The document discusses the importance of documentation in nursing. It outlines reasons for documentation such as continuity of care, communication between healthcare professionals, and detecting early changes in a patient's condition. It also discusses barriers to documentation and legal requirements regarding patient access to their medical records. Proper documentation is important for protecting patient welfare and for potential use as evidence in legal cases.

1. Documentation If it isn’t documented, it didn’t happen Sohail Sangi

2. What is Documentation Review Legal Aspects of Documentation Outline the aims of nursing documentation Discuss the barriers Consider access to records Group work & Feedback Evidential or reference documents: documents provided or collected together as evidence or as reference material. P rocess of providing written information: the process of providing written details or information about something Confirmation that some fact or statement is true through the use of documentary evidence

3. Technology Patient Focus and Public Involvement (2001) Complaints Clinical Governance Used as Evidence in court Underpinned by NMC Standards Information technologies have now matured enough to allow us to create sound and video recordings, and integrate them with text and other explanatory or analytical material.

4. Documentation involves… Fieldwork, going to a place (often a remote location) live and working and living together with them there. To undertake fieldwork the researchers must be properly trained in the techniques of recording (sound and video), transcribing, analysing. Good record keeping helps to protect the welfare of patients and clients by promoting; High standards of clinical care Continuity of Care Better communication between the inter-professional health care team Accurate account of treatment and care planning and delivery The ability to detect problems, such as changes in the patient’s or client’s condition at an early stage

5. Methods Documentation project should aim to collect/create audio, video, graphic and text documentation material covering use of language in a variety of social and cultural contexts. The priorities for collecting, recording, analysing, and archiving are: to create a range of high quality materials to support description of a variety of language phenomena to enable the recovery of knowledge of the language even if all other sources are lost to generate resources in support of language maintenance and/or learning

6. Recording equipment and storage Introduction – pain can be a big problem, make sure this is addressed, introduce yourself as a nurse and document your status. History – Great value in being definitive, what’s in your notes matters (avoid words such as maybe). Examination – if you put query, generally you have to review the patient, avoid word such as slight and big, if pain is a problem during examination document this.

7. Archiving Investigations – You must write all the negatives especially when using guidelines Diagnosis – Tell the patient what you think is wrong and explain the process of reviewing x-rays. Treatment - Be relative, explain that there are different treatments. Create documentation materials suitable for archiving and deposit them Do not need to archive everything you produced during the project. for example, raw notes, unedited video or audio, or large numbers of similar photographs need not be deposited. Archiving is for the benefit of the general people, community & other researchers or interested people in the future. It involves preparing materials so that they are as informative and explicit as possible, ensure long-term accessibility, and then storing them safely

8. Identify an institution Identify an institution such as a library, archive, educational institution, or community centre that is accessible to the interested people, Make arrangements for materials to be deposited with that institution. The extent to which the materials can be searched and navigated depends largely on how you prepare the data and metadata. Preparing materials involves much more than handing over data files. Disposal – Safety first, involve relatives, get patient to carry the risk, educate re dangers of hospital and the benefits of home. Care for relatives. Follow up – If you are concerned arrange follow up, document what instructions you have given to the patient, get them to tell you what they understand. Always get self discharges witnessed.

9. Archiving and dissemination Time Education Attitude – recognising the value Dissemination of digital materials, typically via the World Wide Web, is an entirely different process from archiving. archived materials are typically more comprehensive than would normally be published on the WWW archives contain some materials that are not currently publishable due to sensitivities but may be important for future revitalisation of the language, or research of various kinds

10. Access to Records Data Protection Act 1998 – gives patients and clients access to their paper-based and computer-held records Freedom of Information Act 2000 introduced 2005 – grants rights of access to anyone, to all information that is not covered by the Data protection Act

11. Status of material Documentation should also include properly described records of the status (or restrictions, sensitivities etc) of materials. Typically, an archive will provide World Wide Web access to a catalogue of materials and, where appropriate, access to materials themselves. Restrictions and sensitivities expressed by the language community should be respected. An archive catalogue informs the public about the existence of materials, allowing them to be ‘discovered’ through internet searching. Catalogues may or may not provide direct access to the actual content of the materials. Archive policies differ but some materials will be made available to various users, subject to the conditions/restrictions attached to materials or parts of materials, and depending on the type of user.

12. WHAT IS DOCUMENTATION ? “ Documentation” is what’s written on paper. You need documentation because courts, lawyers, social service agencies, and a lot of other people make decisions by looking at what’s written on paper. Documentation helps you to convince these people that what you are saying is true so they are more likely to make decisions that help you. HOW DO I DOCUMENT WHAT HAPPENS TO ME? The main thing you can do to document the things that happen to you is to save papers. Save court papers, notices, letters, receipts, notes, and anything else you receive that is important and written on paper. You can also make notes of conversations and events. Always put the date of the conversation or event in your notes.

13. Another way to document things that have happened to you or things you have seen is to make a police report. Some people don’t call the police because they don’t think the police will do anything. But, sometimes a report just documents what happened, even if no charges are filed and no one is arrested. Remember to get and keep a copy of the report, too. If you believe that your child has been physically abused in some way, you should report what you know to Children’s Protective Services to help you prove later what happened. In the same way, if you have problems with visitation with your child, make a complaint to the Friend of the Court. Get and keep copies of the paperwork. HOW DO I DOCUMENT WHAT I TOLD SOMEONE? You can document what you say to someone by sending the person a letter. Always remember to put a date on the letter so you can show when you sent it, and always make and keep a photocopy of the letter so you can show what you sent.

14. There are two ways to prove that you mailed your letter. The first is to send the letter by certified mail with a return receipt requested. You get the certified mail receipt at post office when you mail the letter. Staple the certified mail receipt to your photocopy of the letter. You get a green card back after your letter is delivered. When it comes back, staple the green card to the copy of your letter, too. If you are sending a letter to someone you think will refuse to sign for certified mail, there is another way to prove you sent the letter. You can use a little white slip of paper called a “Certificate of Mailing.” The Post Office calls it “PS Form 3817.” A certificate of mailing is really a receipt showing that you mailed a letter to someone and the date you mailed it. It is not the same thing as certified mail (even though they sound like the same thing) because no one has to sign for it. You can fill out a certificate of mailing at any post office. Don’t forget to have the clerk stamp the date of it. Staple the certificate of mailing to the photocopy of your letter.

15. HOW DO I DOCUMENT A PAYMENT? You document that you paid someone money for rent or some other bill by getting a receipt and saving it. If the person you are paying won’t give you a receipt, make your own. How? Either pay by money order or by personal check. Never give cash to anyone if you are not sure you will get a receipt. You may not be able to prove what you paid. WHERE DO I PUT ALL THIS STUFF? The best place to save all of your documents is in a large, brown manila envelope. Put all of those important papers in that envelope, and keep them there. Then, put the envelope in a safe place. (By the way, it is also very important to keep documents like birth certificates, social security cards, vehicle titles, deeds, and immigration papers in a safe place.)

16. The safest place to put your documents would be in a safe deposit box at a bank. You can also keep your papers in any other place that is secure and under lock and key. A car might not be the best place, though, if the car is in danger of being stolen, repossessed or damaged in an accident. Some people like to give their papers to someone they can truly trust to hang onto them and not lose them. This is a very good idea if you are in a relationship where there is abuse or domestic violence and Making a duplicate copy of your really important papers and keeping them in two different places is also a good idea. Organize your papers by date, beginning with the paper with the earliest date and ending with the paper with the most recent date. All of this paper tells the story of important things that happened to you or you did. It is like a book, with a beginning and an end.