lecture recording on 28 February 2025 at 11.59.00 AM

Objectives

• Start by discussing the importance of reporting and documenting patient care.

• Emphasize documentation's role in safety and the continuity of care.

Importance of Documentation

• Documentation Is Essential:

  • If it's not documented, it didn't happen.

  • Vital for accountability in patient care.

• Types of Documentation:

  • Written or electronic formats.

  • Moving towards Electronic Health Records (EHR).

Communication Tool

• Purpose of Documentation:

  • Enables communication among healthcare team members.

  • Provides continuity of care ensuring all team members are on the same page.

• Continuity of Care:

  • Involves following a treatment plan across various providers and shifts.

Quality Improvement and Audits

• Importance of Quality Documentation:

  • Internal audits ensure correct documentation for legal and quality assurance.

  • Examine if medication errors and other critical issues are tracked effectively.

Planning and Evaluating Outcomes

• Documentation helps in evaluating the effectiveness of interventions.

• It must reflect changes in patient status and responses to interventions.

Legal Aspect of Documentation

• Patient's chart serves as a legal document.

• Must be thorough and non-judgmental, similar to how a jury would view it.

• Documentation scrutinized by legal experts in case of disputes about care.

Professional Standards of Care

• Documentation corresponds to minimum standards established by the American Nurses Association (ANA).

• Ensures that nursing actions meet set quality standards.

Education and Research

• Documentation provides data for education and research purposes.

• Necessary for reimbursement from insurance companies.

Challenges in Documentation

• Time-consuming: Nurses can spend up to 25% of their shifts documenting.

• EHR Systems: While they improve efficiency, they may introduce new challenges such as system downtime or lack of integration.

Types of Health Records

1. Source-Oriented Record System:

   • Organized by discipline.

   • Easy to locate specific discipline notes but fragmented data.

2. Problem-Oriented Record System:

   • Organized around patient problems, enhancing collaborative documentation but may not suit all disciplines.

3. Charting by Exception (CBE):

   • Focuses only on abnormal findings, can save time but risks missing critical information.

4. Electronic Health Records (EHR):

   • Streamlines processes, enhances communication, and improves data access.

Best Practices for Documentation

• Document chronologically, using black or blue ink.

• Avoid vague terminologies—write what you see.

• Correct errors appropriately by crossing them out and initialing.

• Never document ahead of time—only document what actually happened.

Handoff Reports and Communication

• Handoff is essential in patient care transition.

• Use SBAR format (Situation, Background, Assessment, Recommendation) for structured communication.

• Ensure to provide face-to-face reports for better clarity and patient involvement.

Incident Reports

• Important for documenting unusual occurrences, however,

  • Do not include incident reports within patient charts.

• Document patient outcomes, evaluations, and safety measures taken.

• Aim to prevent future incidents through documented learning.

Conclusion

• Emphasize the importance of accurate, timely, and thorough documentation as a critical component of patient care.