PRESENTATION ON

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DOCUMENTATION

By the

THEATRE DEPARTMENT

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OUTLINE

• Overview of documentation
• Principles of documentation
• Forms of documentation
• Characteristics of documentation
• Common record keeping forms
• Methods of nursing documentation
• Importance and benefits of documentation
• Don’ts of documentation
• Malpractices in documentation

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OVERVIEW

• Documentation is any written or electronically generated information about a client that describes the care or service provided to that client . Health records may be paper documents or electronic documents such as , electronic medical records, faxes, emails, audios, or video tapes and images.

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• written legal recording of the interventions that concern the patient

CONT. on overview

• Verbal communication between patients and health care providers does not constitute legal documentation of care.

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• The broad assumption is that if something is not documented, it was not done.

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• The record serves as a means of communication among providers for continuity of care.��

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PRINCIPLES OF DOCUMENTATION

The ANA policy documents and publications notes include documentation as an essential component of nursing/clinical care practice.

Accordingly, the American Nurses Association presents these principles:

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Principle 1. Documentation Characteristics

High quality documentation is:

• Accessible
• Accurate, relevant, and consistent
• Auditable
• Clear, concise, and complete
• Legible/readable
• Thoughtful
• Retrievable on a permanent basis in a nursing-specific manner
• Reflective of the nursing process
• Timely, contemporaneous and sequential

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Principle 2. Education and Training

• Nurses in all settings and at all levels of service, must be provided comprehensive education and training in the technical elements of documentation (as described in this document) and the organization’s policies and procedures that are related to documentation.

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• This education and training should include staffing issues that take into account the time needed for documentation work to ensure that each nurse is capable of the following:

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• Functional and skillful use of the global documentation system

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• Competence in the use of the computer and its supporting hardware

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• Proficiency in the use of the software systems in which documentation or other relevant patient, nursing and health care reports, documents, and data are captured

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Principle 3. Policies and Procedures

• The nurse must be familiar with all organizational policies and procedures related to documentation and apply these as part of nursing practice.

Of particular importance are those policies or procedures on maintaining efficiency in the use of the “downtime” system for documentation when the available electronic systems do not function.

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�Principle 4. Protection Systems�

Protection systems must be designed and built into documentation systems, paper-based or electronic, in order to provide the following as prescribed by industry standards, governmental mandates, accrediting agencies, and organizational policies and procedures:

• Security of data

• Protection of patient identification,

• Confidentiality of patient information

• Confidentiality of clinical professionals’ information

•Confidentiality of organizational information

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Principle 5. Documentation Entries

Entries into organization documents or the health record must be:

• Accurate, valid, and complete
• Authenticated; that is, the information is truthful, the author is identified, and nothing has been added or inserted;
• Dated and time-stamped by the persons who created the entry;
• Legible/readable
• Made using standardized terminology, including acronyms and symbols.

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Principle 6. Standardized Terminologies

• Standardized terminologies permit data to be aggregated and analyzed, these terminologies should include the terms that are used to describe the planning, delivery, and evaluation of the nursing care of the patient or client in diverse settings.

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Forms of Documentation

• Written
• Electronic

Characteristics of Documentation

• Factual
• Accurate
• Complete
• Timely
• Legible
• Auditable
• Clear
• Concise
• Consistent

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Common Record Keeping Forms

• Flow sheet
• Medication sheet
• Consent form
• Nursing care plan
• Admission sheet
• Physician order sheet
• Nurses note
• Incidence report form

METHODS OF CLINICAL DOCUMENTATION

The most common types of clinical documentation include the following:

1. Computerized Documentation
2. Nursing Admission Assessment
3. Nursing care plans
4. Graphic sheets
5. Medication administration records
6. Incident report

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Computerized Documentation

• Used by many facilities for patient admission, billing, scheduling, and human resource information
• patient data are recorded and stored electronically at the patient care unit level.
• This data is referred to as electronic health records(EHR) or electronic medical records (EMR)
• the documentation is transmitted electronically to multiple sites including consulting rooms, labs, dispensaries and patient care areas.
• Only selected personnel are permitted to access this information and must log on using employee identification and passwords to enter the computer system

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Nursing Admission Assessment

• documents a patient’s current condition, previous medical history, allergies, prescription drugs and primary complaint at the time of admission to the hospital

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• The information is collected through an interview

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• The information and data gathered during a nursing admission assessment forms the basis of the nursing care plan.

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Nursing Care Plans

Characteristics of these documents include:

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• Standardized plans of care based upon disease or nursing diagnosis
• Modification of the care plans based upon the patient’s individual needs
• Promotes improved and standardized means of patient care
• Ensures treatment based on the same minimum level of knowledge among all healthcare providers

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Graphic Sheets

refer to charts and graph that aid in documenting objective physical measurements required during patient care. These include:

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• Vital signs sheet

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• partograph

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Medication Administration Records (MARs)

• Documents what medications are prescribed to each patient

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• Each nurse indicates administration of each medication as provided to his or her assigned patients.

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• MARs are reviewed prior to each nursing shift to ensure that any medication changes have been properly recorded

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Incident Report

When an accident or unusual incident occurs involving a patient, employee, or property in the facility, the factual details should be reported to the nurse manager/management and documented according to institutional policy.

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• Details should be objective, complete, and accurate.

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• They should be written as statements of facts without interpretation or opinion.��

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Situations That Require an Incident Report

• Falls or unexpectedly finding a patient, visitor, or other personnel lying on the floor

• Injury to patient, visitor, or other personnel

• Needle pricks

• Any fire or smoke event

• Possible theft or loss of an item

• Malfunctioning equipment

• Intruder or unauthorized personnel

• Medication error

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IMPORTANCE AND BENEFITS OF DOCUMENTATION

• Serves as a medium of communication.
• Accountability of care rendered.
• Constitute quality of care.
• Continuity of care.
• It saves time.
• Medium for nursing audit.
• Minimizes risks and errors.
• Best defence for legal and financial claim.
• Educational reference.

Cont. on importance

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• Budget and financial planning
• Staffing ratios
• Patient acuity and census

DON’TS OF DOCUMENTATION

• Don’t document for others.
• Don’t forge patient’s document.
• Don’t document before the actual procedure.
• Don’t use substandard abbreviations.
• Don’t use correction fluids or erasers.
• Don’t leave documentation for a later time.
• Don’t leave spaces in between documentations.
• Don’t leave documentation ends open without signature.
• Don’t use blank statements.
• Don’t report events that did not happen
• Don’t forge others signatures

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MALPRACTICES IN DOCUMENTATION

There are two common malpractices in documentation; which are

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1. The use of correction fluids.

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• Failure to document verbal orders .

REFERENCES�

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American nurses’ association – ANA’s principles for nursing documentation (2010)

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CRNBC practice standard documentation

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THANK YOU�