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Sc Epidemiologist and Public Health Specialist Khyber Teaching Hospital, Peshawar
Documentation is the process of communicating in written form about essential facts for the maintenance of continous history of events over a period of time Record is the permanent written communication that documents information relevent to the patient health care management .
Reporting is communication of information to another individual . Reports are oral or written exchange of information shared between nurses or a number of persons.
and written papers. rounds. client studies. clinics. “ The Nurse has a duty to maintain confidenmtiality of all patient information” (ANA Code of Ethics 2001) The record are used in client conferences. However names or identity of the patients should not be disclosed .
Communication Record serves as vehicle by which different health professionals who interact with a patient communicate with each other Planning Patient Care Each health professional uses data from patient records to plan health care for that patient Auditing Health Agencies Review for Quality Assurance Process .
effective treatment. The treatment plans for a number of patients with same health problems can yield information helpful in treating other patients Education A record can frequently provide comprehensive view of patient illness. strategies and factors that affect outcome of the illness . Research Information in a record can be valuable source of data for research.
Reimbursement Records are required for reimbursement of money to pateint depending on his illness and treatment Legal Documentation Required in Court of Law or for medicolegal purposes Health Care Analysis Assessment of health care needs by health planners .
Date and Time Exact Date and Time should be recorded when notes are being written Timing No recording should be done before providing nursing care Legibility Must be easily read to prevent errors Permanence Must be written in permanent ink with no cutting .
It should include Name and title. Staff Nurse . Correct Spelling Correct spellings are essential as incorrect spellings gives a very bad impression and decreases Nurses credibility Signature Each record must be signed by nurse writing it. for example Noreen RN.
Accuracy Patient name and identifying information should be stamped or written on each page of patient clinical records. Do not identify be Bed No’s etc Write factual information eg ‘patient refused medication (fact) than to write that patient was uncooperative . Before making any entry ensure that it is the correct record.
For example write “ 3 cm bruise noted on right anterolateral thigh rather than writing a small bruise noted on thigh When recording a mistake.When describing something. Do not erase or use correction fluid Write on every line but never between the lines . avoid general words. good or normal. draw a line through it and write the words mistaken entry above or next to original entry. such as large. with your initials or name.
Don’t record irrelevant information. then nursing interventions. Sequence Document events in the order in which they occur. . and then patient responses. Appropriateness Record only information that pertains to the client health problems and care. such as record assessments.
Completeness Not all data that a nurse obtains from patient can be recorded. However information that is recorded needs to be complete and helpful to health care professionals .
Admission Notes Change of Shift Notes Assessment Notes Progress Notes Transfer and Discharge Notes Client Teaching Notes Symptoms or Complaints .
Focus Charting SOAP SOAPIER A(D)PIE Narrative Charting .
assessment of client status. such as return from surgery InFocus Charting. Action and Response . interventions carried out and impact of interventions on patient outcomes are organized under the headings of Data. With this method of documentation the nurse identifies a “focus” based on the patient concerns or behaviors determined during the assessment. For example a focus could reflect Current patient concern or behavior such as decreased urinary output A significant event in the patient treatment.
. Any any given time any thing from D.Sequencing in DEAR is not important. R can be entered.A. E.
Problem oriented Documentation S= Subjective (What patient described) O= Objective (What nurses find on examination) A= Assessment P= Plan (How to address the problem in terms of management) I= Intervention (What the Nurses actually do to address the problem) E= Evaluation (What was the outcome following the intervention) R= Revision (What changes are needed to the health care plan) .
Nursing Diagnosis Expected Patient and Supporting Outcomes Data Assessment and Diagnosis Subjective Objective Planning Nursing Interventions Evaluation Interventions Nursing Diagnosis .
often without an organizing framework. Narrative charting may stand alone or it may be complemented by other tools.Narrative Charting is a method in which Nursing interventions and the impact of these interventions on client outcomes are recorded in chronological order covering a specific time frame. such as flow sheets and checklists . Data is recorded in the progress notes.
Managers spend much time making decisions and solving problems. The process of selecting one action from alternatives Decision making is the learned & scientific problem solving process. especially non routine situations 23 .
- - 1) Identify the problem: defining the problem. 24 . What is wrong? Where is improvement needed? begins when the nurse manager perceives a gap between what is actually happening and what should be happening. The nurse manager can identify the problem by analyzing situation.
What is the desirable situation? What are the presenting symptoms? What are the discrepancies? Who is involved? When? Where ? How? * Develop Feasible hypotheses. . and elimination of hypotheses that fail to conform to the facts. manager should begin exploring possible solutions - 25 .By analyzing available information.Feasible hypotheses should be further tested for causal validity. .
and brainstorming with staff. 26 . review of the literature. professional meetings.This can be done through continuing education.2) Explore alternatives: . .If situation is not covered by policy.Health care is changing rapidly manager should learn how others are solving similar problems. but it may be inadequate. . .more experienced manager had more alternatives to be suggested for solving a variety of problems. manager must draw on his education and experience.
public acceptance. .Dose it maximize effectiveness and efficiency? use available resources before seeking outside assistance. morale.Can the decision be implemented? If not.Manager must try to balance multiple factors such as pt safety. . cost. staff acceptance.Will this decision accomplish the stated objectives? (yes or no) .One alternative is not always clearly superior to all others. and risk of failure. * The following questions may be asked: . it will not solve the problem 27 .3) Choose most desirable alternative: .
28 .Be alert: solutions to old problems sometimes create new problems.4) Implement decision: .The manager will need to communicate the decision to appropriate staff smoothly to win the cooperation 5) Evaluate results: .Evaluate the results of the chosen alternative. . so you need additional decisions.