DOCUMENTATION. Cheryl Bernknopf R.N., BScN Assistant Director Centauri Summer Camp Co- Chair OCA Healthcare Committee Board Member of the ACN. PURPOSE. To provide the multidisciplinary team with a structured note format for documenting
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Cheryl Bernknopf R.N., BScN Assistant Director Centauri Summer CampCo- Chair OCA Healthcare Committee Board Member of the ACN
PURPOSE To provide the multidisciplinary team with a structured note format for documenting • To monitor the campers’ or staffs’ health and well being • To record the care provided • The monitor the effect of the care and the continuity of the care.
Procedure • Black permanent ink is to be used when charting • Each Health Care Professional who documents in the record must sign and initial on the “documentation signature sheet” • All documentation will be accompanied by appropriate identification of the caregiver making the entry in the chart. • In general, staff health information should be separate from camper client) information
Documentation Principles Documentation must state: • When the event happened • What happened • To whom it happened • Why it happened (person or event) • The result of what happened
Documentation Principles cont’d • To maintain confidentiality of all information • Must be retrievable • Must be neat, legible, and non-erasable. • Must be an accurate, true and honest account of what occurred and when it occurred. • Must reflect the assessment, planning, implementation and evaluation of patient care.
Documentation Principles cont’d • Chart in chronological order, documenting entries in sequence of events. Do not document in blocks of time i.e. August 16, 2006 1200 – 1600 hours • Do not delete or alter an entry made by another Health Care Professional.
Documentation Principles cont’d • Forgotten or late entries are to be documented on the next available space within the Clinical Record. • Do not use ‘whiteout’, erasers, highlighter or entries between lines. • Do not leave blank lines between entries. If a blank line is inadvertently left, draw a line through the space so that no further entry can be documented.
Documentation Principles cont’d • When documentation of an entry continues from one page to the next, the bottom of the first page is to be signed off. Enter the date and time in the appropriate column on the next page and document in the Clinical Notes “ cont’d.”
Abbreviations • Use abbreviations according to policy of the college of Nurses Best Practice Guidelines or policies that have been implemented and approved by your camp to avoid confusion. • Example: OD- once a day OD- right eye OD- overdose
Three styles of charting • Narrative notes • Focus charting (D.A.R) • S.O.A.P.I.E.R
NARRATIVE NOTES • Notes are written in story format • The story must follow the chronological order of all events leading up to and following the incident • Example: Charting by exception
FOCUS CHARTING • Notes are written in chart or D.A.R format • Data: Subjective and/or objective information that supports the stated focus or describes the client status at the time of a significant event or intervention. • Action: Completed or planned nursing interventions based on the nurse’s assessment of the client’s status. • Response: Description of the impact of the interventions on client outcomes.
S.O.A.P.I.E.R. METHOD • Notes are written using the acronym s.o.a.p.i.e.r • S = subjective data (e.g., how does the client feel?) • O = objective data (e.g., results of the physical exam, relevant vital signs) • A = assessment (e.g., what is the client’s status?) • P = plan (e.g., does the plan stay the same? is a change needed?) • I = intervention (e.g., what occurred? what did the nurse do?) • E = evaluation (e.g., what is the client outcome following the intervention?) • R = revision (e.g., what changes are needed to the care plan?)
Digital Photography…. Consider use of digital photography to: • Send info about injury to consulting physician. • Capture record of injury for individual’s file. • Document progress of recovery process. • Provide training materials for future staff. • Show parent’s the child’s status upon return from a visit to the doctor.
Electronic or Computer-Based System? • Contol access so individual health information is seen only by designated eyes. • Control for changes made to individual records; alteration should be possible only through an ammended record which maintains the integrity of the original record. • Provide for an “audit” option.
Remember When documenting client care, develop a system that, at minimum, captures this information: • Record of each person’s visits to health centre.\, the nature of their concern, what was done to help them, evaluation of that care, and record of who provided treatment. • Screening note from opening day. • Record of phone conversations (including attempts to contact people) and other electronic transfer of information about a given individual’s health needs. • Summary note of referrals to out-of-camp providers (i.e., dentist, mental health, MD). • Exit note- day/time of leaving program and state of health upon leaving
Charting made Incredibly Easy, Lippincott Williams & Wilkins,2006 College of Nurses of Ontario, Practice Standard Documentation, Toronto Ontario. 2005 E-Learning Centre, College of Nurses of Ontario 2006. www.cno.org Lampe, S., Focus Charting Documentation for Patient-Centered Care, Minneapolis, Minnesota, 1997 Laura Burke and Judy Murphy, Charting By Exception Applications, Milwaukee, Wisconsin. 1995 . Erceg, L.E., & Pravda, M. (2009). The Basics of Camp Nursing, Monteray, CA: Healthy learning REFERENCES