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- Communication between providers
- Educational tool
- Legal documentation of care
- Quality assurance
- The old adage
- “if it wasn’t documented it wasn’t done”
- still rings true.
Justifying care and decisions
- Why the patient/resident needs care
- What care was given
- How the patient/resident responds
- Why the patient/resident continues to need care, and
- When he or she is ready to move to another level of care or go home.
Basic principles of documentation
- The clinical record must be:
- Timely: you have time to document when the info is still fresh. You do. Seriously.
- Easily retrieved
Narrative nursing notes
- Tells a story
- Dated and timed
- Signed by you. Line out extra spaces to prevent others from adding to your notes
- Data (symptom)
Charting by exception
- You only chart what is outside the norms or expected parameters
- What do you think the problems might be with this charting? No baseline.
- What are the advantages of this type of charting? Faster
- Record routine aspects of care (hygiene, turning)
- Document assessments; usually organized according to body systems
- Track client response to care (wound care, pain, intravenous fluids)
- Graphic records - used to record vital signs
- Intake and output record
Nursing Admission Assessment
- Patient history, allergies, etc.
- Sometimes done several times
- Who is present when questions are being asked. May be a good idea, but only if pt wants/permits it.
- May determine where the care is going…..
KARDEX or client care summary
- Demographic data
- Medical diagnoses
- Diet/activity orders
- Safety precautions
- May be different depending on the unit
- Usually in a different location than the main patient chart
Integrated plans of care
- Combined charting and care plan form
- Maps out on a daily basis, from admission to discharge
- Client outcomes, interventions, and treatments for a specific diagnosis or condition
- Laboratory work, diagnostic testing, medications, and therapies included in the pathway
- Informing other caregivers about the client condition
- Nurse to nurse; nurse to physician
- Passage of vital information related to the client’s status/plan of care
- I-SBAR-R – make sure report is organized and concise – this is not a soap opera report
- ISBARR: Identification, Situation, Background, Assessment, Recommendation, Readback.
What is I-SBAR-R?
Look at the handout!
- Call Dr.
- I-Who are you, who is the patient?
What is a Sentinal Event
- A medical error that resulted in death or severe psychological damage.
- So severe, they should never happen.
- Verbal (conversational)
- Taped (not preferred)
- Walking rounds
- Charge nurse to charge nurse
- SBAR or PACE (PACE is actually IPPPAACCCE)
Standardized approach to handoff communications
- Shift-to-shift, transfers, breaks, therapist-to-therapist
- Up-to-date information regarding care, treatment, condition, recent/anticipated changes
- Must allow opportunity for questions between the giver and receiver
- Read back or repeat back as applicable
- SBAR format
- Approach may be customized, but must use SBAR
Stuff that should be in handoff report
- Client demographics and diagnoses
- Relevant medical history
- Special directives
- Significant assessment findings
- Pertinent or upcoming diagnostics or procedures
- Plan of care for the client
- Discharge plan
- Concise and pertinent information only! Emphasis is on being concise without omission.
- Patient education
- Time of departure and method of transportation
- Name and relationship of person(s) accompanying client at discharge
- Condition of client at discharge
- Discharge instructions
- Follow-up appointments or referrals given
- Verbal orders
- Spoken to you; often during a client emergency
- Should be made for critical change in patient condition.
- If can be spoken, should be written.
- Telephone orders
- Received by phone and transcribed onto chart order sheet
- Both have an increased risk for errors