3. Documentation, recording & reporting [1 hr.]
Purpose of documentation
Types of report
Patient parameters recording guideline
Guidelines for reporting client data
Confidentiality of records
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4. Learning outcomes
After this session, students will be able to:
Understand and apply the principles of documentation and communication that align with
legal and ethical aspects of the emergency and critical care process.
Demonstrate effective communication in Emergency Department settings.
Identify effective communications strategies in the ED.
Identify the needs of special populations who require emergency care and develop
appropriate plans of care that are culturally and demographically relevant.
Apply therapeutic communication in patient care
Demonstrate clear, sensitive and effective communication skills in interactions with
individuals, families, communities staff, local health department staff, peers and faculty
Document information’s according to principles of proper recording and documentation
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5. RECORD KEEPING
What is documentation/record keeping?
Purpose of documentation/record keeping?
Principles of documentation/record keeping?
Main characteristics of documentation/record keeping?
Validity of documents/records
Documentation/record keeping responsibility
Documentation/record keeping & medico–legal issues
6. RECORD KEEPING
Definitions
Documentation is written communication
Medical records are a method of communication for healthcare team members and are required to be an
integrated, sequential and contemporaneous record of events, where possible.
Chart is a written record of history, examination, tests, diagnosis, and prognosis response to therapy.
Written communication is as important in the health care arena as both verbal and non-verbal
communication.
Maintaining clear, concise but comprehensive client care records is absolutely essential both in terms of:
providing continuity of client care of a high standard and
meeting legislative requirements.
Remember, in a court of law it is assumed that if the care was not documented then it didn’t happen.
7. Nursing documentation, record keeping and
written communication
INTRODUCTION
Accurate record keeping and careful documentation is an
essential part of nursing practice.
‘Good record keeping helps to protect the welfare of patients
and clients’ – which of course is a fundamental aim for nurses
everywhere. (The Nursing and Midwifery Council (NMC 2002))
It is equally important that you can also communicate by letter
and e-mail with other health and social care professionals, to
ensure that they understand exactly what you mean.
8. NURSING DOCUMENTATION AND RECORD KEEPING
High quality record keeping will help to give skilled and safe care
Nurses have a legal and professional duty of care
Nurses record keeping and documentation should demonstrate:
a full description of assessment and the care planned and given
relevant information about patient/client at any given time and what done in
response to their needs
that you have understood and fulfilled your duty of care, that you have taken
all reasonable steps to care for the patient/client and that any of your actions or
things you failed to do have not compromised their safety in any way
‘a record of any arrangement you have made for the continuing care of a patient
or client’.
9. NURSING DOCUMENTATION AND RECORD KEEPING
Investigations into complaints about care will look at
and use the patient/client documents and records as
evidence, so high quality record keeping is essential.
A court of law will tend to assume that if care has not
been recorded then it has not been given.
10. Documentation
You will see lots of different charts, forms and
documentation.
Every hospital, care home and community nursing service will
have the same basic ones, but with small variations that work
best locally.
The common documents that you will use include some of the
following.
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11. Documentation
Nursing assessment sheet
The nursing assessment sheet contains the patient’s
biographical details (e.g. name and age), the reason for
admission, the nursing needs and problems identified for
the care plan, medication, allergies and medical history.
Nursing care plan
The documents of the care plan will have space for:
Patient/client needs and problems.
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12. Documentation
Sometimes, nursing Dx s will be documented but these are not used as frequently as in
North America.
Planning to set care priorities and goals. Goal-setting should follow the SMART system, i.e. the goal
will be specific, measurable, achievable and realistic, and time-oriented. For exam-ple, a SMART goal
would be that ‘Mr Lee will be able to drink 1.5 L of fluid by 22.00 hours’. Some goals, such as
reducing anxiety, are not easily measured and it is usual to ask patients to describe how they feel
about a problem that was causing anxiety.
The care/nursing interventions needed to achieve the goals.
An evaluation of progress and the review date. This might include evaluation notes,
continuation sheets and discharge plans. In some care areas you might record
progress using a Kardex system along with the care plan.
Reassessing patient/client needs and changing the care plan as needed.
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13. Documentation
Vital signs
The basic chart is used to record temperature, pulse, respiration and possibly blood pressure. Sometimes the
patient’s blood pressure is recorded on a separate chart. Basic charts may also have space to record urinalysis,
weight, bowel action and the 24-hour totals for fluid intake and output.
More complex charts, such as neurological observation charts, are used for recording vital signs plus other
specific observations, which include the Glasgow Coma Scale score for level of consciousness, pupil size and
reaction to light, and limb movement
Fluid balance chart
This is often called a ‘fluid intake and output chart’ or sometimes just ‘fluid chart’. It is used to record all fluid
intake and fluid out- put over a 24-hour period. The amounts may be totalled and the balance calculated at
24.00 hours (midnight), or at 06.00 or 08.00 hours. Sometimes the amounts are totalled twice in every 24
hours (i.e. every 12 hours). Fluid intake includes oral, nasogastric, via a gastrostomy feeding tube, and infusions
given intra- venously, subcutaneously and rectally. Fluid output from urine, vomit, aspirate from a nasogastric
tube, diarrhoea, fluid from a stoma or wound drain are all recorded.
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14. Documentation
Medicine/drug chart
It is important to become familiar with the medicine/drug-related documents used in
area of practice.
A basic medication record will contain the patient’s biographical information, weight,
history of allergies and previous adverse drug reactions.
There will be separate areas on the chart for different types of drug orders.
These include:
drugs to be given once only at a specified time, such as a sedative before an invasive procedure
drugs to be given immediately as a single dose and only once, such as adrenalin (epinephrine) in an
emergency
drugs to be given when required, such as laxatives or analgesics (pain killers)
drugs given regularly, such as a 7-day course of an antibiotic or a drug taken for longer periods
(e.g. a diuretic or a drug to prevent seizures).
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15. Documentation
All drugs will include the dose, route, frequency (with times), start date and
sometimes a finish date.
There is space for the signature of the nurse giving the drug and, in some cases, the
witness.
It is vital to record when you give a drug.
This is done at the time so that all staff know that it has been given, and do not
repeat the dose.
Likewise, if you cannot give the drug for some reason (e.g. patient is in another
department or their physical condition contraindicates giving the drug), make sure
that this fact is recorded on the medicine/drug chart and the doctor is informed if
necessary.
Remember that in some situations you will need to record in the nursing notes when
you give patients a drug (e.g. if you give analgesic drugs (pain killers)).
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16. Documentation
Informed consent
Responsibility for making sure that the person or the parents of a child have all the
information needed for them to give informed written consent rests with the health
practitioner (usually a doctor or nurse) who is undertaking the procedure or operation.
This information will include:
information about the procedure/operation
the benefits and likely results
the risks of the procedure/operation
the other treatments that could be used instead
that the patient/parent can consult another health practitioner
that the patient/parent can change their mind.
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17. Documentation
Incident/accident form
Any non-routine incident or accident involving a patient/client, relative,
visitor or member of staff must be recorded by the nurse who witnesses
(sees) the incident or finds the patient/client after the incident happened?
Incidents include falls, drug errors, a visitor fainting or a patient attacking a
member of staff in any way.
An incident/accident form should be completed as soon as
possible after the event.
Careful documentation of incidents is important for
clinical governance
continuous quality improvement,
learning from mistakes and managing risk, etc. and
in case of a complaint or legal action
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18. Documentation
The following points provide some guidance for
documentation of incidents
be concise, accurate and objective
record what you saw and describe the care you gave, who else was
involved and the person’s condition
do not try to guess or explain what happened (e.g. you should record
that side rails were not in place, but you should not write that this
was the reason the patient fell out of bed)
record the actions taken by other nurses and doctors at the time
do not blame individuals in the report
always record the full facts.
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19. Guidelines for documentation & record keeping
The basic guidelines for good practice in documentation and record keeping
apply equally to written records and to computer-held records.
Patient and client records should:
be based on fact, correct and consistent
be written as soon as possible after an event has happened to provide current (up to date)
information about the care and condition of the patient or client
‘be written clearly and in such a way that the text cannot be erased’ (rubbed out or
obliterated)
be written in such a way that any alterations or additions are dated, timed and signed, so
that the original entry is still clear
‘be accurately dated, timed and signed, with the signature printed alongside the first
entry’
20. Guidelines for documentation & record keeping
Patient and client records should:
‘not include abbreviations, jargon, meaningless phrases, irrelevant speculation and
offensive subjective statements’
‘be readable on any photocopies.
‘be written, wherever possible, with the involvement of the patient, client or their carer’
‘be written in terms that the patient or client can understand’
‘be consecutive’ (uninterrupted)
‘Identify problems that have arisen and the action taken to rectify’ (correct or put right)
them
‘Provide clear evidence of the care planned, the decisions made, the care delivered and
the information shared’.
21. Documentation
documentation and management of health care records are maintained consistent
with common law, legislation, ethical and current best practice requirements.
In ED, you will assess and treat patients and families from all walks of life.
It is important to treat these patients with:
Respect,
Privacy and
Dignity
It is also worth bearing in mind that medico–legal cases frequently arise where
patients have suffered trauma or complications from medical and surgical
treatment, and that your record-keeping might therefore be scrutinized in the
future.
22. RECORD KEEPING
Method of keeping medical records
Electronically or ‘on line’
With the advent of information technology, computerized information systems are
being increasingly used to record, store and evaluate information pertaining to clients.
These are proving very useful in terms of easier and speedier access to information both
within and across care env’ts, for example dep’t to dep’t, hospital & community.
In many units, the patient’s charts, pathology results, X-rays and prescription charts are
now kept electronically or ‘on line’.
Whatever method is used in your area, however, it is important that you familiarize
yourself with the systems and ensure that you do not breach client confidentiality.
23. What to record
Daily examination & progress notes.
the condition of the patient and the treatment given.
Interventions & procedures.
Complications of procedures, which must be recorded accurately &
honestly.
The content and outcome of discussion with the patient’s relatives, so
that other staff do not give conflicting advice or opinions.
each interaction b/n the nurse & the patient and/or significant others
Complications do occur, and providing you have followed correct procedures, they do not imply
negligence. (Failure to record them or act appropriately upon them does!)
24. What to record
Results of important investigations.
The patient’s chart is often used to record:
blood gases,
biochemistry,
hematology and
microbiology results.
Important positive and negative findings,
those which carry either diagnostic or prognostic significance, or
which directly affect management, should be transcribed
This is a legal document and therefore the results do not need to be routinely copied
into the medical notes.
25. Any change in a patient’s condition
should be documented clearly and a
senior member of nursing and medical
staff notified if the patient is
deteriorating, unsafe or there is a
significant change in their condition.
26. Documentation requirements
Client records should be:
factual, consistent & accurate
clear, legible & readable following photocopying
accurate, clear and succinct.
easily accessible
able to be understood
written as soon as possible after the event and, if possible, with the involvement of the client
written in a manner that cannot be erased
timed, dated & signed with name printed by the side & indicating your role,
e.g. PA Hilton (PA Hilton, Staff Nurse)
devoid of abbreviations, jargon or meaningless phrases such as ‘Bed bath given’
written in a language understandable by the client
27. Documentation requirements
Client records should:
not contain any subjective, offensive statements or irrelevant
speculation
identify client problems and steps taken to rectify them
provide evidence of the care that has been planned and
delivered
include information that has been shared with others
include evidence of evaluation of the efficacy of care delivery.
28. Purpose of Patients Chart
Continuity of care
For diagnosis or treatment of a patient while in the hospital (find after discharge) if patient returns
for treatment in the future time.
Legislative purpose
For maintaining accurate data on matters demanded by courts.
Research purpose
For providing material for research
Education purpose
For serving an information in the education of health personnel (medical students, interns, nurses,
dieticians, etc.)
Vital statistics
Promoting public health action
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29. General Rules for Charting
Spelling
Make certain you spell correctly
Accuracy
Records must be correct all ways, be honest
Completeness
No omission, avoid unnecessary words or statement
Exactness
Do not use a word you are not sure of
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30. General Rules …
Objective information
Record what you see avoid saying (condition better)
Legibility
Print/write plainly and distinctively as possible
Neatness
No wrinkles, proper speaking of items
Place all abbreviation, and at end of statement
Composition/arrangement
31. General Rules …
Chart carefully consult if in doubt avoid using of chemical formulas
Sentences need to be complete and clear, avoid repetition
Don’t overwrite
Don’t leave empty spaces in between
Time of charting
Specific time and date
Colour of ink
Black or blue (red for transfusion, days of surgery, body temperature)
It should be recorded on the graphic sheet
All orders should be written and signed.
Verbal or telephone orders should be taken only in emergency verbal orders & should be written in the
order sheet and signed on the next visit.
32. Orders of Assembling Patients Chart
It may vary from one hospital to others
A. Vital sign sheet (graphics)
B. Order sheet
C. Physician’s progress notes
D. Nurses notes sheet
E. Intake and output recording sheet
F. Laboratory and other diagnostic reports
G. History sheet
H. Personal and social data
33. Good communication with and by staff leads to increased
shared information and clear advice.
34. RECORD …
The frequency of entries
is generally determined by local policies
should be complemented by sound professional judgement.
Occasionally, because of the pressure of work in the ICU, it may not be possible to make full
notes at the time, for example when admitting and resuscitating a very unstable patient.
It is crucial, however, that
notes are written at the earliest opportunity, and the fact that they have
been written retrospectively should be recorded.
All entries in the medical records must include date, time, name
(printed) designation (i.e. ICU resident/specialist registrar/nurse)
and signature.
35. MEDICAL RECORDS
The nature of intensive care
Occasionally, because of the pressure of work in the ICU, it may
not be possible to make full notes at the time, for example when
admitting and resuscitating a very unstable patient.
many different individuals are involved in the care of the
patient.
At the same time, the patient’s condition may change rapidly,
requiring frequent changes in therapy.
If everyone is to keep up with the patient’s progress, accurate,
contemporaneous note-keeping is essential.
36. MEDICAL RECORDS
recording the content & outcome of discussion with the
patient’s relatives, prevent other staff do not give
conflicting advice or opinions.
recording in the medical notes what has been said to the
family ensures continuity and prevents
misunderstandings.
leads to increased shared information and clear advice.
37. CONFIDENTIALITY
The patient’s medical condition and treatment are matters of confidentiality.
While it is generally accepted in intensive care that relatives should be kept
informed of what is going on, you must respect the patient’s wishes and
confidentiality at all times.
Therefore:
Make sure you know to whom you are talking before giving out any information.
Avoid discussing a patient’s condition on the telephone.
You do not know who is on the other end of the line.
The press have been known to telephone and not admit who they are.
If a relative lives too far away to make it to the hospital, offer to telephone
them back on a previously agreed number.
38. RECORD …
To fully aware of clients’ rights, familiarizing oneself with
documents is worthwhile.
to access clients’ records for research purposes, written
approval must be obtained from local research ethics
committee.
The use of client records to supplement summative
assignments or other course work
is considered a direct breach of client confidentiality and
should be avoided
39. CONFIDENTIALITY
Occasionally patients may request that information is not given to one or more
of their relatives.
This should be respected.
If difficulties ensue, discuss with senior staff.
Never make any comment to journalists.
Refer them to your hospital press liaison officer or your consultant.
Occasionally the police may request information about a patient or request a
blood test.
Remember that your first duty is to the patient, no matter what he or she is
alleged to have done.
If in doubt, refer them to your consultant.
40. TALKING TO RELATIVES
Discussions with relatives should generally take place in a quiet room away
from the patient’s bedside, unless the patient is awake enough to take an
active part in such communications.
Do not talk ‘ over ’ the patient, who may be aware of the surroundings and
able to hear, but unable to communicate back. (Hearing is said to be the last
sensory modality to be lost with sedative drugs.)
Do not talk standing in the corridor; use a side room away from other families.
Avoid talking to very large groups of relatives.
Speak to key members of the family and encourage them to explain things
to other relatives.
41. TALKING TO RELATIVES
Adjust the explanation of events to the level of
understanding of the relatives, and avoid medical jargon and
abbreviations.
Be honest and not overly optimistic about the ability of
intensive care to turn around desperate situations.
There are inherent uncertainties about the outcome of any
particular disease, and
it is best to be cautious rather than attempting to quote
probabilities of survival.
42. TALKING TO RELATIVES
It is often useful to explain that intensive care offers a level of support that ‘ buys time
’ for the patient’s body to recover, but may do little to ‘ cure ’ the patient.
Rather, recovery depends largely on the physiological and immunological reserve of the
patient.
Do not criticize other medical or nursing colleagues ’ management of the patient.
Remember that hindsight is a wonderful thing.
Difficult questions or decisions should be referred to senior colleagues or the referring
teams.
Do not let family members push you into making statements that are not true.
This is particularly important concerning prognosis.
Don’t agree with statements like ‘ He is going to be all right isn’t he, Doctor ’ if it is
not true.
43. TALKING TO RELATIVES
Record in the medical notes what has been said to the family.
This ensures continuity and prevents misunderstandings.
Accept that relatives will not always absorb bad news the first
time they hear it.
Time and repeated explanations may be required.
Bear in mind that relatives may also be selective about which
particular items of your information they choose to retain.
Complex psychological issues come into play here, and it is
important not to be judgmental.
Remember also that different cultural groups respond in
different ways to bad news.
44. Patients or relatives and friends of
patients are not allowed to read
the chart, when necessary but can
have access if allowed by patient
47. REFERENCES
Nursing and Midwifery Council (NMC) 2002 Guidelines for records and record
keeping. NMC, London.
Hoban V 2003 How to ... handle a handover. Nursing Times 99(9):54–55.
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Editor's Notes
The hospital or care home, the NMC, a court of law or the Health Service Commissioner may investigate the complaint, so it makes sense to get the records right.
Young people can sign the consent form once they reach the age of 16 years and/or have the mental capacity to understand fully all that is involved. If the young person cannot sign the form, the parent or legal guardian may sign it. If an adult lacks the mental capacity, either temporarily or permanently, to give or deny consent, no person has the right to give approval for a course of action. However, treatment may be given if it is considered to be in the person’s best interests, as long as an explicit (clear) refusal to such action has not been made by the person in advance.
The patient or parent and the healthcare practitioner both sign the consent form.
When your patients are due to have any invasive procedure, always check their level of understanding before it is scheduled to happen. If you are not sure about answering a question, ask the healthcare practitioner who is doing the procedure to see the patient and explain again. It is essential that the consent form is signed before the patient is given a sedative or other premedication drugs.
The hospital or care home, the NMC, a court of law or the Health Service Commissioner may investigate the complaint, so it makes sense to get the records right.
The hospital or care home, the NMC, a court of law or the Health Service Commissioner may investigate the complaint, so it makes sense to get the records right.
Documentation of each interaction b/n the nurse and the patient and/or significant others is another area of accountability in practice.
These standards do not just apply to care plans but are equally valid when recording observations and assessments on the multiplicity of charts that abound today.
There is Act and policies that gives clients access to their health care records, whether held manually or on computer.