Record Keeping Jackie Hazeldine, Practice Educator & Modern Matron for Community Services December 2013

How do we Assess? We assess all the time……….. We notice a patient’s Colour Breathing Mobility within seconds of our greeting. We use all our senses to pick up cues… But we do not record all we have intuitively picked up! Competency framework

Why we need to Assess? Nurses need to:– “...carry out comprehensive, systematic nursing assessments...” and; “...plan, deliver and evaluate safe, competent, person- centred care...” (NMC, 2010a). Competency framework

An Assessment is ? the gathering of information to make a decision or plan It forms the basis for planning and implementing care It allows us to identify needs and preferences Without it we have no chance of getting it right Competency framework

Holistic Assessment The term ‘holism’ comes from a Greek word meaning ‘all’, ‘entire’ and ‘total’. The physical, psychological, spiritual and social aspects of a person’s life are considered to be closely interconnected. Competency framework

Approaching Assessment We need to be:- Adaptable and flexible in a variety of circumstances. The language and terminology used needs to be appropriate to our audience. Accommodate the diversity of individuals, their beliefs, values and circumstances. Inclusive of the views of patients, families & carers. Competency framework

Values associated with assessment Consent Working alongside the patient, family and carers to make a plan. Together identifying problems and needs. Together identifying goals of care. Competency framework

How do we Assess? To undertake an assessment we use:- ‘Assessment tool’ and The nursing process Competency framework

An Assessment Tool Provides:- A Systematic Approach ‘Activities of Living’ and is now integral to the assessment process for Isle of Wight NHS Roper, Logan and Tierney (2000) Competency framework

“Activities of living” encompasses:- –Communication –Breathing –Eating and Drinking –Eliminating –Personal hygiene and dressing –Controlling body temperature –Sleeping –Mobility –Sleeping –Expressing Sexuality –Dying Competency framework

Use the Nursing Process To identify all the patient’s needs And the goals of the care to be provided Plan the care to be provided with the patient, family and carer’s where appropriate. Evaluate the effectiveness of the care Competency framework

However…… This cannot become a quick tick list Competency framework

Step One Collect information about the patient's current condition Identify nursing needs from a critical analysis of the information Competency framework

Identifying needs For every identified need we must ask WHY? Explore the underlying causes If someone is falling – WHY? explore footwear, equipment and their medication. If someone has a copiously leaking leg wound –WHY? explore infection, oedema and Hb. Competency framework

Step Two Using critical thinking and clinical judgment identify the goals related to the identified need. These inform the nursing actions to deliver the care and achieve the outcomes Competency framework

Step Three Design nursing care to meet the goals Competency framework

Step Four Evaluate the patient's progress towards or away from goals or desired outcomes Evaluate the effectiveness of the care provided Describe and document progress to date Undertake a final evaluation Competency framework

Working within the multidisciplinary team It is also essential to enable patients are able to have the right care, from the right profession at the appropriate time. We are responsible and accountable for making accurate referrals to members of the multidisciplinary team. SBAR supports an effective referral Competency framework

SBAR (D) Situation Background Assessment Recommendation Decision Competency framework

Accountability Nurses have professional accountability and responsibility for the assessment, planning and evaluation of care, and for delegating work to support staff like Healthcare Assistants. RCN Ensure, those you to whom we delegate, have the appropriate knowledge and skills. Competency framework

The NMC code states You must keep clear and accurate records of the discussions you have, the assessments you make, the treatment and medicines you give and how effective these have been Competency framework

Ongoing Process Assessment is not a one off activity We are responsible and accountable for making this a dynamic ongoing process Encompassing and responding to the patient’s changing needs. Competency framework

Accurately Document It is equally important that all you have observed, discussed, planned and identified as needing further investigation is accurately recorded so that it can contribute to effective compassionate care. Competency framework

Remember Everything you write represents the care you give, therefore ensure it is:- Clear Accurate Professional & Ethical Competency framework

And finally…. Any Questions? Competency framework