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BY: Janna Kristine F. Yosores BSN 4L

One source of information that people

GUIDELINES FOR INFORMED CONSENT The person(s) giving consent must fully comprehend: 1.The procedure to be performed 2.The risks involved 3.Expected or desired outcomes 4.Expected complications or side effects that may occur as a result of treatment 5.Alternative available. Consent may be given by: 1.A competent adult 2.A legal guardian or individual holding durable power of attorney 3.An emancipated or married minor 4.Parent of a minor child 5.Court order. treatments that are

valid consent. A person who is an infant, is mentally incompetent, or is under the influence of drugs is incapable of giving consent. Consent must also be free of coercion or fraud.

seek to help them make decisions about their health care is their testaments or medical records.





consent of a patient or other recipient

thoughtful evidence



against miscommunication

of services based on the principles of autonomy and privacy; this has become the requirement at the center of morally valid decision making in health care and research.

and misunderstanding and may guard against a lengthy litigation process. WRITTEN CONSENT
in law, voluntary agreement with an

action proposed by another. Consent is an act of reason; the person giving consent must be of sufficient mental capacity and be in possession of all essential information in order to give

It is

obtained only after the patient

receives full disclosure of all pertinent information regarding the surgery or any procedure and only if the patient understands the potential benefits and risks of doing so.

Incident reports are records of unusual

pertaining to individual clients or groups of clients. A. GUIDELINES FOR GOOD


or unexpected incidents that occur in the course of a clients treatment. Incident reports are inadvertently






disclosed to the plaintiff are no longer considered confidential and can be subpoenaed in court. Thus, a copy of an I.R. should not be left on a chart. DOCUMENTATION Documentation is any written or

A document or chart must be

written in F-L-A-T to protect nurses to be repeated to the jury for several times. F: A document should be




documentation are

forms - focus charting, SOAP/SOAPIER narrative documentation described in the following sections. Any of these methods may be used to document on an inclusion or exception basis.

FACTUAL, what you see, not what you get.





electronically generated information about a client that describes the care or service provided to that client. Health records may be paper documents or electronic documents, such as electronic medical records, faxes, e-mails, audio or video tapes and images. decisions, Through actions and documentation, nurses communicate their observations, outcomes of these actions for clients. Documentation is an accurate account of what occurred and when it occurred. Nurses may document information

LEGIBLE, with no erasures. Corrections should be made as you have been taught. With a single line drawn through the error and initialled.

With this method of documentation, the nurse identifies a focus based on client concerns or behaviours determined during the assessment. For example, a focus could reflect: A current client concern or behaviour, such as decreased urinary output. A change in a clients condition or behavior, such as disorientation to time, place and person. A significant event in the clients treatment, such as return from surgery. In focus charting, the





ACCURATE and complete. What color was the drainage? How many times was the practitioner notified of changes.

T: A document should be TIMELY,

completed as soon after the occurrence as possible. Late entries should be avoided or kept minimum.






S = subjective data (e.g., how does the client feel?) O = objective data (e.g., results of the physical exam, relevant vital signs) A = assessment (e.g., what is the clients status?) P = plan (e.g., does the plan stay the same? is a change needed?) I = intervention (e.g., what occurred?

recorded in chronological order covering a specific time frame. Data is recorded in the progress notes, often without an organizing

interventions carried out and the impact of the interventions on client outcomes are organized under the headings of data, action and response. Data: Subjective and/or objective

framework. Narrative charting may stand alone or it may be complemented by other tools, such as flow sheets and checklists. C. LEGAL GUIDELINES IN

information that supports the stated focus or describes the client status at the time of a significant event or intervention. Action: Completed or planned nursing interventions based on the nurses assessment of the clients status. Response: Description of the impact of the interventions on client outcomes. 2. S O A P / S O A P I E ( R ) C H A RTING SOAP/SOAPIER charting is a problemoriented client follows approach to documentation then whereby the nurse identifies and lists problems; according documentation to the identified

DOCUMENTATION The following principles are intended to provide nurses and midwives with clear direction for producing and maintaining high quality, defensible documentation: 1. Document fact Fact is what the nurse saw, heard This is what and should be

what did the nurse do?) E = evaluation (e.g., what is the client outcome following the intervention?) R = revision (e.g., what changes are needed to the care plan?)

or did in relation to the patient's care and Similar to focus charting, flow sheets and checklists are frequently used as an adjunct to document routine and ongoing assessments and observations. 3. N A R R A T I V E C H A R T I N G - Narrative charting is a method in which nursing interventions and the impact of these interventions on client outcomes are condition. should documented. Nurses avoid midwives of this

non-committal extension

documentation. An

principle is that nurses should write health care records objectively. Irrespective of where the nurse or midwife is recording information, that is the nursing notes, incident forms or statements,

problems. headings:

Documentation is generally

organized according to the following

documentation emotive. 2.




the author's signature, printed name and designation. This clearly indicates when the record was made and by whom and ensures more reliable documentation. Nurses and midwives should never predate or pre-time any entry on a patient's chart. If an observation is made or a medication is given at a certain time, that time should be recorded on the chart. 4.Maintain documentation This principle refers to the requirement to preserve all that is recorded in a patient's record, even if an error is made. Nurses and midwives should not attempt to change or delete errors made in the patient's notes. An attempt to change or delete an entry could be interpreted as an attempt to cover up events or mislead others. The error should be left so that it is legible, with a single line through it, and the integrity of

factual and objective and not subjective or





information This will of be the dictated by



circumstances of each patient. Nurses' and midwives' documentation should be made with respect to the total condition of the patient, not just a clinical specialty. In particular, nurses and midwives should document any change in the condition of the patient and who was notified of such a change. Nurses and midwives should also document whether the patient's condition has remained unchanged during their shift, as responsibility for the patient is handed over with each change of shift. 3. Document contemporaneously





initialled. The correct entry should then be recorded on the next line or column. Documentation should not include breaks between fact. entries; this ensures that information cannot be added after the

record entries in the patient's notes as soon as possible after the events to which reference is being made have occurred, with the date and time for each entry recorded. All entries should also include