Nursing Documentation: Nursing Documentation Examples

Nursing Documentation: Nursing Documentation Examples

INTRODUCTION
It is a fact that accurate record keeping and careful documentation is an essential part of nursing practice and effective communication among nurses vital to the quality of client care. Generally nurses communicate with their
colleagues, clients and other healthcare professionals through discussion, reports and records.

A discussion is an informal oral discussion of subject by two or more nurses or other healthcare
personnel to identify a problem or establishes strategies to resolve a problem.

A report is an oral, written or computer-based communication intended to convey information to others. For instance, nurse report on client’s progress at the end of a work shift during handing over.

A record is a written or computer –based communication intended to convey information to others. The process of making an entry on a client record is called recording, charting or documenting.

A clinical record, also called a chart. Client record is a formal, legal document that provides evidence of client care.

The procedure for documentation may vary from institution to institution, but the principle involved are generally the same. The history of documentation and record keeping in nursing emanated from Florence Nightingale who, during her time, documented all she saw and did. Nurses are responsible for accurate, complete and timely documentation and reporting. As an instrument of continuous client care and as legal document, the client record should contain all pertinent assessment, planning, intervention and evaluation for the client. Documentation and reporting of the client’s condition require adherence to the highest standards of confidentiality. After actions have been performed on a client, they should be documented.

If a nurse performs her duty in error, and without documentation, she is accountable to the client who received the care; the doctor who prescribed the treatment, the nursing service that sets the standard of expected performance, the institution in which nursing services is practiced and the society that demands professional excellence. When nurses perform care, they must be accountable for their action as documentation connotes accountability.

All members of a healthcare team share information through documentation and reporting. Documenting client’s records is important for the following reasons:

1. Serves as a vehicle by which different health professionals who interact with a client communicate with each other. This prevents fragmentation, repetition, and delays in client care.

2. Ensure continuity of patient care for future management.

3. Provides evidence for evaluation purposes. For instance, nurse use baseline and ongoing data to evaluate the effectiveness of the nursing care plan. In addition, records and reports assist nurse managers to evaluate staff performance.

4. Serves as an audit tool. Client’s records may be reviewed to determine if a particular health institution is meeting its stated standards.

5. Serves as an educational tool for nursing students. The information contained in a record can be a valuable source of data nursing research.

6. Investigations into complaints about care will look at and use the patient/client documents and records as evidence, so high quality record keeping is essential. The hospital or care home, the NMC, a court of law or the Health Service Commissioner may investigate the complaint, so it makes sense to get the records right. A court of
law will tend to assume that if care has not been recorded then it has not been given.

7. A client’s record is a legal document and is admissible in court as evidence.

8. Aid hospital management in planning. Information from record may assist healthcare planner to identified institutional needs, such as over utilized and underutilized hospital services. They can often establish from record the cost benefit and cost effectiveness of various services and identify those services that cost the hospital money and those that generate revenue.

GUIDELINES FOR DOCUMENTATION AND RECORD KEEPING
The basic guidelines for good practice in documentation and record keeping apply equally to written records and to computer- held records.
The Nursing and Midwifery Council (NMC 2002) has said that patient and client records should:
– Be based on fact, correct and consistent.
– Be written as soon as possible after an event has happened to provide current (up to date) information about the care and condition of the patient or client.
– Be written clearly and in such a way that the text cannot be erased’ (rubbed out or obliterated).
– Be written in such a way that any alterations or additions are dated, timed and signed, so that the original entry is still clear.
– Be accurately dated, timed and signed.
– Not include abbreviations, jargon, meaningless phrases, irrelevant speculation and offensive subjective statements’.
– Be readable on any photocopies’.
– Be written, wherever possible, with the involvement of the patient,.
– Be written in terms that the patient or client can understand’.
– Be consecutive’ (uninterrupted).
– Identify problems that have arisen and the action taken to rectify’ (correct or put right).
– Provide clear evidence of the care planned, the decisions made, the care delivered and the information shared’.

Documentation and record keeping are vital instruments in the management of nursing services, since the client record may be used to provide evidence in court. Nurses must not only maintain confidentiality of the client’s record but also meet legal standard in the process of documentation.

Aside from client’s record, ward, unit and departmental meetings should be documented as evidence for important decisions taken. The manager should equally keep records of ward rosters, protocol of care, policies and procedures
as they help to clarify actions. Inventory record of equipment, material supplies made to the ward should be kept and monitored. This enables the manager to keep track of supplies. In summary, documentation is a skill to be
acquired by all nurses. A ward manager should be highly educated, intelligent, competent, and assertive. For effective ward management, he/she should combine his/her professional as well as managerial roles in the performance of his/her duties.

By Ali Muhammad Goniri RN, RM, DNE, BNSC, PGDE

Importance of Nursing Documentation and Purpose

Importance of Nursing Documentation and Purpose

1. Serves as a vehicle by which different health professionals who interact with a client communicate with each other. This prevents fragmentation, repetition, and delays in client care.

2. Ensure continuity of patient care for future management.

3. Provides evidence for evaluation purposes. For instance, nurse use baseline and ongoing data to evaluate the effectiveness of the nursing care plan. In addition, records and reports assist nurse managers to evaluate staff performance.

4. Serves as an audit tool. Client’s records may be reviewed to determine if a particular health institution is meeting its stated standards.

5. Serves as an educational tool for nursing students. The information contained in a record can be a valuable source of data nursing research.

6. Investigations into complaints about care will look at and use the patient/client documents and records as evidence, so high quality record keeping is essential. The hospital or care home, the NMC, a court of law or the Health Service Commissioner may investigate the complaint, so it makes sense to get the records right. A court of
law will tend to assume that if care has not been recorded then it has not been given.

7. A client’s record is a legal document and is admissible in court as evidence.

8. Aid hospital management in planning. Information from record may assist healthcare planner to identified institutional needs, such as over utilized and underutilized hospital services. They can often establish from record the cost benefit and cost effectiveness of various services and identify those services that cost the hospital money and those that generate revenue.

Nursing Handover: Nursing Handover Guidelines

Nursing Handover: Nursing Handover Guidelines

The handover is one of the most important parts of the nursing day. It doesn’t matter what setting you work in, the same rule applies – if the right-hand doesn’t know what the left hand is doing then mayhem ensues. Probably the most important thing to remember about the handover is that if it’s done right, the incoming staff can pick up from where you left off, confident that they know what’s expected of them, and able to catch up any slack that was missed.

Never rush
The first rule of handover is never rush the handover – and never let it go over time either or there will be unhappy people waiting to get home. Allow enough time for your area of nursing to get all the information you need. This may be 10 minutes or 45 minutes – we all work in different environments.

Value questions
Create an atmosphere for handover where questions are encouraged, perhaps after each patient, before moving on to the next one.

Share team news
It’s a lovely opportunity to gel together as a team, and that includes ‘handing over’ that it’s Julie’s birthday and that Sarah is retiring, and so on.

Avoid jargon
It is the mother and father of all misunderstandings.

Add notes
Common terminology and abbreviations can be printed at the bottom of the handover sheet if they must be used. For example: CTTO = clips to take out.

Involve students
It’s a good opportunity to get students to practice being in charge by letting them lead the handover.

Handing over… to yourself
If you’re handing over to yourself, write clear notes as to what needs to be done the next day, just in case you forget/run away to Boko Haram/get a vendor supply.

Make your own documents
Create a handover document that suits your environment. It may include details about the patient and their family, relevant medical history, reason for admission or being under your care, long term plan, daily plan, booked procedures, appointments and so on. This should be updated throughout the day and not cobbled together five minutes before handover.

The Importance of Teamwork in Healthcare

The Importance of Teamwork in Healthcare

Have you ever worked with some nurses who cant and don’t lift a finger to help others?
This kind of nurses often are lazy and boring to work with.

Nursing is individual responsibility yes but collective efforts or TEAM work makes it much easier.
When you work with good and effective TEAM members you will feel like nursing is the best job on earth irrespective of the ver high level of stress in nursing.

TEAM means:
T:Together
E:Everyone
A:Achieves
M:More

When assignments are shared in your group I want you to decide to be the one who upliftes team spirit.
Always ask others:
1. Are you ok?
2. Is there anything I can do for you?
Your willingness to help others rubs-off smoothly on everyone including you who is helping.
The help you give another today will come back to you someday in double fold.
You never know when it will be your turn to have a bad day.
Team work :
1. Helps reduce each team member’s stress and burden.
2. Builds friendship.
3. Improves communication among nurses.
4. Improves general patient care.
5. Helps develop each team member’s skills.
6. Improves knowledge as questions are asked and answers are shared.
7. Helps recognise and develop leadership qualities in each member.
8. Keeps each team members healthier.

When next you go to work, begin to develop team spirit in your unit.
As you offer to help others, eventually they will learn from you and offer to help you or someone else.

Recognise what you are very good at. Maybe it is setting an infusion line or calming an anxious patient. Whenever a situation arises for you to use the good skill you have be willing to offer assistance to do it or humbly teach the one who needs it how it is done.

From each nurse according to his/her skills and to each nurse according to his/her needs.

Make your unit a place of friendship and a place of fun.

Offer to help. ALWAYS.

Sussan Igwe

The Use of Gloves in Infection Control: Factors Influencing Glove Use In Student Nurses

The Use of Gloves in Infection Control: Factors Influencing Glove Use In Student Nurses

Glove use may prevent the spread of micro-organisms in healthcare settings, but student nurses’ use of gloves appears to follow ward culture rather than formal policies

Background
Gloves can prevent infection but their use among student nurses is inconsistent.

Aim
To explore pre-registration student nurses’ views of non-sterile glove use in clinical practice.

Method
An online survey was conducted and focus groups carried out among third-year student nurses.

Results
The online survey showed that gloves were often worn inappropriately, while the focus groups revealed students conformed to their mentors’ use of gloves.

Discussion
Student nurses’ decisions on wearing gloves seem to be based on the culture of the clinical care environment rather than trust policy. Glove overuse deprives patients of therapeutic touch and may lead to contact dermatitis in nurses.

Conclusion
All student nurses must be able to identify clinical situations when gloves are not indicated, using appropriate risk assessment.

5 KEY POINT

1.Infection prevention and control is an integral part of pre-registration nursing education

2.Appropriate glove use is an important way to prevent the spread of healthcare-associated infection

3.There is still confusion among student nurses regarding the appropriate use of non-sterile gloves

4.Role modelling and the culture of the clinical care environment influence student nurses’ decision making

5.The World Health Organization’s “glove pyramid” may be a useful tool to inform student nurses’ clinical practice

Infection prevention and control are integral to pre-registration nurse education and practice (Nursing and Midwifery Council, 2010). A vital part of this education is enabling students to understand appropriate glove use in clinical practice. This pilot study explored student nurses’ glove use when carrying out routine, non-invasive nursing interventions such as bed making, personal cleansing and dressing, and recording vital signs.

Wearing gloves as a routine measure may have implications for the nurse-patient relationship, as gloves may act as a barrier to therapeutic touch (Gleeson and Timmins, 2005). There are also implications linked to inappropriate glove use including: costs; an increased risk of dermatitis during long-term glove use, with associated loss of employment (Royal College of Nursing, 2012); and a negative impact on hand hygiene (Loveday et al, 2014).

Literature review

The prevention and control of healthcare-associated infections (HCAIs) has always been an integral part of nursing practice. During the last decade, concern about the increase in HCAIs has lead to a greater emphasis on infection prevention and control. The Epic guidelines for preventing HCAIs provide the most systematic and comprehensive advice, based on up-to-date evidence, to prevent the spread of HCAIs in acute care environments (Loveday et al, 2014a). They state that gloves should be worn to:
Protect hands from contamination with organic matter and micro-organisms;
Reduce the risk of cross-transmission of micro-organisms to staff and patients (Loveday et al, 2014a).

The guidelines also state there is evidence that clinical gloves are not used in line with current guidance, and that glove use has a negative impact on hand hygiene (Loveday et al, 2014a).

In England and Wales, the National Patient Safety Agency (200 reinforced its 2004 Cleanyourhands campaign with the message: “Clean hands save lives.” The Department of Health subsequently published a code of conduct to ensure that health and social care providers comply with the Care Quality Commission’s registration requirements for cleanliness and infection control (DH, 2010).

In response to global concerns related to HCAIs, the World Health Organization has produced guidelines on hand hygiene in healthcare (WHO, 2009a). The guidelines suggest that since 1987 there has been an increase in glove use, and recognise that this may result in their misuse and overuse. They also suggest there is a poor understanding among healthcare workers about appropriate glove use.

WHO’s (2009b) “glove pyramid” (Fig 1) provides guidance for glove use in clinical practice, suggesting a hierarchal approach to glove use within clinical practice. At its base are the indications for not wearing gloves, followed by indications for using examination gloves then, at the top, sit the indicators for wearing sterile gloves.

The use of gloves for routine care has been observed by lecturers when pre-registration students are practising in clinical education simulation sessions. Anecdotally, when questioned, students suggested they were role modelling their mentors in practice or acting in accordance with trust policies or protocols. A recent qualitative study by Loveday et al (2014b) identified that health professionals’ decisions to wear gloves were influenced by role modelling, or they had been instructed to wear gloves when challenged by other members of the clinical team. It is interesting to note that local trust policies and protocols, while ostensibly based on research evidence, do not always provide clear guidance for the wearing of non-sterile disposable gloves in situations where there is no perceived risk.

Nurses Retiring Early: Life Of Retiree Nurses Case Study

Nurses Retiring Early: Life Of Retiree Nurses Case Study

I took a review of retiree nurses in Rivers state and i weep for a beautiful profession that fetches thousands of dollars over sea.

The business of nurturing from birth to grave ought to be given priority attention and dignity it deserves to practitioners especially as it’s difficult to manage people who are well let alone people caring for the sick and interacting with all form of diseases and infection while caring for the sick.
The biggest question i do ask: Who cares for the nurses that cares for all?

Nurses gave up their night rest with their husbands and wives doing a security work of caring, nurturing people from dependent status to independent status only to be called ordinary nurses by the society. They are burden bearers to their respective families.
The question is who is against the nurses?

My careful observation suggest only nurses are against the nurses. For example:
1. Who denigrate student nurses in front of patients?
2. Who refuse nurses promotion to directorate level?
3. Who schedule duties like errand nurse?
4. Who petition nurses every day for little benefit?
5. Who stop nurses from diversifying their economic base after work to be comfortable as their pears in the medical profession?
6. Who refuse to participate in strike action against government that treat nurses with levity?
7. Who accepts salaries of N20, 000.00 in private hospitals?
8. Who trained auxiliary nurses without auxiliary doctor?
9. Who said only BNSC is the requirement for management position irrespective of higher degrees one possess even in management, psychology, public health, health education, medical sociology, law ,nutrition, microbiology which are all health related disciplines?
10. Who said RN, RM recognized all over the world as the prerequisite for nursing practice and a certificate without malpractice is not a qualification?
11. Who sees a community health extension officer promoted as directors and still feels nurses can’t be director under his/her watch?
12. Who post nurses to distant places from their home simply to punish them to have family problem.
13.who traces nurses who have multiple job opportunities but still can offer 128 hrs a month and 8hrs daily to government with a view to ensure they are queried and sacked?
14. Who told the public nurses are not supposed to be comfortable like a professional and should never own a car and good house?
15. Who refuses to sign study leave with pay?
16. Who rejects nurse’s sick leave?
17. Who fail students with scores of 49.9?
18. Who said a man cannot be a director no matter how qualified because its women profession?
19. Who refuses to give accommodation to junior nurses in the hospitals?
20. Who schedule night duty for a nurse on honey moon?
21. Who are the only implementer of civil service rule even in recession?

The answers to these question is nurses have been inhuman to nurses not any other professional in the health sector.

Unfortunately the consequences of punishing a colleague manifest in retirement. Most of our colleagues retire without a home, without a car, poor retirement benefit, untimely retirement, some denied managerial promotions, some regretting being a nurse. Some retiree nurses now sells akara in the market to survive and others rejected by their families.

No nurse is a permanent secretary they say no problem!
No nurse is represented on the hospitals management boards they say no problem!
No nurse is a commissioner nor minister they say no problem!
No nurse is on the board of primary health care they say no problem!
No nurse on disaster committee they say no problem!
No student union government in schools of nursing they say it doesn’t matter
No payment to junior nurses for several months they say it doesn’t matter!
NANNM calls for meetings they don’t attend with all excuses!
Hospitals are empty almost all senior nurses are retiring it doesn’t matter!
Student’s hostels collapsing it doesn’t matter!
No offices for cno’s it doesn’t matter!
No official car for nurses it doesn’t matter!
No emergency or call duty phones no problem!
No medical equipment no problem!
No nurse consultant no problem!

As much as it’s no problem and it doesn’t matter we may be a victim someday. Let’s correct our mistakes now before we become a victim.

I am sincerely sorry if i am denigrating our profession in the public but crying for nurses attention to nurses plight while calling on the attention of nurses in position of authority to please help their colleagues grow in capacity, character, competence and economically .their colleagues could be a source of succor to them at retirement as well promote the public status of the profession.
Paper qualification is good but skilled nurses is better because only a skilled nurse can save a life not paper not certificate. It’s not a sin to be a nurse rather it’s a blessing.

Solutions.

1. I encourage all nurses to further their education for reason of adding knowledge, prestige and evidence base practice to the profession not for discrimination. a true scholar tries to raise the weak and build a viable profession for all not for only the strong.
2. Remove all self-inflicted barriers in nursing.
3. Keep promoting your colleagues provided the decision is within your table.
4. Support nannm with information and advises that can move the profession forward
5. Nannm should rise to the occasion of defending nurses in the labour market.
6. Organise duties to give younger ones the opportunity to go back to school be it for bsc, msc, phd, post basic courses.
7. Love one another.
8. Defend your colleague at work.
9. Correct your colleague with love.
10 Get involve in the health sector politics.
11. Develop your skill of caring through evidenced base practice to give the best to your patients and clients.
12. Reach out to our retirees and form a retired nurses forum to serve as our experience bank.
13. Approve study leaves for your colleagues.
14 Initiate a 1-2years rn to bnsc programme that is hospital based like residency programme for mass movement of nurses to degree level
15. Initiate a nurses national dialogue on what nurses want for their profession.
16. Initiate immediately nurse practice bill to the national assembly.
17. Propose bill to state assemblies for schools of nursing and colleges of nursing.
18. Collaborate with NUC to make colleges of nursing specialized degree awarding institutions only in nursing and midwifery courses, and making various other specialties appealing program of qualifications for growth and development in skills in nursing profession.
19. Initiates an alumni association in all schools of nursing and midwifery.
20. Institute student union government in all schools of nursing, midwifery and colleges of nursing.

Please assist and support a nurse to be economically independent because they are leaders by virtue of nursing training, their responsibilities to families are enormous. Help your colleague in whatever capacity you can.
Note: whatever you deny a fellow nurse will never be given or added to you. if we pray for favour we should also be a source of favour to others. Then you force your leadership on a people you end up achieving nothing but when you earn your leadership from the people your achievements becomes uncounatble. Nurses arise to save your profession now!
No matter your qualification once a nurse is a nurse hence be respected
And accorded the dignity of a professional.
God bless nursing profession in Nigeria.

Written by Joy Emuze

Nursing Medication Errors Stories: Confronting Doctors With Wrong Orders

Nursing Medication Errors Stories: Confronting Doctors With Wrong Orders

Confronting doctors can be intimidating, but we are the patient’s final defense against wrong orders. Somebody has to make sure we get it right. (As always, the illustrations are the products of my imagination or names or events used in a fictitious manner. Any resemblance to actual events is purely coincidental.

Confronting Doctors with Wrong Orders
We are standing at the counter of the nurse’s station in the ER when I tell Dr. Hanson that his patient in 18 is asking for pain medication.
“There’s nothing wrong with her,” he retorts. “She’s just full of BS.”
“If there’s nothing wrong with her, and she’s just full of BS, why are doing $8,000 worth of tests?” I ask bluntly. “Maybe we should give her some pain medication just in case.”

When Dr. Hanson slides back into the doc box to order some morphine, another nurse who had overheard the exchange nudges my arm to get my attention. She half whispers, “I like the way that went down.” I hadn’t given the exchange a second thought while it was happening, but, based on her comment, it occurs to me that I’d just done something she would have found hard to do. It may be easier for me to confront doctors because I’m older than a lot of them and worked here longer than most of them. Also, in the ER, we are used to working alongside different classes of providers, interacting on a casual level that might feel uncomfortable to nurses in other departments. Admittedly, I am writing from an ER perspective. But, even if you are relatively young, new, or intimidated for any other reason, there are three times nurses must be assertive enough to speak up.

First, we need to confront providers when their orders don’t make sense or demonstrate a clear mismatch to a patient’s individual situation. In the era of point and click, entire panels of orders are quickly entered. Sometimes the entire set is intended for another patient. Or maybe the doctor fails to remove a fluid bolus from a panel ordered on a potentially septic patient who is also showing signs of acute CHF. Maybe a provider orders an x-ray on the wrong hip, or omits a Digoxin level on a patient with symptoms of toxicity, or orders antibiotics without ordering the usual blood cultures. These simple, potential, or even obvious oversights are easy to confront because we’re “just checking” without questioning judgement. It’s an easy question: “Hey, I just wanted to double check. Do you want any blood cultures before we start the Rocephin?”

The second level is a slightly harder conversation. But when there appears to be clear judgement error, we still need to ask. For example, an 87-year-old with multiple system failures comes in via EMS. He is crashing, and we intubate him on arrival. The workup shows he needs immediate surgery to remove a large intra-abdominal abscess. But, when the family shows up, we learn that the patient has an Advance Directive and doesn’t want any heroic measures. He probably would have refused intubation if he had been alert enough to express himself. The surgeon evaluates the patient and states that he will not survive the surgery. The family decides to have him extubated and go to comfort measures only. The daughter specifically asks, “But you won’t do anything to make him die quicker, will you?” Dr. Stone assures her that we will not.

Dr. Stone and the surgeon spend several more minutes discussing the case with the family while the respiratory therapist removes the ET tube, and the patient starts breathing on his own again. As Dr. Stone walks away, he says, “We can restart Fentanyl drip.” The Fentanyl drip was held along with the Diprivan due to low blood pressure prior to the decision to extubate the patient. It was running at 300 mics/hour. I ask Dr. Stone, “Are you sure you want to restart it? You just told the daughter we wouldn’t do anything proactive to cause his death.” He replies that it will be okay and turns to walk away. I just questioned his judgement, and he confirmed his intention.
Now we hit level three. It gets more challenging when we have already questioned a doctor’s judgement once, but he persists in following a course we cannot condone. Continuing the case above, I follow the doctor toward the doc box. I’m not belligerent, but I can’t let this go. “Dr. Stone, at the very least I’m going to need you to enter a new order, and I’ll have to chart we had this conversation just in case we all end up in court together trying to explain why we ran Fentanyl at a rate that stopped this guy from breathing right after you assured the daughter we wouldn’t do anything to hasten his death.” He stops on a dime, whirls back toward me, slaps himself on the forehead, and says, “I forgot we just extubated him. Good catch.” They can be very good. They are not gods. Sometimes the third level is essential.

If we get to level three, a second or third opinion may help bolster courage before going back for the decisive confrontation. For example, there is an order for a bolus of Integrilin which is well over the standard protocol dose. I question the doctor, and he confirms the dose. But he is looking at an x-ray, and I have a feeling I don’t have his full attention. I double check the order in the computer, pull the medication from the Pyxis, and turn to another seasoned RN in the med room. I hold up the bottles and show her that the order for the bolus alone grossly exceeds the volume in the large bottle for the total infusion. We look at each other and say in unison, “No way.” Emboldened by her confirmation, I go back to the doctor with both bottles in my hands. I get his complete attention and show him the bottles, explaining the usual dose compared to his current order. He checks again and finds that he is off by two decimal places, accidentally ordering 100 times his intended dose. Oops.

A friend gave me a t-shirt years ago. It is threadbare now, and the slogan is hardly readable. But it has generated some interesting comments and stories through the years: “Be kind to nurses. We keep doctors from accidentally killing you.” It’s true. We are it. We are the patient’s final defense in the delivery of most healthcare, and we must have the courage to confront other providers on whatever level is necessary to make sure we all get it right.

by RobbiRN, RN Pro