Facts at your fingertips: Review important practice guidelines and the roles and responsibilities nurses play in specific procedures.
The health record includes documentation of care by all disciplines.
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).
Documenting in the health record demonstrates accountability. Nurses are accountable or responsible for the care they give. Since records are considered to demonstrate the nurseís 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.
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
Documenting Care is an Integral Part of Giving Care.
Nursing Documentation should include evidence of the following:
- Assessing the patientís 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.
Documenting Practices are Consistent
Current and accessible policies are needed to facilitate consistent documentation. Following your establishmentís 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 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 patientís 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.
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 clientís 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.
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.
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.
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.