Nursing Documentation Principles PDF

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Introduction Nursing documentation is essential for good clinical communication. Appropriate documentation provides an accurate reflection of nursing assessments, changes in clinical state, care provided and pertinent patient information to support the multidisciplinary team to deliver great care. Documentation provides evidence of care and is an important professional and medico legal requirement of nursing practice.

Aim To provide a structured and standardised approach to nursing documentation for inpatients. This will ensure consistent clinical communication processes across the RCH.

Definition of Terms 

EMR: electronic medical record

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EMR Review: process of working through the EMR activities to collect pertinent patient details

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Real time: nursing documentation entered in a timely manner throughout the shift.

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Required documentation: minimum documentation required to reflect safe patient care. On admission and at the commencement of each shift, all ‘required documentation’ must be completed to comply with the National Safety & Quality Health Service Standards. There is an expectation that shift required documentation is completed within 3 hours of shift start time.

Process Nursing documentation is aligned with the ‘nursing process’ and reflects the principles of assessment, planning, implementation and evaluation. It is continuous and nursing documentation should reflect this. Fig 1. Nursing Process

Assess At the beginning of each shift, a ‘shift assessment’ is completed as outlined in the Nursing Assessment Guideline. The information for this assessment is gathered from handover, patient introductions, required documentation (safety checks and risk assessments, clinical observations) and an EMR review and is documented in relevant the ‘Flowsheets’. Review of the EMR gives an overview of the patient. To complete an EMR review, enter the patients’ medical record and work through the key activities in order. These tabs can be customised to meet the specific needs of your patient group (EMR tip sheet link - coming soon). It is recommended that each ward standardises the layout of their activity bar based on their patient population. The EMR review should include (*indicates essential); 

*Storyboard - age, bed card, gender, FYIs, infections, allergies, isolations, LOS, weight

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*IP Summary - Medical problem list, treatment team, orders to be acknowledged

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*ViCTOR Graph - observations trends, zone breaches

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*Notes - e.g. admission, ward round, any other useful details (mark all as not new)

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*Results Review - recent and pending results (time mark)

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*MAR - overdue medications, discontinued, adjust due times for medications

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Fluid Balance- input/output and balance

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Avatar- review lines/drains/airways/wounds, including, location, size, date inserted

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*Orders:

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review all active, continuous, PRN and scheduled, discontinue expired,

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nursing orders create and manage as required for patient care

Flowsheets - document specific information, ‘last filed’ will show most recent entries, review and manage unnecessary rows e.g. ‘complete’

Patient assessments are documented in the relevant flowsheets and must include the minimum ‘required documentation’. To ensure required documentation for each patient is complete, use the summary side bar link (EMR Req Doc tip sheet link -- coming soon).

Plan With the information gathered from the start of shift assessment, the plan of care can be developed in collaboration with the patient and family/carers to ensure clear expectations of care. The nursing hub is a shift planning tool and provides a timeline view of the plan of care including, ongoing assessments, diagnostic tests, appointments, scheduled medications, procedures and tasks. The orders will populate the hub and nurses can document directly from the hub into Flowsheets in real-time. Orders are visible by the multidisciplinary team. Management of orders is crucial to the set up and useability of the hub. It must be ‘cleaned up’ before handover takes place - too many outstanding orders is a risk to patient safety. For more information on how to place and manage orders, click on the following link: https://www.rch.org.au/Nursing_Hub.aspx Additional tasks can be added to the hub by nurses as reminders. All patient documentation can be entered into Flowsheets (observations, fluid balance, LDA assessment) throughout the shift. Clinical information that is not recorded within flowsheets and any changes to the plan of care is documented as a real time progress note. This may include: 

Abnormal assessment, eg. Uncontrolled pain, tachycardic, increased WOB, poor perfusion, hypotensive, febrile etc.

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Change in clinical state, eg. Deterioration, improvements, neurological status, desaturation, etc.

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Adverse findings or events, eg. IV painful, inflamed or leaking requiring removal, vomiting, rash, incontinence, fall, pressure injury; wound infection, drain losses, electrolyte imbalance, +/-fluid balance etc.

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Patient outcomes after interventions eg. Dressing changes, pain management, mobilisation, hygiene, overall improvements, responses to care etc.

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Family centred care eg. Parent level of understanding, participation in care, child-family interactions, welfare issues, visiting arrangements etc.

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Social issues eg. Accommodation, travel, financial, legal etc.

Implement and evaluate Progress note entries should not simply list tasks or events but provide information about what occurred, consider why and include details of the impact, outcome and plan for the patient and family.

All entries should be accurate and relevant to the individual patient - non-specific information such as ‘ongoing management’ is not useful. Duplication should be avoided - statements about information recorded in other activities on the EMR are not useful, for example, ‘medications given as per MAR’. Professional nursing language should be used for all entries - abbreviations should be used minimally and must be consistent with RCH standards, for example, ‘emotional support was provided to patient and family’ could be documented instead of ‘TLC was given’. Real time notes should be signed off after the first entry and subsequent entries are entered as addendums. Example of real time progress note entry: 09:40 NURSING. Billie is describing increasing pain in left leg. FLACC 7/10. Paracetamol given, heat pack applied with some effect. Education given to Mum at the bedside on utilising heat pack in conjunction with regular analgesia. Continue pain score with observations. (Progress Note, sign at the end) 10:15 NURSING. Episode of urinary incontinence. Billie quite embarrassed. Urine bottle given. (Addendum) 14:30 NURSING. Routine bloods for IV therapy taken, lab called- high K+ (? Haemolysed). Medical staff notified, repeat bloods in 6/24. Encourage oral fluids and diet, if tolerated. IV can be removed. (Addendum)

Companion Documents 

Documentation: Medical Records Procedure

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National Safety & Quality Health Service Standards

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Nursing Assessment Clinical Practice Guideline

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Patient Identification Procedure

Evidence Table The evidence table for this guideline can be viewed here.

References 

Australian Commission on Safety and Quality in Health Care (2017). National Safety and Quality Health Service Standards: Guide for Hospitals (2nd Ed.). Sydney: ACSQHC.

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Blair, W., & Smith, B. (2012). Nursing documentation: Frameworks and barriers. Contemporary Nurse, 41(2), 160-168

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Collins, S. A., Cato, K., Albers, D., Scott, K., Stetson, P. D., Bakken, S., & Vawdrey, D. K. (2013). Relationship between nursing documentation and patients’ mortality. American Journal of Critical Care, 22(4), 306-313.

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De Marinis, M. G., Piredda, M., Pascarella, M. C., Vincenzi, B., Spiga, F., Tartaglini, D., Alvaro, R., & Matarese, M. (2010). ‘If it is not recorded, it has not been done!’? consistency between nursing records and observed nursing care in an Italian hospital. Journal of Clinical Nursing, 19, 15441552.

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Häyrinen, K., Lammintakanen, J., & Saranto, K. (2010) Evaluation of electronic nursing documentation—Nursing process model and standardized terminologies as keys to visible and transparent nursing. International Journal of Medical Informatics, 79 (8), 554-564.

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Jefferies, D., Johnson, M., & Griffiths, R. (2010). A meta ‐study of the essentials of quality nursing documentation. International journal of nursing practice, 16(2), 112-124.

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Johnson, M., Jefferies, D., & Langdon, R. (2010). The Nursing and Midwifery Content Audit Tool (NMCAT): a short nursing documentation audit tool. Journal of nursing management, 18(7), 832845.

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Kargul, G. J., Wright, S. M., Knight, A. M., McNichol, M. T., & Riggio, J. M. (2013). The hybrid progress note: Semiautomating daily progress notes to achieve high-quality documentation and improve provider efficiency. American Journal of Medical Quality, 28(1), 25-32....