inventery management

1. Documentation in ICU
Dr Selam Tebeje
Anesthesiology

2. Learning Objectives:
• Explain the principles of documentation
• Identify legal aspects of proper
documentation

3. Outlines:
• Introduction
• Parts
• Uses of documentation
• Principles of documentation

4. Introduction
• Safe, quality, and evidence-based practice
requires Clear, accurate, and accessible
documentation .
–Important for appropriate communication of
patient information among all members of
the inter-disciplinary team

5. What to document…
– Assessments & Clinical problems
– Communications with other health care
professionals
– Communication with the patient, family, and other
third parties
– Medication records (MAR)
– Order implementation, and management plan

6. What to document…
– Patient clinical parameters
– changes in the patient’s status
– Plans of care
– Document if there is any special social and cultural
consideration

7. Uses of documentation
1) Timely documentation of information should
be made and maintained in a patient’s record to
ensure informed decisions and high quality
care.

8. uses
2) Credentialing
-to monitor performance of health care
practitioners’
-to monitor the health care facility’s
compliance with standards

9. uses
3) Legal repercussions
• Documentation that is incomplete, inaccurate,
untimely, illegible or inaccessible, can lead to:
– Jeopardize the legal rights, claims, and defenses of
both patients and/or health care providers
– Put health care organizations at risk of liability

10. uses
4) Regulation of laws and legislation changes
according to audits of reports
5) Research…Data from documentation
6) To measure performance outcomes against
the standards and to improve quality of care

11. Principles Of Documentation
Principle 1. High quality documentation:
• Accurate, relevant, and consistent
• Clear & concise
• Legible/readable
• Timely and sequential

12. Principle 2. Education and Training:-
• Functional and skillful
• Capable of using computer and its supporting
hardware and software systems

13. Principle 3: Policies and Procedures:-
– be familiar with all organizational policies and
procedures related to documentation

14. Principle 4. Protection Systems:- whether
paper-based or electronic.
• Security of data
• Protection of patient identification,
• Confidentiality of information

15. Principle 5. Documentation Entries: -
• Accurate, valid, and complete;
• Authenticated/name
• Dated and time-stamped
• Legible/readable

16. Principle 6. Standardized Terminologies
:-should include standardized expressions
to describe the planning, delivery, evaluation
and management of the patient

17. Thank you