D3

DOCUMENTATION

Hallmark of Nursing Accountability

Why? If it is not written, it didn’t happen.

Written or computer-based

Served as a permanent record of client’s information and progress care

Formal, legal document that provide evidence of a client’s care

PURPOSES OF DOCUMENTATION

• Planning client care

• Communication

• For legal documents purposes

• For research

• For education

• Reimbursement

• For statistics, reporting, epidemiology

• Auditing health agencies

• Health care analysis

TYPES OF RECORDS

• Source-Oriented Medical Record (Traditional Client Record/ SOMR)

Each person or department makes notations in a separate section/s of client’s chart

Specific information is easier to locate

• Components of SOMR

Admission sheet

Face sheet

Medical history and physical examination and sheet

Diagnostic finding sheet

TPR graphic sheet

Doctor’s treatment and order sheet

Therapeutic sheet

Special flow sheet

Medication record

Nurses notes

Client discharge plan and referral summary

Initial nursing assessment

PROBLEM-ORIENTED MEDICAL RECORD

• Data about the client are recorded and arrange according to the sources of the information

• Records integrates all data about the problem, gathered by members of health team

4 BASIC COMPONENTS OF POMR

1. DATABASE- contains all information from the patient when he first entered the agency. It includes

nursing assessment, physician’s history, social and family data, results of physician’s examination.

2. Problem Lists- contains all the aspects of the person’s life requiring health care

-Kept in front of the chart

-Problems are listed in the order, which they are identified

-Continually updated as new problems are identified and others are resolved

3. Initial list of orders or plan of care- made with reference to the active problems and are

generated by the person who lists the problem

4. Progress Notes- which includes nurses narrative notes (SOAPIE, SOAPIE, SOAPIER)

KARDEX

• Provides a concise method of organizing and recording data about the client, making information readily

accessible to all members of the health care team

• May be written in a pencil to ease in recording frequent change in details of client care

• A series to flip cards usually kept in portable file

DELIGATION

• Directing

• 4 Points

  1. Position of the staff: LICENSED OR UNLICENSED

  2. Ward (SAAN GALING OR KUNG SAAN PUPUNTA)

  3. Capabilities of the staff (DEPEND ON THE POSITION & WARD)

  4. Condition of the patient

QUALITY IMPROVEMENT

Upgrading quality

Latest

Continuous

Act reinforce strength and take corrective actions to weakness→ 2 aspects (technical and interpersonal)

QUALITY ASSURANCE

Maintaining quality

Obsolete (out of date)

Determine compliance standards & criteria “evaluate”

→ Nsg. Audit and Nsg. Appraisal

Identify strengths and weakness

TOTAL QUALITY MNGT.

4 basic steps for Controlling

  1. Develop standards and criteria

  2. Determine compliance standards and criteria “evaluate”

  3. Identify strengths and weakness

  4. Act reinforces the strength and take corrective action of weakness→ 2 aspects (technical and interpersonal)

BENNER

STAGE I (Novice)

• No experience (student nurse)

• Performance is limited, flexible, and governed by context-free rules and regulations rather than experience

STAGE II (Advanced Beginner)

• Demonstrates marginally acceptable performance

• Recognizes meaningful “aspects” of a real situation

• Experienced enough real situations to make judgments about them

STAGE III (Competent)

• 2-3 years of experience

• Demonstrates organizational and planning abilities

• Differentiates important factors from less important aspects of care

• Coordinates multiple complex care demands

STAGE IV (Proficient)

• 3-5 years of experience

• Perceives situations as a whole rather than in terms of parts

• Uses maxims as guides for what to consider in a situation

• Has holistic understanding of the client, which improves decision making

• Focuses on long term goal

STAGE V (Expert)

• Performance is fluid, flexible, and highly proficient

• No longer requires rules, guidelines, or maxims to connect an understanding of the situations to appropriate

actions

• Inclined to take a certain action because “it felt right”.

ETHICAL PRINCIPLES

Most fundamental principle: Respect for people

• Autonomy: voluntary decision

• Beneficence: do good (medications)

• Non-maleficence: do no harm (asepsis)

• Justice: fairness, equal risks and benefits

• Veracity: complete & true info

• Confidentiality: data not revealed

- Anonymity: data not linked to person

• Paternalism: decision-making for others (in emergency)

• Fidelity: promise-keeping

• Utilitarianism: greatest good for the greatest number of people