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DOCUMENTATION As Communication

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26 views54 pages

DOCUMENTATION As Communication

Uploaded by

gabgabb1123z
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PPTX, PDF, TXT or read online on Scribd
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DOCUMENTATION

AS
COMMUNICATION
VILMA D. DOMALAON, MAN, RN
❑ Nursing documentation
is essential for clinical
communication.
What is Documentation?
⮚Documentation provides an accurate
reflection of nursing assessments, changes in
clinical state, care provided and pertinent
patient information to support the
multidisciplinary team to deliver individualized
care.
What is Documentation?
◦The term “documentation” refers to “any
written or electronically generated
information about a client that describes
client status, or the care or services
provided to that client”.
DOCUMENTATION provides
evidence of care and is an
important professional and
medico legal requirement of
nursing practice.
DOCUMENTATION
establishes accountability, promotes quality
nursing care, facilitates communication
among nurses and other healthcare
providers, and conveys the contribution of
nursing to health care.
What is Documentation?
◦The term “documentation” refers to “any
written or electronically generated
information about a client that describes
client status, or the care or services
provided to that client.”
NURSING DOCUMENTATION
- it
is the record of nursing care
that is planned and delivered to
individual clients by qualified
nurses or caregivers under the
direction of a qualified nurse.
NURSING DOCUMENTATION
- it
contains information in
accordance with the steps
of the nursing process.
Written evidence of the administration
of test, procedures, treatment and client
education.
Documentation
The results of client’s response to
the diagnostic test and interventions.

Written evidence of the interactions between


and among health professionals, clients, their
families and health care organizations.
Purposes of documentation
communication research
education
legal and practice
professional responsibility standards

reimbursements
COMMUNICATION
Recording is a method of communication that validates
the care provided to the client. It should clearly
communicate all important information regarding the
client

EDUCATION
Health care students use the medical record as a tool to learn
about the disease process, complications, medical surgical
diagnosis and interventions.
RESEARCH
Rely on clients’ medical records as a clinical data source to
determine if clients meet the research criteria for study.

Legal and Practice Standards


Failure to document is a key factor because medical record is
a legal document, and in case of lawsuit, the records serves
as a description of exactly what happened to the client.
WHAT SHOULD BE DOCUMENTED
◦ Environmental factors( safety, equipment), self care, client education
◦ Client’s outcomes, client’s response to treatments, or preventive care
◦ Discharge assessment data
◦ More comprehensive notations to clients who are seriously ill
◦ All relevant assessment data, including monitoring strips
◦ Information related to any client transports
WHAT SHOULD BE DOCUMENTED

⚫Collaboration / communication
with other health care providers
⚫Medication administration
⚫Verbal orders
⚫Telephone orders
⚫Verbal Orders
- giving and receiving verbal orders is
considered a high risk activity .
- miscommunication or lack of
communication could lead to
negative implications for the client.
HOW SHOULD INFORMATION BE
DOCUMENTED

-CLEARLY
- COMPREHENSIVELY
- COMPLETELY
- ACCURATELY
- HONESTLY
HOW SHOULD INFORMATION BE
DOCUMENTED?
- Legible and correct spelling
- Forms, flow sheets, Checklists and progress
notes
- NEVER LEAVE Blank space
- Changes or additions
- Abbreviations
WHEN SHOULD INFORMATION BE
DOCUMENTED
✔ TIMELY
✔ FREQUENTLY

✔ CHRONOLOGICALLY
DOCUMENTATION SHOULD BE DONE AS SOON
AS POSSIBLE AFTER AN EVENT HAS OCCURRED
Example:

• Care provided

• Medication administered
• Client fall
FREQUENCY OF DOCUMENTATION
SUPPORTS ACCURACY particularly when
precise assessment is required as a result of
client conditions
ex. Intensive care
fluctuating health status
LATE, DELAYED OR LOST ENTRIES
• Late entries should be made according to agency
policy.
• Late entries must be clearly identified
(addendum to care) and should be individually
dated, time and must be signed by the nurse
involved.
DOCUMENTING EVENTS IN THE
CHRONOLOGICAL ORDER in which
they took place is IMPORTANT,
particularly in terms of revealing
CHANGING PATTERNS IN A
CLIENT’S HEALTH STATUS
WHY?
- it enhances the clarity of
communications,
enabling health care providers to
understand what care was provided.
EFFECTS OF INCOMPLETE MEDICAL
RECORDS
▪ COST HOSPITAL’S REIMBURSEMENT WHEN THERE IS NO DOCUMENTATION
OF THE SERVICES THAT WERE GIVEN

▪ HAMPER QUALITY ASSURANCE AND RISK MANAGEMENT EFFORTS.

▪ FORCE HOSPITALS TO SETTLE SUITS OUT OF COURT TO LOSE CASES


BECAUSE LAWYERS CANNOT PREPARE A SOLID DEFENSE

NOTE: 85% OF MALPRACTICE CASES THAT COULD BE DISMISSED FOR LACK


OF EVIDENCE END UP IN COURT BECAUSE THE PATIENT RECORD IS TOO
POOR TO DEFEND THE HOSPITAL.
General documentation
guidelines
• Ensure that you have the correct client record
• Document as soon as possible to ensure accurate
recall of data
• Date and time each entry
• Sign each entry with your full legal name and with your
signature
• Do not leave space between entries
• Use quotation marks to indicate direct client
responses
• Document in a chronological order if not, state why

• Write legibly

• Use of permanent ink


• Document in a complete and but concise manner
Do’s in documentation
Check that you have the:
▣ correct chart
▣ reflects nursing process
▣ Write legibly
▣ Chart the time you gave a medication, the administration
▣ route, a patient’s response
▣ chart precautions or preventive measures used
▣ record each phone call to a physician
▣ Chart patients care at the time you provide it
▣ If you remember an important point after you’ve
completed your documentation, chart the information
▣ With a notation
Don‘ts in nursing documentation
⚫ Don’t chart a symptom such as c/o pain
⚫ Don’t alter a patient’s record
⚫ Don’t use short hand or abbreviations that are
not widely accepted
⚫ Don’t write imprecise descriptions
⚫ Don’t chart what someone else said, heard, felt
or smelled unless information is critical
⚫ Don’t chart ahead of time
General Guidelines for proper charting:
1. Charting should be consistent with your
employers written policies
2. If you did it or saw it, you should chart it
3. If you didn’t chart it, you didn’t do it
4. Charting should include any interactions
with staff members or doctors, including
failed attempts to reach them, concerning the
care of a patient
5. Do not erase an error or remove pages, draw a
line thru the error, note, it was an error and
initial it
6. Records should be clear, legible, accurate and
should use proper terminology
7. Chart chronologically at the time of occurrence
or as soon as possible afterward
8. Charting should be in ink and signed
appropriately
Methods of documentation
- Flow Sheets, Graphic sheet, F-DAR

⚫These are often called “graphic records” and


are used as a quick way to reflect or show
clients condition.
⚫They are helpful records in documenting vital
signs, medications, intake and output, bowel
movements, etc.
We must always stress the
importance of a complete, accurate and up
to date documentation because it does
not only project the image of an
efficient, conscientious, and reliable
staff,
but more importantly, it gives the
impression to patient that he is being
taken cared of properly.
FRIEND
OR
ENEMY ?
•In a malpractice suit, good documentation in the
medical records can be one’s best friend or worst
enemy.
• If a claim is not settled an proceeds to trial, the
most important evidence presented to the COURT
is the medical record.
• The COURT uses the medical record as a legal
guide to assess the health care providers
professional conduct to determine whether they
adhered to or deviated from the standard
In conclusion, the nurse documentation is a
legal record that provides information about
the continuity of care from admission to
discharge.
Careful documentation is one of the best
defenses against liability exposure and provides
a supportive record of medical and treatment
interventions and evidence of quality patient
care.
It is important to remember
the basics for good
documentation to protect
yourself legally and to be able
to provide good care to your
patients
Remember that what you
write today, can save you and
your license in the future,
should the record end up in a
court room.
Keep in mind, whether your
facility uses any type of
documentation systems, you
need to document your
actions expertly.
BY FOLLOWING THESE TIPS
AND GUIDELINES, YOU WILL
BE WELL ON YOUR WAY TO
PROTECTING YOURSELF
LEGALLY AND PROVIDE THE
BEST POSSIBLE CARE TO
YOUR PATIENTS.
QUALITY DOCUMENTATION & RECORDING
ARE THE ESSENCE OF A GOOD QUALITY
MEDICAL RECORD and HAS ALWAYS BEEN
the CONCERN IN HEALTH CARE… ……
WHY ?

THE RISK TO
HUMAN LIFE
AND WE WILL SAY IT….
“IF YOU DIDN`T CHART
IT,
IT WASN`T DONE”
Thank you ! ! !

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