Documentation

Question 1

Communication in documentation

Answer 1

• Enables others to assume care of patient
• Documentation provides patients status, nurses actions and patients outcomes
• Should show patients preferences, understanding of situation, plans and involvement of family

Question 2

Purpose of Documentation

Answer 2

• Accountability- records nurses practices
• Professional responsibility; provides evidence of care
• Legislative requirements
• Quality; evaluates practice for audits and accreditation
• Research; data for evidence based practice and care outcomes
• Resource management; activity based funding and resource management evidence

Question 3

Nursing Documentation is…and includes

Answer 3

Record of direct knowledge, observation, action, decisions and outcomes

Includes progress notes and other charts (SAGO, FBC, NIMC)

Question 4

Health Care Records Documentation must provide:

Answer 4

• Accurate description of each patient
• Episodes of care and treatment
• Patients episodes of illness
• Contact with health care personnel

Question 5

Identification on every page

Answer 5

DOB
Sex
Family name and given name
Unique identifier (Medical Record Number)

Question 6

Type of content in documentation

Answer 6

• Patient’s condition

Objective→ General assessment by nurse

Subjective→ How patient states they feel

• Details of specific treatments
• Observations and fluid balance recorded; actions taken and outcomes
• Transfer to other ward (time, name of staff member who received handover in other ward)
• Clinical interventions and outcomes (E.g. medicine administration and effect of)
• Refusal of treatment to be documented

Question 7

Standards for documentation (what is required in writing)

Answer 7

• Clear and accurate, in dark ink, difficult to write over and erase
• Use approved abbreviations and symbols
• Time of entry and date (24hr time e.g. 2300 hrs) (ddmmyy, e.g. 230617)
• Signed by author (using printed name and role)

Question 8

Frequency of documentation

Answer 8

• Minimum of once per shift

- Documented as they occur→ diagnostic investigation results, changes to condition

Question 9

Progress notes

Answer 9

• Write objectively; avoid using ‘apparently’; use patient’s words in quotation marks (‘I am anxious about surgery’ rather than patient seems worried)
• Distinguish between what was observed or performed
• Made at time of event or as soon as possible after; time of writing must be distinguished from event reported
• Sequential; rule line after entry
• Only include personal info about others when necessary for care and treatment of patient

Question 10

Written in Error

Answer 10

• All errors must be appropriately corrected; no alteration can make records illegible
• An original incorrect entry must remain readable (just strike through and ‘written in error’ with signature)