Quality of documentation of nursing file
- 1. Documentation task By: Hany Salah Hussein Assistant lecturer Nursing administration department
- 2. Types of Communication 2 Verbal Communication Non Verbal Communication
- 4. Written Communication • Letters, policy manuals, reports, E-mail, and other documents used to share information in an organization
- 5. Uses of Nursing Documentation • Communication within the Health Care Team • Legal • Research • Quality and performance improvement
- 6. Nursing Documentation Principles • Accurate, valid, concise and complete. • Authenticated; that is, the information is truthful, the author is identified, and nothing has been added or inserted. • Dated and time-stamped . • Legible/readable; and • Made using standardized terminology.
- 7. Managerial documents • Plans • Policy and procedures • Assessment formats • Reports and records
- 8. Incident report • is an electronic or paper form that is filled out in order to record details of an unusual event that occurs at the facility, such as an injury to a patient.
- 9. purpose of the incident report • is to document the exact details of the occurrence while they are fresh in the minds of those who witnessed the event. This information may be useful in the future when dealing with liability issues stemming from the incident
- 10. What is Included in an Incident Report? • The name of the person(s) affected and the names of any witnesses to an incident • Where and when the incident occurred • The events surrounding the incident
- 11. • Whether an injury occurred as a direct result of the incident • The response and corrective measures that were taken • It should be signed and dated prior to handing it in to the appropriate person, such as a supervisor
- 12. What Situations Should be Reported? • Injuries – physical such as falls and needle sticks, or mental such as verbal abuse • Errors in patient care and medication errors • Patient complaints, any episodes of aggression
- 13. • Faulty equipment or product failure (such as running out of oxygen) • Any incident in which patient or staff safety is compromised
- 14. Incident report guidelines • Use objective language • Write what was witnessed and avoid assigning blame; write only what you witnessed and do not make assumptions about what occurred • Have the affected person or witnesses tell you what happened and use direct quotations • Ensure that the person who witnessed the event writes the report • Report in a timely manner
- 15. Type of incidence • events related to prescribed medications and/or treatments ▫ Examples: adverse reactions, equipment failure or misuse, medication errors • Bodily injury ▫ Examples: assaults, burns, falls, needle sticks
- 16. • Patient-related occurrences ▫ Examples: complaints, treatment refusal • Near misses ▫ Example: potential for an error existed but was corrected before it occurred
- 17. Preventive benefits of incident reports: • Identify and correct system failure • Prevent recurrence of events • Create a database for risk management and quality improvement. • make the patient care environment safer • Reference an unbiased record of the event to get immediate medical advice and legal counsel.
- 18. • examples of situations in which an incident report should be filed:
- 19. (1) • You’re working as a nurse on an acute inpatient psych unit when one of the patients begins to act violently and attacks a staff member or another patient.
- 20. (2) • You’re ambulating a patient in the hallway and securely holding onto their gait belt when the patient abruptly falls to their knees before you had a chance to react.
- 21. (3) • You’re interviewing a clinic patient who passes out and falls from the examination table onto the floor without warning. Upon awakening, the patient appears to be fine but passes out again a few minutes later. Emergency medical services are called to respond.
- 22. Shift report • shift report is a meeting between healthcare providers at the change of shift in which vital information about and responsibility for the patient is provided from the off-going provider to the on-coming provider
- 23. purpose of shift report • The purpose is not to cover all details recorded in the patient's medical record, but to summarize individual patient progress.
- 24. How to write Shift Report • Document department 'name • Document Head nurse name of the shift • Document Date of shift report • Document Number of beds
- 25. • Patient’s name, age, doctor, past medical history, allergies • Patient’s reason for admission date of admission, days post operation • Present restrictions: i.e. Do Not Resuscitate, Nothing per Mouth, Free Fluids, Non Weight Bearing, Diabetic Diet
- 26. • Progress :Report must be progressive: Must contain what needs to happen in the next shift • list changes in the patient’s condition, which give cause for concern: • Important medication changes or therapies • Document Actual and Potential Safety Risks To Patients • Risks to patients • Restraining • Infection control / isolation
- 27. • Changes in treatment e.g. drug discontinuation • Physical change e.g. patient with first degree bedsore • Unfilled orders that need to be continued to the next shift • Abnormal occurrences during shift • Document all medical and nursing interventions during the shift • Document patient transfers, discharge, Progress and deaths
- 28. Thank you