Documentation and Reporting

Documentation and Reporting 1. Recall the purpose of documentation in healthcare  Communication  Legal documentation  Funding and research management  Auditing and monitoring  Research and education 2. Apply knowledge and principles of accurate documentation to specific nursing care situations  Individualized  Confidential  Permanent and retrievable in accordance with legislation, laws, and policies.  The three C’s (complete, clear, comprehensive)  Chronological and timely  Objective (relevant facts only)  Legible (no abbreviations, deleting, whiteout) 3. Differentiate between accurate and inaccurate documentation accurate inaccurate - Accurate - Complete - Detailed - Bias free - Defensible - Easy to read - Factual - Grammatical - Failing to record relevant health/drug information - Failing to record drugs given - Recording on the wrong chart - Failing to discontinue medication - Failing to record negative reactions to medication or changes in condition - Transcribing orders incorrectly or using an improperly transcribed prescription 4. Compare and contrast written and electronic documentation Written Electronic - Separate record for each visit - Key information such as allergies and complication to treatment are sometimes misplaced - Note as safe - Writing can be hard to read - Data easily accessible - All visits will be linked - Allergies and complication easily viewed - Easy to read - Multiple specialties have access 5. Explain how nursing documentation is used within the legal process - Clear, concise, and accurate documentation is the best defence in a legal proceeding. It can take years for a lawsuit to get to court- will you remember specifics? Delayed documentation entries create negative inferences and question credibility.

Documentation serves as your evidence of the nursing care provided to clients. Accurate, complete and timely documentation of care is equally as important as the care provided to clients. Quality documentation is an essential aspect of care nurses provide and is a professional expectation 6. Discuss documentation practices for reducing your liability - What care/service was provided (the event). ACTION - To whom the care/service was provided (right client record) - By whom the care/service was provided (who was involved). M.HAMM PNL - When the care/service was provided (right time & date). YYYY MMM DD HHMM - Why the care/service was provided (motivating factors). - DATA - Result of consequences (damages, injury or death).- RESPONSE - Where care was provided (hospital, unit location) - How information was provided ( Dr. Hyde notified by telephone) - •Be Objective •Be Complete •Be Accurate •Avoid using abbreviations •Document all steps taken •Document chronologically •Never leave blank lines •Document Contemporaneously (timely) •Document more often as risk increases •Never document in advance •Write legibly •Don't delete or white out errors •Maintain confidentiality •Avoid personal notes, biases and judgements Policies Address: - Methods of documentation, Forms used, who should document, Approved abbreviations (if any), Date format, Designation and signature 7. Describe practical nurse responsibilities when using health care technology and electronic health records Legal accountabilities: Personal Information Protection and Electronic Documents Act (PIPEDA) Firewall, spyware detection, and antivirus. Automatic sign-off to protect information. Location of computers. Creation of access codes and passwords Safe disposal of printed information. Removal of identification from all patient data for assignments to a student nurse. Following the disposal policies for records in the institution. Policies for the use of fax machines LPNs must: •Maintain documentation and reporting according to established legislation, regulations, laws and employer policies •Collaborate in the development, review and revision of care plans to address client needs and preferences and to establish clear goals that are mutually agreed upon by the client and the health care team •Modify and communicate to appropriate person changes to specific interventions based on the client's responses •Provide relevant and timely information to clients and co-workers