Documentation the basics


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Documentation the basics

  1. 2. <ul><li>In this presentation you will learn about: </li></ul><ul><li>Types of documentation </li></ul><ul><li>Handover </li></ul><ul><li>Basic writing – Progress notes </li></ul><ul><li>Care planning </li></ul><ul><li>Aged Care Funding Instrument (ACFI) </li></ul>
  2. 3. <ul><li>To ensure that continuity of resident care is provided by all health care professionals through professional, accurate and contemporary documentation in keeping with legislative and ethical requirements </li></ul>
  3. 4. <ul><li>Care Reports </li></ul><ul><li>ACFI, progress notes, incident reports, care plans etc </li></ul><ul><li>Other reports </li></ul><ul><li>Daily, Hazard and maintenance etc </li></ul><ul><li>Requisition forms </li></ul><ul><li>Transfer letters </li></ul><ul><li>Phone calls </li></ul>
  4. 5. <ul><li>We can communicate what is happening </li></ul><ul><li>Funding can be dependent on what is contained in reported information </li></ul><ul><li>Continuity of client care – so that we all are ‘on the same page’ - If a particular worker records everything accurately in notes and care plans, the next workers can easily take on the support of the clients, without missing any details of what has already occurred, what is in process and what needs to be done </li></ul>
  5. 6. <ul><li>Relevant </li></ul><ul><li>Documented </li></ul><ul><li>Timely </li></ul><ul><li>This is a legal requirement </li></ul><ul><li>Can also become part of an </li></ul><ul><li>audit process </li></ul><ul><li>It is generally considered that </li></ul><ul><li>if something is not documented </li></ul><ul><li>it is not done! </li></ul>
  6. 7. <ul><li>Extremely important that reports be presented within the appropriate time frame </li></ul><ul><li>Plan ahead </li></ul><ul><li>Negotiate a new deadline if need be </li></ul><ul><li>Examples : - message re care of resident </li></ul><ul><ul><li>-frayed toaster cord </li></ul></ul><ul><li> -providing a new sharps container </li></ul><ul><li>Which is the most urgent? </li></ul><ul><li>They are all equally important to be reported to the right person in the right format </li></ul>
  7. 8. <ul><li>Familiarise yourself with all of the types of forms used in your organisation - assessment, admission, care plans, case notes, incident reports, ACFI, Pressure care </li></ul><ul><li>Records are always confidential - keep them secure – shut down computer screens, return paperwork to correct storage area, don’t leave identifiable items in public areas </li></ul>
  8. 9. <ul><li>Brief information exchange at the change of a shift </li></ul><ul><li>Essential information you need to pass on: </li></ul><ul><ul><li>details of client preferences </li></ul></ul><ul><ul><li>details of anything which happened that was out of the ordinary </li></ul></ul><ul><ul><li>new treatments, symptoms </li></ul></ul><ul><ul><li>any information required to provide continuity of care – Drs appointments, day leave etc </li></ul></ul>
  9. 10. <ul><li>Be factual, concise and accurate- be objective and nonjudgmental </li></ul><ul><li>Make sure your writing is neat, clear and legible </li></ul><ul><li>Writing should be in blue or black ink </li></ul><ul><li>Use exact words when quoting - use quotation marks to show it is a direct quote </li></ul><ul><li>Never use whiteout - draw a single line through the error, initial and date the change </li></ul><ul><li>Record the date and time - especially when relating incidents that have occurred </li></ul><ul><li>Present information in logical sequence </li></ul><ul><li>Use abbreviations approved in your organisation </li></ul>
  10. 11. <ul><li>Use correct spelling, punctuation and grammar - use a dictionary ! </li></ul><ul><li>Edit your report before presenting it - get rid of errors and mistakes </li></ul><ul><li>Always sign and date each entry, with your surname printed and designation at the end </li></ul><ul><li>Eg: (OTOOLE, PCW) </li></ul><ul><li>Make sure you check your organisation’s requirements regarding documentation </li></ul>
  11. 12. <ul><li>Read through this common abbreviation list and undertake the matching activity </li></ul><ul><li>Insert hyperlink activity here </li></ul><ul><li>Remember that each organisation should have its own accepted abbreviation practice guideline or policy that you will need to abide by </li></ul>
  12. 13. <ul><li>Not necessary to write any entry every day – known as by exception </li></ul><ul><ul><ul><li>E.g change in behaviour, visit by GP and commencing new antibiotic </li></ul></ul></ul><ul><li>If it is already on the long term care plan there is no need to write another entry as nothing new has happened </li></ul><ul><li>If is a new problem then write in the progress notes and be specific- read your entry back to make sure it makes sense to someone who has not cared for the client before </li></ul>
  13. 14. <ul><li>Date </li></ul><ul><li>Time </li></ul><ul><li>Designation </li></ul><ul><li>Written in the correct time sequence </li></ul><ul><li>Be concise and factual </li></ul><ul><li>Signature and Name clearly identifiable </li></ul>
  14. 15. <ul><li>What happened – subjective and objective information </li></ul><ul><li>What you saw / heard or did </li></ul><ul><li>What action you took </li></ul><ul><li>What the result was </li></ul><ul><li>Subjective </li></ul><ul><li>Resident’s description of problem/event </li></ul><ul><li>e.g. ”Mrs Brown stated she had abdominal pain” </li></ul><ul><li>Objective </li></ul><ul><li>Objective data that can be measured or observed by you </li></ul><ul><li>e.g. “Mrs Brown pale, holding abdominal area, lying in bed” </li></ul>
  15. 16. <ul><li>Assessment </li></ul><ul><li>Assessment of the subjective and objective data available </li></ul><ul><li>e.g. “Vital signs recorded – NAD, no vomiting or diarrhoea” </li></ul><ul><li>Plan </li></ul><ul><li>What you are going to do/have done about it </li></ul><ul><li>e.g “ Pain relief given by RN for pain in abdomen, warm gel pack offered. Mrs Brown to remain in bed and review in 2/24” </li></ul>
  16. 17. <ul><li>A full assessment of the health status and care needs of each resident is to be carried out and documented as part of the admission process and an ongoing re assessment of care needs is carried on a continuous basis </li></ul><ul><li>This ensures a holistic and individualised approach is undertaken in providing care to each resident, that is meaningful to them </li></ul>
  17. 18. <ul><li>The crucial information that explains what you need to do for a client </li></ul><ul><li>Can be in an electronic format </li></ul><ul><li>2 TYPES </li></ul><ul><li>Short term </li></ul><ul><li>problems of short duration </li></ul><ul><li>e.g skin tear </li></ul><ul><li>Long term </li></ul><ul><li>Continuous ongoing problems </li></ul><ul><li> e.g. mobility </li></ul>
  18. 19. <ul><li>Assessment phase – on each aspect of care </li></ul><ul><li>Planning phase – write up the care plan </li></ul><ul><li>Implementation – share information with others, discuss plan of care, implement the care you’ve planned </li></ul><ul><li>Review – at least monthly if not before, living document; can change as necessary to meet the clients needs </li></ul>
  19. 20. <ul><li>Read these care plan guidelines and look at the examples provided </li></ul>
  20. 21. <ul><li>Identify the issue </li></ul><ul><li>Statement of the issue/s or problem </li></ul><ul><li>One per care plan </li></ul><ul><li>Basis of what you are writing the care plan about </li></ul><ul><li>If it is clearly stated it is easy to work out the interventions </li></ul>
  21. 22. <ul><li>Overall aim of what you want to achieve </li></ul><ul><li>What do you want to achieve for the resident? </li></ul><ul><li>What does the resident want to achieve? </li></ul><ul><li>Ideally the resident would be an active participant in setting the goal/s of their care </li></ul><ul><li>What does the family want to achieve? </li></ul>
  22. 23. <ul><li>What you are going to do about it </li></ul><ul><li>Review the assessment documentation </li></ul><ul><li>Eg personal hygiene assessment – how much help does the client need when showering, don’t assume they can’t do anything themselves </li></ul><ul><li>Use information recorded in the assessment documentation to work out the content of the care plan </li></ul>
  23. 24. <ul><li>Consideration is to be given to the residents abilities, needs, expectations, choices and preferences, wants and needs in relation to each of the following: </li></ul><ul><li>·         Residents rights </li></ul><ul><li>·         Personal affairs </li></ul><ul><li>·         Social </li></ul><ul><li>·         Cultural </li></ul><ul><li>·         Spiritual </li></ul><ul><li>·         Physical </li></ul><ul><li>·         Emotional (psychological) </li></ul>
  24. 25. <ul><li>Puts the plan into action – guides your care </li></ul><ul><li>Implementation includes the documenting of care in progress notes, treatment sheets, medication charts </li></ul><ul><li>Documenting is part of the carer’s direct responsibility, rather than a clerical function, it is a vital part of the professional care practice, providing a permanent record of what you want to achieve, how, when and why you do it </li></ul>
  25. 26. <ul><li>Determines the extent to which goals or outcomes have been met or achieved </li></ul><ul><li>Final phase in the process which is an integral part of professional practice, it is ongoing </li></ul><ul><li>Based on resident need, facility policy, legal requirements </li></ul><ul><li>Could be date or funding driven </li></ul>
  26. 27. <ul><li>Interim Care plan </li></ul><ul><li>Short Term Care plans </li></ul><ul><li>Mini Care plans </li></ul><ul><li>Electronic care plans </li></ul><ul><li>Community Care plans </li></ul><ul><li>Mental health plan </li></ul>
  27. 28. <ul><li>Long Term Care Plan </li></ul><ul><li>For ongoing total care </li></ul><ul><li>Interim Care Plan </li></ul><ul><li>Snapshot picture on admission </li></ul><ul><li>Short Term Care Plan </li></ul><ul><li>For problems of short duration </li></ul><ul><li>Mini Care Plans </li></ul><ul><li>Snapshot picture – often found in a client’s wardrobe </li></ul>
  28. 29. <ul><li>Electronic Care Plans </li></ul><ul><li>“ I Care” one example of a computer generated care plan used on palm pilots </li></ul><ul><li>Community Care Plans </li></ul><ul><li>Other Facilities </li></ul><ul><li>Vary greatly but every facility will have the same basic components, ensure you find out at your orientation how to document care plans properly – particularly if your funding relies on it! </li></ul>
  29. 30. <ul><li>Care Planning is a partnership with residents, it is resident focused not driven by or for staff convenience </li></ul><ul><li>ALWAYS engage the client to be an active participant in what is happening to them </li></ul>