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Recommended Guidelines for Documentation in the Endoscopy Setting
Terminology
The health
record includes documentation of care by all disciplines.
Background
The
information contained in this document pertains to both Inpatient and
Outpatient settings. Each Endoscopy setting is different and to provide
information that is easily adaptable to each patient care environment these
guidelines include documentation for three components: Assessment, Procedure
and Post - Procedure. The intent is not to provide a specific documentation
form, but to provide information and criteria that can be selected in
formulating an individualized document that meets the requirements of the
institutional policy and to the Endoscopy setting. Policies for
documentation is a minimal expectation.
Purposes of Documentation
-
Communicating Client Health
Information.
The health record facilitates
communication by making information about the client available in a
permanent form to all health care providers. In order for all providers to
have access to the record, consideration also needs to be given to where
individual pieces and the total record itself are kept.
-
Providing
Continuity of Care.
The health
record facilitates continuity of care by enabling nursing staff and other
health-care providers to use current and consistent data, problem
statements, diagnosis, goals, and strategies. By reading and using
documented information, Nurses are able to be more systematic in providing
effective nursing care. The health record facilitates continuity of health
care providers to use (One such example of this is health teaching).
-
Demonstrating Accountability.
Documenting in
the health record demonstrates accountability. Nurses are accountable or
responsible for the care they give. Since records are considered to
demonstrate the nurse’s accountability, the record may be used to settle
concerns or questions about the care that was given. Nursing documentation
is normally readily admissible in legal proceedings. Facts documented at
the time an event occurred are generally regarded to be more credible than
an oral account of events from memory.
-
Providing
Quality Assurance
Documentation
is often an integral part of quality assurance mechanisms to evaluate the
quality of care. Whenever records are reviewed as part of quality
assurance, it is assumed that quality of care is reflected in the
documentation. Records as a quality assurance tool however may reflect
poor documentation rather than poor care. If so either the system or the
documentation requires improvement.
-
Facilitating Research
The health
record can be a valuable source of data for health research. From a
nursing perspective, the health record can be used to assess nursing
intervention, and evaluate patient outcomes, as well as identify care and
documentation issues. Accurate recorded information is essential to
providing accurate research data.
Principles of Documentation
1.
Documenting Care is an Integral
Part of Giving Care.
Nursing Documentation should include evidence of the
following:
-
Assessing the patient’s health status including identifying
problem/strength
statements or nursing diagnosis.
-
Developing a plan of care.
-
Implementing the plan.
-
Evaluating both the nursing strategies and patient outcomes.
It is
important for nurses to document their actions in carrying out both their
independent and interdependent roles. For example documenting social
interaction and health teaching is as important as documenting medication
administration.
The health
record is a vital communication link between health-care providers. For this
reason, it is important that relevant information exchanged between
professionals is documented. For example when a nurse calls a Dr., he or she
what was reported to the physician and the physicians
response.
2.
Documenting Practices are
Consistent
Current and accessible
policies are needed to facilitate
consistent documentation. Following your establishment’s policies is a
minimal expectation in documenting care given. Nurses must ensure that they
understand any existing policies and advocate improvements in them.
Governing
Agencies such as the College of Nurses of Ontario suggests that nursing
records contain at least:
- The name
and address of the client, the location in which
care was given, the
date and time of the interaction and the
time of recording.
- The
subjective and objective data obtained on assessment
and the nursing
diagnosis or clinical judgment made.
- The
care plan.
-
Outcomes, results, and observations of the care provided.
3.
The Forms Facilitate the
Documentation
Forms provide a framework to guide documentation.
In Endoscopy one of the
most common forms for documenting is the flow sheet. Flow sheets can be
helpful in documenting routine and frequently needed information accurately
and concisely. When documenting on the flow sheet it is advised that nurses
initial rather than tick space accountability for giving
that care. Space needs to be available so that each care provider can be
identified. Flow sheets are part of the permanent record and are legally
recognized, however the use of flow sheets does not eliminate the need for
other documentation. The patient’s acuity is the leading factor in how much
charting is done. Documentation is not to be a rambling narrative but an
accurate concise account of events.
4.
Records are written by the
person who saw the event or performed the action.
The HEALTH
DISCIPLINES ACT refers only to the requirement for RN's to document. Agency
policy will identify others who may or may not write on the client’s record.
The policy may require that RN's document observations and actions of other
care providers' such as health care aides or techs. In this case, ensure
that records are clear so that those reading the record will know saw the
occurrence or performed the action, and who did the documenting. In some
settings, it is the practice for the documentation to be done by anyone, not
necessarily the person who gave the care. This practice is not recommended.
Help colleagues, not by documenting for them, but by assisting earlier with
the care. Each RN then documents the care that he or she gave.
5.
The Closer to the Event the
Record is made, the Greater the Credibility.
Nursing standards
state that" the nurse documents and updates all information as soon as
possible without compromising client safety”. The longer the interval
between the event and the documentation the less credible the information
may be.
6.
Entries are in Chronological
Order.
Entries written
chronologically present a clear picture of events.
For example:
If on occasion entries must be
out of chronological order, document both the time of documentation and the
time the event occurred. An example of this is charting after the clinic is
done or after an unstable patient has been stabilized.
7.
Abbreviations are in General
Use and Uniform.
Abbreviations must be consistent so that they mean the same thing to all
persons reading the record. For instance while many of us may assume that a
flex may mean a flexible sigmoidoscopy, a law professional could see this as
poor documentation" poor notes discredit". Consistent abbreviations mean
consistent care. Abbreviations should be kept to a minimum and a list of
acceptable abbreviations be developed.
8.
The date, time, signature, and
designation are included for every entry.
9.
Records are accurate, true,
complete, clear, concise, legible and in ink.
10.
Documentation is confidential
and can be retrieved.
Documentation
Assessment Phase
A patient
assessment is performed and documented by the registered nurse. The
assessment factors should include physical, psychosocial, current
medications, treatment, and previous medical/ surgical, and drug history.
Review of the patient's symptoms and history will supply any pertinent
information to be documented, i.e. pacemaker, COPD, hepatitis etc. all
documentation must include time of performance and name of person performing
assessment or intervention. The frequency of assessment is
determined by
institutional/departmental policy, the physician or the Registered Nurse.
Minimal documentation requirements are as follows:
-
Patient's name, birth date age
and hospital number
-
Time of arrival.
-
Time of assessment.
-
Patient stated reason for
procedure, procedure and name of physician to perform procedure.
-
Patient/family
teaching-including discharge criteria.
-
Signed informed consent.
-
Baseline vital signs
(Temperature, Pulse, Respiratory status, Blood pressure, and Oxygen
saturation prior to procedure)
-
Warmth, dryness and colour of
skin.
-
NPO status.
-
Bowel prep compliance (if
applicable)
-
Current medications and time
of last dose- including ASA, anticoagulants, nonsteroidals, sleeping
pills, tranquilizers.
-
Allergies to foods or
medications.
-
Presence of prosthetic
devices
-
Physical disabilities.
-
Intravenous line, type, site,
inserted by, rate, or presence of saline or heparin lock.
-
Lab results (if applicable)
-
Pre-procedure pain.
-
Patient concerns.
-
Emotional status
-
Admitting nurse's signature.
Procedure
Phase
-
Minimal monitoring includes,
BP, Heart rate and rhythm, respiratory rate and effort, level of
consciousness, warmth and dryness of skin, and level of comfort.
-
Procedure performed.
-
Physician, nurse and support
staff involved in the procedure.
-
Name, dosage of all drugs
agents used including Oxygen (time, route of administration and by whom)
and patients response.
-
Type and amount of all fluids
administered.
-
Equipment.
- Scope
including serial #
-
Dilators, make and size, colour
-
Ligation bands.
- Cautery
including # of machine setting of cut and coagulation, pad placement,
skin condition pre and post procedure.
-
Unusual events, interventions
and outcomes.
-
Patient status at end of
procedure.
-
Specimens obtained and
disposition.
-
Post procedure diagnosis.
-
Signature of procedure nurse.
Post-Procedure Phase
-
Time of arrival in
post-procedure area
-
Vital signs (TPR, BP,
Oxygenation), level of comfort, colour, warmth and dryness of skin.
-
Name dosage of all drugs,
agents used including oxygen and patient response (time, route
of administration and by whom)
-
IV fluids administered or
discontinued including blood and blood products.
-
Unusual events, intervention
and outcomes.
-
Abdominal
assessment/pulmonary assessment.
-
Mode of transportation for
discharge.
-
Person responsible for
patient at discharge i.e. (wife, son, significant other)
-
Discharge instructions given
to outpatient and/or patients family and comprehension of instructions-
signed by person responsible for patient.
-
Discharge criteria applied.
-
Time of discharge.
-
Signature of discharge nurses
and designation.
Disclaimer
This outline is based on
current understanding and practice in the field. Each Gastrointestinal/
Endoscopy Unit is responsible for establishing its own documentation
procedures and for creating its own forms, allowing for the differences in
operation of each Unit.
The CSGNA
assumes no responsibility for the practices or recommendations of any member
or practitioner, or for the policies and practices of any Endoscopy Unit.
Bibliography
Accreditation Manual for
Hospitals, 1995.
Canadian
Nurses Association: Code of Ethics for Nursing. 1992.
Nurses
Association of New Brunswick. Charting: A Professional Responsibility, 1995.
Registered
Nurses Association of British Columbia. Nurse to Nurse: Information for
Nurses. 1992.
Rozovsky and
Rozovsky. The Canadian Law of Patient Records. 1984.
SGNA monograph
of documentation in the Gastrointestinal setting.
The College of
Nurses of Ontario. Nursing Documentation, 1995.
The Canadian Nurses Protective
Society. Info Law Vol 1-3, 1995.
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