TECHNIQUES OR SYSTEMS OF DOCUMENTATION AND REPORTING IN NURSING
Rabu, 04 Januari 2023
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A. Definition of Documentation
Documentation of the nursing care process is a display of the behavior or performance of the implementing nurse in providing the nursing care process to the patient while the patient is being treated in the hospital. The quality of nursing documentation can be seen from the completeness and accuracy of writing down the nursing care process provided to patients, which includes assessment, nursing diagnoses, action plans and evaluations.
Documentation of the nursing care process is useful for strengthening recording patterns and as a guide or guideline for documentation practice in providing nursing actions. If there is a problem related to the nursing profession, where the nurse is the service provider and the client is the service user, then documentation of the nursing care process is needed, where this documentation can be used as evidence in court.
(Berman Snyder, Kozier, B. Erb, 2008)
- Documentation System
The documentation system is the entire format used to record data, report data on client conditions and policies and procedures established to record data. For efficiency in documenting, a protocol is needed that explains who has the right to record, where data groups will be recorded, how information will be reported (narratives, flow sheets and graphs) and when data must be documented.
The main purpose of the documentation system is to get a complete and accurate description of patient information into an easy-to-read data organization. Ease of obtaining data for the entire health team will facilitate the quality of care, research and for educational purposes.
1. Documentation System Elements
Determining the ideal documentation system is a challenge. Problems can arise when writing data so that it becomes organized and logical and contains all the information about the client, as well as when determining nursing care planning and the client's response to treatment.
Thus the nursing documentation system must be organized in such a way, can be measured, can describe nursing care and can be communicated to other health teams. The main elements in the nursing documentation system are following the flow of the nursing process, while the other elements are :
a. Compatibility
Recording methods should be consistent with clinical record keeping requirements.
b. Ease To Obtain
The recording system must be stored in a data storage system that is easily accessible to all health workers.
c. Interconnected
A good recording system that must be recorded in a form that as a whole must comprehensively describe the client's health status and how the health team's efforts are in determining client problems, determining interventions and managing clients.
2. Documentation System Typology
a. Source oriented
Focus on information sources and sequences.
b. Exception oriented
Focus on abnormal events or facts (observations) that are exceptions. The format is usually separate. Commonly used SOAP format (Subjective, Objective, Analysis, Planning).
c. Process oriented
Focus on process. The recording model follows the flow of the nursing process or problem-oriented recording.
3. Commonly Used Systems and Their Formats
a. Source-oriented documentation and narrative format
Narrative form recording is a traditional form recording system, more widely used and flexible. The recording system in the form of narrative is very dependent on the way each individual takes notes.
b. Problem-oriented documentation
A problem-oriented documentation system is a method of organizing client data whose structure is identified as a nursing or medical problem.
(Berman Snyder, Kozier, B. Erb, 2010)
- Documentation Standards
1. The Importance of Documentation Standards
Standard is defined as a measure or model of something that is almost the same. The model includes quality, characteristic properties, and expected performance in an action, service and all components involved. The value of a standard is determined by the use of consistency and evaluation. A nursing standard is a statement describing the qualities, characteristics, properties, or performance expected of some aspect of nursing practice.
Nurses need a documentation standard as a guide and direction towards proper storage and recording techniques. Therefore, the standards must be understood by colleagues and other health professionals, including the accreditation team. Anyone who needs accurate nursing records and useful information has the right to have such documentation in accordance with applicable standards. If standards are observable, nurses, workers, and patients will be respected and protected from misconduct.
Characteristics common to all standards overall | General characteristics of nursing standards |
| 1.Based on the definition of nursing and the nursing process that has been determined. |
| 2.Applicable to all practical care in the health care system. |
| 3. Instructions for nursing actions |
| 4.Can be maintained and optimal health promotion. |
| 5. The language is meaningful and understood by nurses who implement these standards. It can be obtained by anyone who needs it. |
2. Professional Individual Responsibility Standards
Implementation of standards can be achieved at the individual level. For the individual nurse this means demonstrating responsibility for the documentation of nursing practice within the context of the nursing process. By assuming responsibility and good quality work in nursing practice, including documentation of independent and interdependent actions.
Participation in implementing codes (such as the ANA code) on the part of nurses implies responsibility. This code provides guidance for individual practitioners so that their responsibilities to individual patients and society can be met.
3. Individual Professional Accountability Standards
The individual professional accountability standard describes the nurse's responsibilities in documenting nursing practice based on the nursing process. The responsibility to do the best in nursing practice includes independent and independent documentation activities.
1. Ten Standards of Nursing Measures (from ANA, 1973)
Nurses have the responsibility:
a. Providing services by respecting clients as living beings.
b. Protect patient rights (privacy; confidential).
c. Maintain competence in nursing actions and know the patient and accept personal responsibility for his actions.
d. Protect patients if their actions and safety are caused by other people who are incompetent, unethical and illegal.
e. Using individual ability as a criterion for accepting responsibility and delegating tasks in nursing actions to other health workers.
f. Participation in research activities if the respondent's rights are protected.
g. Participation in the activities of the nursing profession to improve the standards of nursing service practice and education.
h. Improving and maintaining the nursing quality of other nurses by participating in professional activities.
i. Promote health by working with communities and other health workers.
j. Refuse to consent to the promotion or sale of commercial products, services or other entertainment.
2. Scope of Independent Activities
The responsibilities of an independent nurse in documentation activities include:
a. Maintain accuracy of nursing service records, together with data and results of monitoring, observing, and evaluating the client's health status, so that the documentation remains consistent with the doctor's program and nursing actions.
b. Record all nursing actions used to reduce or prevent patient risk and maintain safety.
c. Record all patient care actions. The nurse responds to the clinical situation and determines the next action plan. These responses include assessments regarding treatment administration, nursing actions to provide comfortable rest, plans for client education, determination of self-care levels, and assessments of the results of consultations with other health teams.
d. Record all components of the nursing process according to the time of implementation. These components include the review, the nursing diagnosis, the goal modification action plan, and the client's teaching notes.
3. Scope of Interdependent Action
Interdependent activities are nursing activities, which are carried out in teams with other health professionals. Knowledge, skills and focus of nursing practice are interdependent activities. Documentation of the overall segment of the medical plan initiated by other departments (such as pharmacy or blood bank) but carried out by the nurse.
During interdependent activities, nurses make nursing plans with other members of the health team (doctors, pharmacists, nutritionists, physiotherapists). Nursing records need to reflect a description of where a process was carried out. At this stage it is important to document the reasons for "writing" an activity.
Independent nursing activities require documented evidence in which medical orders or instructions are linked to nursing activities that require a special "medical program" for the treatment given, treatment, procedure, other tests/examinations, hospital admission, referral or discharge of clients. .
Interdependent documentation activities:
Examples of medical programs or other health team recommendations, the nurse must document include: vital signs, suctioning of secretions, tracheostomy care, positioning, information from cardiac recordings, pacemaker, support, administration of enemas, treatment of irritation or other interdependent activities. Creating a nursing plan incorporates a description of activities or procedures that complement or are not responsive to the client. Documentation of incoming patients and discharge plans is carried out according to the doctor's program.
4. Standards of Responsibility for the Nursing Profession
Determination of a standard and implementation guidelines and standards of nursing documentation is a function of a nursing organization. A profession, if it has set a standard, indicates a commitment to the application of consistent action in the "problem solving" process.
The nurse has a certain expertise to identify, interpret, provide recommendations, and validate a useful standard. It is very appropriate that the nursing profession, in collaboration with other health professionals, has an important role in determining a standard of nursing.
The responsibility of the nursing profession in nursing documentation includes:
1. Using standards for recording and storage
2. Provide input as a “code”
3. Use the discretion of the nursing staff for record keeping.
4. Carry out activities related to nursing practice and the multi-disciplinary nursing profession.
5. Prioritize client problems and needs.
6. Fulfilling group requests; accreditation team and users/community
5. Standards Compiled by Health Services
The documentation standard on the front is the summary of records based on the health service institution. These standards include policies, procedures and implementation of standards as well as criteria for qualifying written statements. If the policy has been written to the staff, then all documentation must refer to that standard. The contents of policies and procedures include general and specific guidelines expected in the documentation. These expectations include:
a. Fill in each data entry, including date, time, legal aspect, title and individual/nurse identification.
b. Agreed use of abbreviations and symbols.
c. Correction procedure if there is an error.
d. The person authorized to enter data on client records.
e. Procedure for documentation correction.
f. Procedure for recording verbal commands
g. Recording date
h. Access to client records
i. Use of standard forms
j. Procedure for recording treatment actions.
Examples of Differences in Standard Policies and Procedures:
Policy Standards:
The nurse will write down the treatment measures and will sign in the space provided.
Standard Procedure :
If there is an error, it must be marked by crossing out the wrong word, then writing the correct word.
(Berman Snyder, Kozier, B. Erb, 2010)
- Reporting
1. Purpose of Reporting:
The purpose of reporting is to convey specific information to a person or group of people. Reports, whether oral or written, should be concise, including relevant information, but not unrelated details. In addition to shift reports and telephone reports, reporting may also include sharing information or ideas with colleagues and other health professionals about some aspect of client care. Examples include nurse planning conferences and nursing rounds
2. Types of Reports:
a. Sip Change Report
The sip change report is a report given to all nurses at the next sip. The goal is to provide continuity of care to the client by providing the new caregiver with a quick summary of the client's needs and details of the care to be provided.
SIP change reports can be in writing or given orally, either through direct exchange or audio tape recording. Live reports allow listeners to ask questions during reporting, written reports and tape recorder reports are often shorter and less time consuming. Reports are sometimes given at the bedside and the client and nurse can participate in the exchange of information.
b. Telephone Report
Health professionals often report on clients over the phone. The nurse informs the doctor about changes in the client's condition; the rediologist reports the results of the x-ray examination; the nurse may report to the nurse on another unit about the client being transferred.
The nurse receiving the call must document the date and time, the name of the person who provided the information, and the subject of the information received, and sign the notation. For example :
6/6/03 30:35 GL Messina, the lab technician, reports over the phone that Mrs. Sara Ames is 39/100 ml._B. Ireland RN
If there is any doubt about the information provided over the telephone, the person receiving the information should repeat the information back to the sender to ensure accuracy . When giving a telephone report to a doctor, it is very important that the nurse keep the report concise and accurate. Begin with the name and relationship to the client (eg, “This is Jana Gomez, RN; I'm calling regarding your patient, Dorothy Mendes. I'm the nurse on sip 7pm to 7am”).
The telephone report usually includes the client's name and medical diagnosis, changes in nursing assessment, vital signs relative to baseline vital signs, significant laboratory data, and related nursing interventions. The nurse should prepare the client's notes to provide the doctor with more information.
After reporting, the nurse must document the date, time, and content of the message. For example :
Dorothy Mendes was admitted to the hospital at 12:00; complained of burning pain in the right upper quadrant of the abdomen. TD 120/80, N 100, P 20 on entry. Demorol 100 mg IM on admission. At 15.15 pm BP 100/40, N 120, P 30. Pain has not changed. Pale color and diaphoresis. Reported by phone to Dr. Burns at 2:10 p.m._TS Jones RN
c. Phone Instructions
Doctors often order a therapy (eg, medication) for a client over the phone. Most agencies have specific policies regarding telephone instructions. Many agencies only allow registered nurses to take instructions over the phone.
When the doctor gives instructions:
1. Write down and repeat the instructions back to the doctor to ensure accuracy
2. Ask the doctor any instructions that are ambiguous, unusual (eg, very high doses of drugs), or contraindicated with the client's condition.
3. Write instructions on the doctor's instruction sheet, indicating instructions as verbal instructions (VO) or telephone instructions (TO).
After the instructions are written on the doctor's instruction sheet, the instructions must be signed by the doctor within the time period set by agency policy. Many acute care hospitals require this to be done within 24 hours.
d. Plan of Care Conference
A care plan conference is a meeting of a group of nurses to discuss possible solutions to a client's particular problem, for example, an inability to cope with an event or a lack of progress towards achieving a goal. A care plan conference gives each nurse an opportunity to provide an opinion on possible solutions to a problem. Other health professionals may be invited to attend the conference to provide their expertise. For example, a social service worker might discuss the family problems of a child who has been severely burned, or a dietician might discuss the dietary problems of a client with diabetes.
Care plan conferences are most effective when there is an atmosphere of mutual respect that is, nonjudgmental acceptance of others even though their values, opinions, and beliefs may appear to differ. Nurses must accept and respect each individual contribution, listening with an open mind to what others have to say even if they disagree.
(Ermawati Dalami, 2011)
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