DOCUMENTATION MEDICAL RECORDS NURSING RECORDS

OBJECTIVES
Able to understand : what is documentation and what to document Why is documentation important How to document or record Where and when to record

Nursing Documentation
Documentation is any written or electronically generated information about a client that describes the care or service provided. Health records may be paper documents or electronic documents, such as electronic medical records, faxes, e-mails, audio or video tapes and images.

Nursing documents include

Admission/Referral/Discharge document The Patient Profile Care plans. Multi-Professional Continuation Notes / variance Record Treatment/procedure/surgery records Vital Signs assessment Chart Triage notes Medication Record Fluid balance charts. Other assessment charts e.g. Neuro observation chart, weight chart etc.

Through documentation, nurses communicate their observations, decisions, actions and outcomes of these actions for clients. Documentation is an accurate account of what occurred and when it occurred. Nurses may document information pertaining to individual clients or groups of clients. When caring for an individual client (which may include the clients family), the nurses documentation provides a clear picture of the status of the client, the actions of the nurse, and the client outcomes.

Nursing documentation clearly describes

assessment of clients health status, nursing interventions carried out, and the impact of these interventions on client outcomes a care plan or health plan reflecting the needs and goals of the client needed changes to the care plan information reported to a physician or other health care provider and, when appropriate, that providers response; and advocacy undertaken by the nurse on behalf of the client.

REASONS FOR DOCUMENTATION To facilitate communication To promote good nursing care To meet professional and legal standards

To facilitate communication
 nurses communicate to other nurses and care providers their assessments about the status of clients, nursing interventions that are carried out and the results of these interventions. Documentation of this information increases the likelihood that the client will receive consistent and informed care or service Thorough, accurate documentation decreases the potential for miscommunication and errors.

To promote good nursing care

Documentation encourages nurses to assess client progress and determine which interventions are effective Documentation can be a valuable source of data for making decisions outcome information or information from a critical incident can be used to reflect on practice and make needed changes based on evidence.

To meet professional and legal standards

Documentation is a valuable method for demonstrating that, within the nurse-client relationship, the nurse has applied nursing knowledge, skills and judgment according to professional standards. The nurses documentation may be used as evidence in legal proceedings such as lawsuits, coroners inquests, and disciplinary hearings through professional regulatory bodies. In a court of law, the clients health record serves as the legal record of the care or service provided. Nursing care and the documentation of that care will be measured according to the standard

TOOLS FOR DOCUMENTATION

There are many tools used for documentation e.g.worksheets and kardexes, care plans, flowsheets and checklists, clinical rocords and monitoring records. These tools may be written or electronic in format. Regardless of the tool used, pertinent information specific to an individual client resides within the clients health record.

Accountability
Record keeping is a tool of professional practice and one that should help the care process. It is not separate from this process and it is not an optional extra to be fitted in if circumstances allow. Registered nurses have both a professional and a legal duty of care. They are accountable for the record keeping undertaken by those they have delegated duties to. As such they must countersign any entries

Confidentiality
All records will be stored securely from unauthorised or inadvertent viewing, alteration or erasure. Records should be stored in a secure location when not being used e.g. lockable filing cabinets, cupboards, rooms In all circumstances, records should only be made available and accessible to those who are authorised to do so i.e. patient records should be stored securely to protect patient confidentiality, but readily accessible for clinical care. When transported to other locations, the transportation bag should be used

Use patients record, care plan/nursing process for the below scenario

1. patient admitted with cholelithiasis,

scheduled for laproscopic cholecystectomy.

2. Patient was breathless and weak, admitted

with diagnosis of renal failure.

Content of records
Patient or client records must:
y y Be factual, consecutive and succinct. Be written as soon as possible after the event has occurred, providing current information on the care and condition of the patient or client. Be recorded in black/blue ink and be legible. Be accurately dated, timed and signed, with the signature printed alongside the first entry. Have the patients name, hospital number, date of birth recorded on every page.

y y

Content of records

Have alterations or additions dated, timed and signed. The original entry must still be read clearly. Entries must never be erased.

y Not include abbreviations, jargon, meaningless phrases, irrelevant speculation and offensive subjective statements. y Be readable y Be written in terms that the patient or client can understand y Identify problems that have arisen and the action taken to rectify them

y Provide clear evidence of the care planned the decisions made, the care delivered and the information shared.

Good and complete Nursing records must demonstrate:

A full account of the nursing assessment, the care planned and given. Relevant information about the condition of the patient or client at any given time and the measures taken to responds to their needs. Evidence that all reasonable steps to provide care for the patient or client have been taken and that any actions or omissions have not compromised patient safety in any way. A record of any arrangements that have been made for the continuing care of a patient or client

The multi-professional continuation/ variance record should be used to record all aspects of the patients planned and given care in chronological order . It provides a means of communication between all the members of the multidisciplinary team The date and time of any entry must be recorded alongside each entry. Any health professional making an entry must identify their discipline according to the identifiable codes and sign and print their name in full.

Do's and Don'ts of Nursing Documentation

NURSING LEGAL ISSUES

Nurses are well aware of the standard, which states that if a certain matter affecting patient care is required to be charted and it is not, the overwhelming presumption is that it may not have been done. Good documentation will help you defend yourself in a malpractice lawsuit, it can also keep you out of court in the first place.

Do's
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.

Dont's

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 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.

Legal Aspects of charting should include

make sure you have the correct chart (MOST IMPORTANT PRIORITY) Writing neatly and legibly (with blue or black ink) Conveying significant details Signing and dating every entry Using proper spelling, grammar and appropriate medical phrases Using authorized abbreviations only Assuring patients name is on every page A single line through entry errors and your initials (no erasing or white out)

Nursing documentation and progress notes that are filled with misspelled words and poor grammar create a negative impression. Readers (lawyers and jurors) may infer that a person with poor spelling and grammar is uneducated and careless.

The following are true examples of spelling errors noted on nursing flow sheets:

Walk patient in hell. Patient lying on eggshell mattress. Fecal heart tones heard. Patient observed to be seeping quietly. Foley draining fowl smelling urine.

The following are true examples of errors in grammar and incorrect use of words noted on nursing flow sheets: May shower with nurse Patient has no rigor or chills, but husband states she was hot in bed last night Patient had a cabbage done The pelvic exam was done on the floor Vaginal packing out, Doctor in Skin Somewhat pale but present

In addition to use of appropriate grammar and use of words, it is also important to avoid writing inappropriate comments on the nursing flow sheet. Finger pointing and accusations of incompetence are surely a red flag to lawyers and jurors. Evidence of fighting among healthcare professionals in the nursing documentation is just what a plaintiffs lawyer is looking for.

The following are true examples of inappropriate comments found in nursing and physician documentation:
IV infiltrated because nightshift forgot to check it Patient going into shock, could not reach Dr. Jones per usual Once again, the lab forgot to draw the patients PTT this am If the nurses would learn to read medication orders, we would have a lot fewer emergencies around here Patient received insufficient care today because nurse patient ratio was 1:7 Patient fell due to lax nursing supervision Patient in extreme pain because previous nurse too busy to give pain meds to check with x-ray typist about wrong patients particular

The Risk of abbreviating in legal documentation: When documenting, its imperative that you dont put your patients life at risk because of the abbreviations that you use. Abbreviations can be extremely dangerous to you and your patient, besides being a major waste of time.

The following are reasons why you should avoid abbreviations:

Abbreviations can be a total mystery to the reader. If a physician wrote, Patient may get up AFAWG, would he have communicated with you? How much time would you have to spend trying to figure out what he meant? If you and two other nurses looked at this order for 90 seconds each, four and a half minutes of patient care time would have been wasted, and you probably still wouldnt have the correct answer. (For the record, this was a physician order and AFAWG means As far as wire goes).

Abbreviations are easily confused. Patients are still being overdosed with insulin and heparin because people use u for units. Another critical error can occur with the use of ug for microgram, which has been misinterpreted to mean mg for milligrams. Errors such as these occur more frequently then we would like to admit, and all because someone used and unclear abbreviation.

Patient admitted with bleeding per rectum, had colonoscopy done, result normal. Surgeons plan: KIV PPH Nurses carry forward the message : KIV PPH What is PPH??

QUESTION?

conclusion
Documentation allows nurses and other care providers to communicate about the care provided. Documentation also promotes good nursing care and supports nurses to meet professional and legal standards.

Documentation should include

Direct quotations from the patient, family or visitors Data that has been gathered Actions taken Individuals notified about concerns and issues Evaluation of Actions

Maintaining records is an essential and integral part of patient care. Records are directed at enabling the provision of care, the prevention of disease and the promotion of health. Accurate record keeping helps to protect the welfare of patients and clients.

THANK YOU

MEDICAL RECORDS
* PATIENTS FILE, TRACER

SAMPLES

* NOTIFICATION OF INFECTIOUS CASES