Documentation

2 Documentation


It is a legal requirement while a patient is in a healthcare facility that accurate, objective and relevant documentation is maintained. Documentation is confidential and should be viewed only by those who have a legitimate right—that is, healthcare personnel who are directly involved in the patient’s care. Hospital records are owned by the hospital or institution; however, the patient has the right to access their records through the Freedom of Information Act 1982 (Cth) in Australia or the Code of Health and Disability Services Consumer’s Rights Regulation 1996 (New Zealand). It is not only documents in paper form that are accessible.




Types of documentation



image Documentation can include:
• Written health records, e.g. medical history, progress notes

• Electronic health records

• Audio or video tapes, including taped handovers

• Images, e.g. photos of wounds, X-rays

• Incident reports

• Nursing charts, e.g. medication records, observational charts

• Checklists, e.g. preoperative checklist

• Emails

• Nursing anecdotal notes
image Note: If a personal journal is kept, it can be requested during a trial or inquest.


Reasons for documenting



image Documenting is done:
• To facilitate communication between nurses and allied health members

• To provide a record of the care provided
image Demonstrates accountability

• To promote effective and consistent nursing care
image Shows which elements of nursing care have achieved their goals

image Can be used for research purposes (to promote evidence-based practice)

• To meet the legal/ethical requirements of the profession
image Legislation requires that specific information be recorded and maintained

image For quality assurance, to evaluate professional practice.


Documentation methods



image There are two main types:
• Document by inclusion, e.g. standard progress notes

• Document by exception, e.g. clinical pathways
image With this method, it is understood that all care was met with an expected response unless documented otherwise.


How to document



image Notes should be written as stand-alone documents.
• The nurse should document as if the notes were going to be read out in court—that is, the notes should not need further clarification.

image Information should be clear, concise and accurate.
• Only use abbreviations approved by the institution.

• Note: Most abbreviations are not legally approved—be very cautious when using them in notes.

• Do not use SMS type language, e.g. write ‘you are’ rather than ‘UR’!

image Notes should be legible and permanent.
• Write in a blue or black pen (not pencil or texta).

image Never erase a note.
• Never use ‘white-out’ or ‘liquid paper’.

• If an error is made, draw one line through the note in error and write ‘error made’ and your initials.

image The person who writes the notes should be easily identified.
• Sign and print your name and designation.

• If you are a student nurse, your year level and university or institution should also be named.
image Notes written by students usually need to be co-signed by the registered nurse supervising them.

image Ensure that the patient’s name and hospital record number is on every page.
• It is also helpful to have the ward listed on each page, as patients often move between wards in their hospital stay.

image Notes should be timely.
• The time and date should be written at the start of the record.

• The notes should be written at the end of each shift (although they can be written as the shift progresses).

• Critical incidents should be documented as soon as possible (while the incident is fresh in the mind).

• If a doctor is contacted, write the exact time of contact and the name of the doctor, as well as any orders given.

• Never document in advance.
image Always sign medication orders after the medication has been administered.

• If late records are added, write the time and date of the late record, and label it ‘additional record’.
image Never leave a gap to write notes later.

image If a line or part of a line is left, draw a line through it (to prevent someone adding further information to your notes).

image Only record first-hand observations.
• Never record observations told by a third person.
image If a relative makes an important comment, you can document it but you need to record the source.

• If another team member gave care to the patient clearly identify that member, e.g. ‘Patient showered by the occupational therapist’ (although the occupational therapist should also write notes).

image Be professional with observations or assessments.
• Do not chart subjective opinions, just facts.

• Only ever be objective and specific:
image ‘Patient is not compliant’ is not an appropriate comment. ‘Patient refused to take 1600 medications due to nausea’ is a better notation.

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Oct 22, 2016 | Posted by in NURSING | Comments Off on Documentation

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