Good Documentation Practice. Caroline Connelly Practice Development Facilitator Nursing Homes Ireland

Transcription

1 Good Documentation Practice Caroline Connelly Practice Development Facilitator Nursing Homes Ireland

2 Introduction Why do we Document? What do we Document? When do we Document? Where do we Document? How do we Document? Who Documents?

3 Why Do We Keep Records The Primary purpose of record keeping is to facilitate resident care and the sharing of information To ensure that those coming after you can see what has been or not been done, and why and by whom (NMC 2002).

4 Why do we keep Records Each Nurse should establish and maintain accurate, clear and current client records within a legal, ethical and professional framework. (An Bord Altranais Recording Clinical Practice Guidelines, November 2002 ) Nurses are professionally and legally accountable for the standard of their professional practice and this includes record keeping (Scope of Nursing and Midwifery Practice framework, April 2000)

5 Record Keeping The quality of records maintained by nurses and midwives is a reflection of the quality of the care provided by them to their residents. Good Practice in Record keeping is an integral part of nursing care (An Bord Altranais Recording Clinical Practice 2002) Good record keeping protects the interests of the patients by promoting, high standards of care, continuity of care and communication between members of the multidisciplinary team. ( A guide to good clinical record keeping, Midland Health Board, 2004 )

6 What are clinical Records Paper records, including books, files, letters, loose papers, continuation sheets, diaries, post it notes and computer print outs Electromagnetic records including discs, servers and databases. Audio-visual records including films, tapes, video s, CD s, Photographs, maps, plans, X- ray and microfilm.

7 Common deficiencies in clinical records Failure to sign date and time enteries Failure to document care or advice given Failure to document special needs Failure in communication between health professionals Use of jargon, derogatory remarks Using pencil Not in chronological order Late entries, timing of entries Abbreviations from an unapproved list

8 Common deficiencies in clinical records Absence of Clarity e.g. had a good day, sleep well Failure to record action taken when a problem identified e.g. c/o pain then no record of action Missing information Spelling mistakes, name spelt wrong so could lead to wrong treatment given Inaccurate records e.g. recording treatment not given Failure to document conversations/telephone conversations

9 Common deficiencies in clinical records Altering your original entry Altering entries of others Documenting for somebody else Lack of records Lack of date or wrong date Tipp-ex, destruction, deletion Residents details not on all pages Documenting Early 35-40% of medical negligence claims are indefensible due to documentation issues (La Touch 2007)

10 Effective Resident records should be Factual, consistent and accurate Written as soon as possible after an event has occurred Written clearly, dated timed and signed Any alterations, additions are dated timed and signed in such a way as to ensure the original entry can still be read. Errors have a line through date, time and signature Do not include jargon, meaningless phases, irrelevant speculation and offensive statements.

11 Effective Resident records should be Be written wherever possible with the resident or his/her representative Be individual and person centred Be readable on photocopies Only use abbreviations from the approved list and not to be used in transfer or discharge letters Identify problems that have arisen and action taken Provide clear evidence of the care planned, decisions made, the care delivered and information shared Maintain a register of sample signatures

12 Effective Resident records should be Consultation with or referral to another member of the healthcare team should be clearly identify by name and profession in the record A single record per resident is recommended as best practice for continuity and person centred care, and the practice of maintaining a number of files is not recommended. Regular Audit is an integral part of maintaining quality records.

13 Guidelines for good practice in using NHI resident record Use Black Pen Complete the Signature sheet using the name you are registered with An Bord Altranais with prior to documenting in the record. Fill in all sections of the integrated resident record. Document if a section is not applicable. Name, Date of Birth, Next of Kin and contact details. Presenting history, a set of observations, any know allergies, pressure sore risk assessment, falls risk assessment and nutritional screening must be completed on admission.

14 Guidelines for good practice in using NHI resident record The Nursing assessments must be completed within 7days and a plan of care commenced within 48hrs Write in block capitals for patient s name, next of kin and contact telephone numbers. Write legibly Use the 24hr clock, date and sign each entry Make all entries as soon as possible after the event and are in chronological order. Be accurate, concise and factual.

15 Guidelines for good practice in using NHI resident record Abbreviations only from the approved list and must not be used on transfer or discharge letters. Alterations and errors must be dated and signed with a single line through the error. When a student nurse documents ensure that it is countersigned by a Registered Nurse. (NHI Guidelines 2008)

16 Conclusion Why do we Document? What do we Document? When do we Document? Where do we Document? How do we Document? Who Documents?

17 Good Documentation Practice Questions?