PRINCIPLES OF DOCUMENTATION By Claire Ramsay

DOCUMENTATION IN THE HOME Within the realm of Nursing the health record is regarded as more than just a set of legal documents or records of care. It is a symbol of partnership, representing a link between various health professionals and the client and family.

Documentation is vital. 1.Encouraging client participation and acceptance. 2.Helping to increase compliance of clients goals and time frames.

WHY DOCUMENT ? Communicate information accurately, effectively and in a timely fashion. Provides records of ongoing Nursing ASSESSSMENT PLANNING IMPLIMENTATION EVALUATION OF CARE

Why Document? Evaluation, treatment and monitoring Communication and continuity of care Appropriate utilization review and quality of care Collection of data for research and teaching

A permanent, legal record of care. A means of communication among team members. A base for continuous, comprehensive care despite multiple-agency involvement. An opportunity for client/carer education.

Be complete and legible Include chief complaint (CC), reason for encounter, assessment, plan of care, date and identity of observer Indicate rationale for ordering diagnostic and/or ancillary services Indicate past and present diagnoses Indicate appropriate health risk factors Show patient’s progress or lack there of

Comprehensive and flexible Quality and continuity Track patient outcomes Reflect current standards Patient identification on every page of the record Use approved abbreviations or standard specialty abbreviations Date, time and name/initials, title of the health professional When referencing another note, always identify by name and date

Actual and Potential Problems Client Education Discharge Planning Financial billing. Assessment. Research. Auditing.

DOCUMENTATION RECORDS Confidential information About the client and family Client’s health status ASSESSMENT OF NEEDS Social situations Interpersonal relationships Physical Psychosocial Environmental Self care

EFFECTIVE COMMUNICATION Health care workers may only be present for sort periods of time. A multidisciplinary team, that may never actually meet. Health care record must act as a communication tool. Therefore enhances the need to provide: COMPREEHENSIVE INFORMATION ABOUT HEALTH TREATMENT WITH FEEDBACK AND REVIEW

IMPERATIVE THAT RECORDS ARE KEPT CONTAINING: DOCUMENTATION THAT IS: ACCURATE CURRENT RELEVANT FACTUAL ORGANIZED CONCISE COMPLETE

WHICH IS LEGIBLE AND ACCESSIBLE TO ALL PEOPLE PARTICIPATING IN THE PROVISION OF CARE (Bellack,1992; Jacob,1985)

WITHOUT ACCURATE VITAL DOCUMENTATION WE MAY POTENTIALLY ENCOUNTER PROBLEMS

EXAMPLE: An incident may have been avoided when Mr B fainted whilst transferring from the shower recess. His carer forgot to inform the nurse that Mr B had been experiencing “dizzy spells” when arising from bed or chair over the past weeks. Had the information been written directly into M B’s record, the nurse would have been able to assess the situation facilitate investigation and avoid showering Mr B in the meantime.

Record Keeping Forms Nursing history (HX) Graphic or flow sheet Medication administration record Standardized care plans / Clinical Pathways Discharge summary

Progress Notes Soap(IE) Subjective Objective Assessment Plan INTERVETNION Evaluation Pie Problem, intervention, evaluation Dar: Data, action, response

Consequences Of Inadequate Documentation Fragmented care Repetition of tasks Delayed therapy Omitted therapy Delayed recovery

Legal Principles of Nursing “Every activity of the nurse in the performance of her nursing services is the subject of potential analysis by the law.” M. J. Lesnik and B. E. Anderson

Nurse practice acts …are the policing power of the state enacted to protect the health and welfare of the public.

Principle Ignorance of the law is no excuse. When a law exists and the nurse violates it, the nurse is subject to criminal charges.

THE END ? Reference M.J.Lesnik, B.E. Anderson, Susan C. Manning,JD,RHIA,CPC