

• Doctors' boards: Display information relevant to patient care within medical teams.

• Kardex: A quick reference for patient information and care plans.

CRNA STANDARDS FOR DOCUMENTATION

1. Accountability: Nurses must take responsibility for their documentation and actions.

2. Communication and safe provision of care: Documentation must ensure clear communication to uphold patient safety.

3. Security: Compliance with security standards to protect patient information (CRNA, 2022).

GUIDELINES FOR DOCUMENTATION

• Record facts only.

• Correct errors promptly (Example: “…Right Error M.B. Left lower leg…”).

• Include both subjective and objective data.

• Avoid generalizations.

• Chart only for yourself; do not chart for others.

• Always start with the date, time (in 24-hour format), and end with your name and designation.

• Never “pre-chart.”

• If writing by hand, ensure it is legible, using permanent ink.

• Verify correct spelling in all documentation.

• Utilize only approved abbreviations.

• Never leave blank spaces in documentation.

• Protect passwords and follow electronic charting guidelines to ensure data privacy.

DOCUMENTATION FORMATS

• Narrative: Chronological record of the patient's experiences and treatments.

• SOAP: Subjective-Objective-Assessment-Plan format for structuring notes.

• PIE: Problem-Intervention-Evaluation structuring format.

• SOAPIE: An extended version of SOAP including Intervention and Evaluation.

• DAR: Data-Action-Response format for documenting patient responses.

• Narrative and/or Verbal: Less formal communication, often used in discussions.

• SBAR: Situation-Background-Assessment-Recommendation format for communication among healthcare providers.

PATIENT CASE STUDY MR H

Medical History

• Hypertension

• Obesity

• Dyslipidemia

No Previous Surgical History

Medications

• Lisinopril

• Amlodipine

• Atorvastatin

Vital Signs

• Blood Pressure: 148/88

• Heart Rate: 98

• Temperature: 37.2°C

• Respiratory Rate: 20

• SpO2: 96%

Significant Symptoms Reported by Patient

• States: “My belly hurts a lot when I move.”

• Rates pain: 7/10

• Observations during assessment: Grimacing while repositioning, slowed movement, nausea, and decreased appetite.

• Noted guarding during abdominal examination.

• Sound assessment shows decreased bowel sounds; patient mentions passing gas.

• Incisions appear clean and dry with no drainage.

• Patient has not ambulated since surgery.

EXAMPLE OF SOAP(IE) FORMAT

• S (Subjective): Mr H complains of pain rated 7/10, mentions ‘his belly hurts a lot when he moves,’ reports nausea, vomiting, and decreased appetite, and passing gas.

• O (Objective): Observations include grimacing during repositioning, slowed movement, guarding during abdominal assessment, decreased bowel sounds, and lack of ambulation since surgery.

• A (Assessment): Mr H is at risk for ineffective pain management which could impact his recovery.

• P (Plan): Address Mr H’s issues with pain and lack of appetite.

• I (Intervention): Provide analgesics as ordered, offer non-pharmacological methods for comfort, consult dietitian for appetite issues.

• E (Evaluation): Mr H reports pain decreased to 4-5/10 within 24 hours, is ambulating around his room, and consumed 75% of breakfast and lunch today.

EXAMPLE OF PIE FORMAT

• P (Problem): Pain rated 7/10; Mr H states ‘his belly hurts a lot when he moves.’ Reports nausea, vomiting, decreased appetite, and passing gas; exhibits grimacing during repositioning, slowed movement, guarding during abdominal assessment, and decreased bowel sounds.

• I (Intervention): Administer analgesics as ordered, provide non-pharmacological comfort measures, consult dietitian for dietary advice to increase appetite, encourage ambulation, and monitor bowel movement.

• E (Evaluation): Mr H reports decreased pain levels to 4-5/10 within 24 hours, ambulating in the room, and had one bowel movement, with 75% of breakfast and lunch consumed.

SBAR FORMAT

• Situation: Introduction of the caller and the primary reason for communication or concern.

• Background: Share relevant patient health information and circumstances leading to the current situation.

• Assessment: Provide personal assessment of the situation related to the patient’s condition.

• Recommendation: State the recommended follow-up actions or requests of the staff receiving the report (AHS, 2010, pg. 4).

EXAMPLE OF SBAR

• S: “I’m giving you report on Mr H in room 27-1 before I go on my break.”

• B: “Mr H had a laparoscopic cholecystectomy yesterday.”

• A: “This morning, Mr H complained that his belly hurts when he moves, rated his pain 7/10, demonstrating guarding during the abdominal assessment, and grimacing when repositioned.”

• R: “I have administered Mr. H his PRN analgesic 10 minutes ago. We have given Mr. H a bedpan at his request. When he rings once he is done, could you please also reassess his pain to evaluate the effectiveness of the analgesic? Thank you.”

HEALTH INFORMATION ACT (HIA)

• A provincial legislation governing the expectations for the collection, use, disclosure, and security of health information.

• Protects the privacy and confidentiality of individuals along with their health information (CRNA, 2023).

COMMUNICATION CHALLENGES

Challenges to Communication

• Sensory Deficits: Issues with vision and hearing.

• Cognitive Deficits: Conditions like dementia and aphasia.

• Language Barriers: Difficulties faced due to different languages or dialects.

OVERCOMING COMMUNICATION CHALLENGES

• Utilize aids such as glasses and hearing devices.

• Employ patience and take time when interacting.

• Use therapeutic communication skills effectively.

• Use pictures or common words that are easily accessible, especially when translators are unavailable.

• Engage family members in communication where feasible.

PRIVACY & CONFIDENTIALITY

• Nurses must be aware of the ethical obligation to protect the public and maintain trustworthiness and integrity, particularly concerning online presence (CRNA, 2020, page 1).

REFERENCES/RESOURCES

• Alberta Health Services (2010), Orientation: SBAR communication tool.

• College of Registered Nurses of Alberta (2022), Documentation standards.

• College of Registered Nurses of Alberta (2019), Practice standards for registrants.

• College of Registered Nurses of Alberta (2023), Privacy and management of health information standards.

• College of Registered Nurses of Alberta (2021), Social Media and e-Professionalism: Guidelines for Nurses.

• Kilgour, K.N. (2020). Effective documentation. In D. Gregory, C. Raymond, L. Patrick, & T. Stephen (Eds.), Fundamentals: Perspectives on the art and science of Canadian nursing (2nd ed., pp. 647-670). Wolters Kluwer.

• Pasieka, D. (2020). Documentation and interprofessional communication. In T.C. Stephen & D.L. Skillen (Eds.), Canadian nursing health assessment: A best practice approach (2nd ed., pp. 70-89). Wolters Kluwer.