N2111 UNIT 4 - Ch. 5 nursing documentation PDF

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Nursing documentation notes...

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2111 – Unit 4 Ch. 5 notes – Nursing Documentation  Activities of Daily living= (ADLs) routine activities people do every day without needing assistance; eating, bathing, dressing, toileting, transferring (walking), continence.  Minimum data set= (MDS) smallest number of a standardized data set that can be collected to identify essential, common, and core data elements of patients receiving nursing care.  Personal Health Information Protection Act= (PHIPA) 2004 revised 2016; legislates handling of confidential patient information  Resident Assessment Instrument= (RAI) standardized approach to examining quality of care and to improve regulation  Resident Assessment Protocol= (RAP) reference to documents that form part of the RAI. It provides a statement about the health problem; on the basis of that information, the minimum data set then triggers care planning. Documentation o o

Nursing documentation is a mandatory practice of making permanent record of nursing actions, the patient’s conditions, and the patient’s responses to nursing actions or the actions of others. A mandatory practice – if it’s not documented then it didn’t happen.

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Clinical documentation: - lists, supports, and communicates condition of person receiving care at all times - Helps the nurse identify, implement, monitor, and evaluate treatments/interventions - Ensures patient continues to receive care needed regardless of shifts, HCPs, and care settings - Demonstrates nurse’s quality of care provided

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Gerontological nursing documentation: - Especially important; older persons are at special risk for accidents, iatrogenic problems (illness by medical treatment), and adverse reactions (side effects) - Natural changes of aging combined with acute & complex health problems - Will require continuity of care from one setting to another (ex: hospital – home) - Documentation serves as basis for determining overall quality of care and justifying funding for care resources

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Advance Directives (advanced care planning): - fall under provincial & territorial jurisdictions & are documented in health record - Put in place for benefit of substitute decision maker who nurses must receive consent from if older person cannot give their own consent - Bill C-14: (passed in 2016) federal government outlined requirements all patients must meet in order to receive medical assistance in dying. Also what HCPs must follow to legally provide it. - Nursing records add to this documentation with more details of patient’s wishes; who they want involved, who can access your records, use of CPR, handling of bodies after death  Patients discuss with nurses while receiving care, nurses document to ensure other HCPs can respect these wishes.

Acute Care Setting o

Documenting a particular event = SOAP - Subjective= (also called chief complaint) patient’s own words - Objective= data on what nurse can measure, observe, see, feel, touch, smell - Assessment= result of nurse’s analysis of patient condition - Plan = interventions

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Other approaches: - DARE= document data, action, response, evaluation - FOCUS= integrates narrative notes with care plan and records relevant patient info in systematic, accessible fashion - SBAR= situation, background, assessment, recommendation - IDRAW= Identify patient, diagnosis, recent changes, anticipated changes, what to watch for - Narrative charting= nursing interventions & impact of interventions on patient outcomes, recorded chronological order & covering specific time frame

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Documentation: - Bar codes: scanned for access to records and for administration of treatments and medications - Electronic checklists & flow sheets, care maps used to predict & document care - Less common: ‘lower-tech’ approaches: documentation done in form of problem-oriented notes made in clinical record. Residential Care Settings

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LTC (long term care) homes, assisted living, retirement homes: documentation is generally only done only if nurse has provided care - Retirement homes: nursing services optional and usually limited to medication administration and assisting with ADLs by care aides - Some care aides not allowed to chart – if nurses chart on their behalf they must follow their provincial professional regulatory organization's documentation guidelines for second-hand charting - LTC home: recording ADL care, vital signs, periodic assessment, medication & treatment administration, assessment of unusual event or change in condition. Through use of narrative progress notes, flow sheets, checklists, mandated standardized & comprehensive instruments.  Nurse ultimately responsible for quality of care & completeness/accuracy of documentation

Resident Assessment Instrument (RAI) o

Standardized approach used to gather comprehensive assessment information of person’s functioning= 3 parts: MDS 2.0, RAPs, and Utilization Group data (UGs)

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Consists of different minimum data sets 2.0 (MDS), each are specific to care setting (LTC, home care, mental health) - 2010; 8 provinces & territories were using RAI-MDS 2.0 in LTC homes - Core component of MDS 2.0 enables care team to assess multiple key domains (like function, health, social support, and service use)

Resident Assessment Protocols (RAPs) -

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Additional assessments completed depending on info collected from initial MDS 2.0 assessment Are structured, problem-oriented frameworks for organization & direction of care Provides statement about health problem and then based on that info the MDS then triggers care planning In most provinces/territories nurses are responsible for coordination of MDS 2.0 within 14 days of resident’s admission, at quarterly intervals, and any time there’s a significant change in resident’s status MDS 2.0 then sent to Continuing Care Reporting System database for analysis & communication of patient profiles. This info is then shared with Canadian Institute for Health Information to become part of national database (for research and improving ltcs)

Home Care o o o

Often provided informally by family and friends Requisite professional care provided through home visits from HCPs. These services delivered by provincial/territorial governments, and sometimes by municipal Home care utilizes the RAI system to collect MDS for home care clients & determine care required -

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Clinical Assessment Protocols (CAPs) used for documenting assessments, inform & guide comprehensive care & service planning in home care setting. intended as companion resource for RAI-home care Completed in person’s home, recorded on portable or hand-held computers, later transferred to central database in provider’s office

Implications for Gerontological Nursing and Healthy Aging o o o o

Confidentiality protected through professional code of ethics Personal Health Information Protection Act (PHIPA) = 2014 & 2016; outlines rules for collection, use, and disclosure of personal health info Office of Information and Privacy Commissioner of Canada has responsibility to ensure this protection For those incapable of making health care decisions, info can be shared with guardian or whoever has power of attorney (respecting PHIPA rules)...