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Documentation. Done by : Mohammad Kleen Mosab Bin Al-a’shish. Objectives. At the end of this seminar. we will be able to: Identify the nursing documentation correctly. Identify the purpose of client records . recognize documentation nursing activities

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  1. Documentation Done by : Mohammad KleenMosab Bin Al-a’shish

  2. Objectives • At the end of this seminar. we will be able to: • Identify the nursing documentation correctly. • Identify the purpose of client records . • recognize documentation nursing activities • Know the general guideline for nursing Documentation.

  3. Outline • Definition of documentation • Confidentiality of computer records • purpose of client records • Documentation nursing activities • General guidelines for recording • Kardexes • Telephone order • Computerized Documentation • Article • References

  4. Definition of documentation Effective communication among health professionals and is a vital to the quality of client care. Health personal communicate through :

  5. discussion Is informal oral consideration of a subject by two or more health care personnel to identify a problem or establish strategies to resolve a problem.

  6. report Is oral ,written, or computer-basedcommunication intended to conveyinformation to others • For instance, nurse always report on clients at the end of hospital work shift.

  7. record Is Written Or Computer Based The Process Of Making An Entry On A Client Record Is Called Recording, Charting, Or Documentation

  8. Confidentiality of computer records • Personal password is needed to enter and sign off computer files • After logging on, never leave a computer terminal unattended • Do not leave client information displayed on the monitor where others may see it • Know the facility policy and procedure for correcting an entry error

  9. Why nursing documentation is important

  10. Purpose of client records 1-Communication : It Helps Communicate Between Health Care Team And Prevents Fragmentation, Repetition, And Delays In Client Care. 2-Planning Client Care: We Use Data From The Client’s Record To Establish Nursing Care Plan For That Client. (rising temperature ,give antibiotic) 3-Auditing Health Agencies: An Audit Is A Review Of Client Records For Quality Assurance Purposes.

  11. 4)Research: • The treatment plans for a number of clients with the same health problem can yield information helpful in treating other client. 5)Education • Students in health disciplines often use client records as educational tools. • A record can frequently provide a comprehensive view of the client, the illness, effective treatment strategies, and factors that affect the outcome of the illness.

  12. 6)Reimbursement : Documentation Also Helps A Facility Receive Reimbursement From The Federal Government And Insurance Companies 7)Legal Documentation : The Client Record Is Legal Document And Is Usually Admissible In Court As Evidence. 8)Health care analysis: Information from records may assist health care planners to identify agency needs, such as overutilized and underutilized hospital services

  13. documenting nursing activities • admission nursing assessment : an initial database ,nursing history . • the nurse generally records ongoing assessments or reassessments on flow sheets or nursing progress notes .

  14. documenting nursing activities • nursing care plans : • The clinical record include evidence of client assessment ,nursing diagnoses and/or client needs , nursing interventions,client outcomes,and evidence of a current nursing care plan.

  15. Nursing Care Plan:

  16. documenting nursing activities • Types of nursing care plans : • Traditional care plan: is written for each client. the form varies from agency to agency according to the needs of the client and the department. most forms have three columns : one for nursing diagnosis, a second for expected outcomes, and a third for nursing interventions. • standardized care plans: were developed to save documentation time. these plans maybe based on an institution's standards of practice,thereby helping to provide a high quality of nursing care . must be individualized by the nurse in order to adequately address individual client needs. • .

  17. documenting nursing activities • Kardexes: • is widely used , concise method of organizing and recording data about a client , making information quickly accessible to all health professional • it consists of a series of cards kept in a portable index file or on computer-generated forms and can be quickly accessed to reveal specific data . it is a temporary worksheet written in pencil for ease in recording frequent changes in details of a client's care .

  18. documenting nursing activities • The information on kardex may be organized into sections , for example : • -Patient information about the client such as name , room number ,age ,admission, type of surgery and date. • -Allergies • -list of medication ,with the date of order and the times of administration for each. • -list of intravenous fluid ,with dates of infusion. • -list of daily treatment and procedure ,such as irrigation ,dressing change

  19. documenting nursing activities • -list of diagnostic procedures ordered such as x-ray or laboratory test. • - A problem list ,stated goal,and approuches of nursing goal

  20. documenting nursing activities • Flow sheets : • A flow sheet enable nurses to record nursing data quickly and concisely and provides an easy to read record of the client's condition over time. • -Graphic record : • indicate body temperature ,pulse ,respiratory rate ,blood pressure and weight. in some agencies may include admission or postoperative day, bowel movement and activity. • -Intake and output record : • all routes of fluid loss or output are measured and recorded .

  21. documenting nursing activities • -medication administration record : • include designated areas for date of medication order ,the expiration date,the medication name and dose, • - skin assessment record; • these record may include categories related to stage of skin injury,drainage,odor,culture information and treatment. • progress note : • progress note made by the nurse provides information about the progress a client is making toward achieving desired outcomes.

  22. documenting nursing activities • - in addition to assessment and reassessment data progress notes include information about client problems and nursing intervention .

  23. documenting nursing activities • nursing discharge / referral summaries : A discharge note and referral summary are completed when the client is being discharged and transferred to another institution or to a home setting where a vist by a community health nurse is required . • if the discharge plan is given directly to the client and family, it is imperative that instructions be written in terms that can be readily understood. ( for example : medications , treatments, and activities should be written in layman's terms, and use of medical abbreviations ( such as ad lib ) should be avoided.

  24. documenting nursing activities • if a client is transferred within the facility or form a longterm facility to a hospital, a report needs to accompany the client to ensure continuity of care in the new area. it should include all components of the discharge instructions, but also describe the condition of the client before the transfer. any teaching client instruction that has been done should also be described and recorded.

  25. content of discharge/referral summaries : • - description of client's physical, mental, and emotional status at discharge or transfer. • - resolve health problems . • - unresolved continuing health problems and continuing care needs may include a review-of-systems checklist . • - treatments that are to be continued . • - current medications . • - restrictions that relate to (A) activity ... (B) diet ... (C) bathing .

  26. - functional self care abilities in terms of vision, hearing, speech, ... etc. • - comfort level • - support networks . • - client education provided in relation to disease process, special treatment or care, follow up appointments. • - discharge destination and mode of discharge. • - referral services.

  27. 0.0310

  28. general guidlines for recording : • date and time : document the date and time of each recording. (e.g., 6/2/2017 ,9:00 AM )

  29. Timing: follow the agency's policy about the frequency of documenting, and adjust the frequency as client's condition indicates; for example, a client whose blood pressure is changing requires more frequent documentation than a client whose blood pressure is constant. ***No recording should be done before providing nursing care.

  30. Legibility: All entries must be legible and easy to read to prevent interpretation errors. hand printing or easily understood hand writing is usually permissible. • Permanence: All entries on the client's record are made in dark ink so that the record is permanent and changes can be identified. dark ink reproduces well on microfilm and in duplication processes.

  31. correct spelling : correct spelling is essential for accuracy in recording. if unsure how to spell a word, look it up in a dictionary or other resource book. two decidedly different medications may have similar spellings; for example, fosamax and flomax, digitox and digoxin • accepted terminology : abbreviations are used because they are short, convenient, and easy to use. Ex: D/C MAY MEAN ( DISCHARGE OR DISCONTINUE) **many abbreviations are standard and used universally

  32. Signature : each recording on the nursing notes is signed by the nurse making it. i includes the name and title; for example, "susan J. Green, RN" or "SJ Green,RN." some agencies have a signature sheet and after signing this sheet, nurses can use their initials. with computerized charting, each nurse has his or her own code, which allows the documentation to be identified

  33. the following title abbreviations are often usedo sign: • RN ---> registered nurse • LPN ---> licensed practical nurse • NA ---> nursing assistant • NS ---> nursing student

  34. Accuracy: the client's name and identifying information should be written on each page of the clinical record. before making any entry, check that it is the correct chart. do not identify charts by room numbers only; check the clients name. special care is needed when caring for clients with the same last name.

  35. Sequence : document events in the order in which they occure. Ex: record assessment then nursing DX , nursing intervention, then client responce. • Appropriateness: record only information that pertains to the client's health problems and care.

  36. Conciseness: recording need to be brief as well as complete to save time in communication. the client's name and the word client are omitted. • legal prudence : accurate, complete documentation should give legal protection to the nurse, the client's other caregivers, the health care facility, and the client

  37. Telephone reports : Health professionals frequently report about a client by the telephone The nurse receive a telephone report should document :

  38. Do • 1-chart a change in a client’s condition and show that follow-up. • 2-read the nurses’ notes prior to care to determine if there has been a change in the client’s condition. • 3-be timely: “but a late entry is better than no entry”. • 4-correct charting errors.

  39. 5-chart the client’s response to interventions. • 6-review your notes. • 7-use objective,specific, and factual descriptions. • 8-Chart all teaching.

  40. Do and Don’t of Nursing Documentation: • Don’t: • 1-leave blank space for a colleague to chart later. • 2-chart in advance of the event.(e.g,procedure,medication). • 3-use vague terms. • 4-chart for someone else. • 5-record assumptions or words reflecting bias. • 6-alter a record even if requested by a superior or a physician. • 7-use “patient” or “client” as it is their chart.

  41. Telephone order: • Physicians Often Order A Therapy (E.G., A Medication) For A Client By Telephone. Many Agencies Allow Only Registered Nurses To Take Telephone Orders. • While Physician Gives The Order, Write It Down And Repeat It Back To The Physician To Ensure Accuracy.

  42. Guidelines for telephone order: • Know the state nursing board’s position on who can give and accept verbal and phone order. • Know the agency’s policy regarding phone orders. • Do not accept an order from a prescriber you do not know. • Ask the prescriber to speak slowly and clearly. • Ask the prescriber to spell out the medication if you are not familiar with it.

  43. Cont”.... • Question the drug, dosage, or change if they seem inappropriate for this client. • Read the order back to the prescriber at the end. • write the order on the physician’s order sheet. • when writing a dosage always put a number before a decimal. • follow agency protocol about the prescribe’s protocol for signing telephone orders.

  44. Computerized documentation • Manage the huge volume of information required in contemporary health care • Nurse use computers to store the client database, add new data, create and revise care plane • Some institutions have a computer terminal at each client bedside, or nurses carry a small handheld terminal, enabling the nurse to document care immediately after it is given.

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