You know, the importance of documentation in nursing cannot be overemphasized "as if you didn't document what you did is considered you did nothing as a caregiver". As a nurse no matter where you work.. It is necessary to know how to write precise, factual and meaningful documentation.
My name is Nurse Abubakar Mustapha Koya, Kano a presenter of the today's presentation. It is great always to stand on the existing protocol and use the podium to share the little I can on the 'Documentation in Nursing.'
Inn sha Allah I gonna briefly highlight some important aspect of the topic..
I categorised my little presentation under the following:
° Do's and Don'ts
° Writing Tips
° How to keep a good nurses records
° Common Nursing Documentation Errors
Nursing documentation is the principal clinical information source to meet legal and professional requirements, and one of the most significant components in nursing care.
Quality nursing documentation plays a vital role in the delivery of quality nursing care services through supporting better communication between different care team members to facilitate continuity of care and safety of the clients.
Nursing documentation mainly consists of a client's background information or nursing history referred as admission form, numerous
assessment forms , nursing care plan and progress notes.
These documents record the client's data captured at the relevant stages of the nursing process.
Improper documentation can open up an employer to liability and malpractice lawsuits, while proper nursing documentation helps prevent medical errors and promotes the delivery of high-quality patient care.
Nursing documentation is the record of nursing care that is planned and delivered to individual
clients by qualified nurses or other caregivers under the direction of a qualified nurse.
It contains information in accordance with the steps of the nursing process .
* Purpose of the Nursing Documentation
A basic purpose of the nursing documentation is the creation of a data base in which the patients' files are included.
The patient's file is kept for many reasons, from which the most important ones are:
• Communication among the professionals of the health system, through the exchange of information that concerns the patient.
• Creation of the Patient Care Plan;
Each scientist uses documents from the patient's file to prepare the care plan of the particular patient.
• Control of the health organizations;
The control is a review of the patient's file with the view to confirm the provided quality.
The information, that is contained in a file can form a valuable source of elements for research. The care plan can bring up useful information on the care of many patients.
Students in various schools of the health science often use patients' files as educational tools.
• A guide for reimbursement of care costs.
• Provides data for quality assurance studies and shows progress toward expected outcomes.
Do's and Don'ts of Documentation
° Check that you have the correct chart before you begin writing. Make sure your documentation reflects the nursing process and your professional capabilities.
° write legibly
° Chart the time you gave a medication, the administration route, and the patient's response.
° Chart precautions or preventive measures used, such as bed rails. Record each phone call to a physician, including the exact time, message, and response.
° Chart patient 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 that it's a "late entry." Include the date and time of the late entry. Document often enough to tell the whole story.
° Chart a patient's refusal to allow a treatment or take a medication. Be sure to report this to your manager and the patient's physician.
• Don't chart a symptom, such as "c/o pain," without also charting what you did about it.
• Don't alter a patient's record--this is a criminal offense.
• Don't use shorthand or abbreviations that aren't widely accepted.
• Don't give excuses, such as "Medication not given because not available."
• Don't write imprecise descriptions, such as "bed soaked" or "a large amount."
• Don't chart what someone else said, heard, felt, or smelled unless the information is critical. In that case, use quotations and attribute the remarks appropriately.
• Don't chart care ahead of time--something may happen and you may be unable to actually give the care you've charted. Charting care that you haven't done is considered fraud.
* Nursing Documentation Writing Tips:
The following tips , recommendations , and best practices can ensure your documentation is as precise and useful as possible.
• Be Accurate.
Write down information accurately in real-time. Inaccurate or misleading documentation is unethical and can harm patients.
• Avoid Late Entries.
Late entries can introduce inaccuracies. If you have to document something after the fact, follow your employer's late entry policy and clearly mark late entry notations.
• Prioritize Legibility.
Others must be able to read your documentation without difficulty. In addition, legible writing improves your credibility and authority.
• Document Physician Consultations.
Document all parties consulted during patient care, including names, times, responses, and any resulting actions. This is critical in case a need or emergency arises.
• Chart the Symptom and the Treatment.
Make sure you document both the symptom and the treatment you administered to address it.
• Avoid Opinions and Hearsay.
Don't write down opinions as facts. Use quotation marks to indicate an opinion and attribute the remarks to the correct person.
• How to keep good nursing records
The patient's record must provide an accurate, current, objective, comprehensive, but concise, account of his/her stay in hospital. Traditionally, nursing records are hand-written. Do not assume that electronic record keeping is necessary.
• Ensure the record begins with an identification sheet. This contains the patient's personal data: name, age, address, next of kin, carer, and so on. All continuation sheets must show the full name of the patient.
• Date and sign each entry, giving your full name. Give the time, using the 24-hour clock system. For example, write 14:00 instead of 2 pm.
• On admission, record the patient's visual acuity, blood pressure, pulse, temperature, and respiration, as well as the results of any tests.
• State the diagnosis clearly, as well as any other problem the patient is currently experiencing.
• Record all medication given to the patient and sign the prescription sheet.
• Ensure that the consent form for surgery, signed clearly by the patient, is included in the patient's records.
• Include a nursing checklist to ensure the patient is prepared for any scheduled surgery.
• Write in dark ink (preferably black ink), never in pencil, and keep records out of direct sunlight. This will help to ensure they do not fade and cannot be erased.
* Common Nursing Documentation Errors
Common errors to avoid in nursing documentation include the following:
√ Unclear Orders.
Just as you should never write unclear documentation, you should never accept orders you have questions about. If you disagree with or don't understand an order, seek clarification. It's better to take the extra time to understand what a patient's treatment should be. When documenting orders, leave out the guesswork; ensure that you are conveying information as clearly and precisely as possible.
√ Blank Items on a Chart.
Blank spaces on a chart do more than fail to provide necessary information; they also create ambiguity. Was a space left blank because treatment wasn't administered or because the nurse forgot to document the treatment that was administered? Blank spaces on charts can have legal ramifications, too. A patient who sues has a much stronger case if treatment wasn't documented, even if it was provided; there's no way to prove the treatment occurred.
√ Medication or Allergy Omission.
Knowing what medications patients are taking and what they're allergic to is critical to a doctor's ability to administer the right treatment.. If a patient complains of a symptom, and that symptom is a side effect of a medication interaction introduced because the patient's medications weren't documented properly, it's that much harder to narrow down what's causing the symptom. Specify each medication administered, any permissions required, dosages, and patient reactions.
To conclude, documentation is vital in all aspect of nursing care as without it nothing can prove what you did to patient in the lawsuit..
1. Catalano K, Perlman K, Pinney C. Critical path network. Improve patient safety to comply with new standards : Demonstrate evidence to JCHAO surveyors. Hospital Case Management 2010; 9(7): 103-106.
2. Celia LM. Legally speaking. Keep electronic records safe. RN 2014; 65(6):69 -71.
3. Feldakamp JK. Legally speaking. The legal landscape of long-term care. RN 2012; 65(6):61-62.
SOURCE: AREWA NURSES FORUM
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