documentation practice in icu

7/28/2019 Documentation Practice in ICU

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Documentation practice


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Learning objectives

Describe the concept documentation

Describe the documentation tool used in the

ICU

Explain the type of information that is

appropriate for documentation

Explain the purpose of documentation Discuss the case study on documentation

given and lessons that can be learnt.


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Description and definition

Documentation is a vital component of safe,ethical and effective nursing practice.

provide registered nurses with professional

accountability in record keeping Nursing documentation provides an account

of the judgment and critical thinking used in

the nursing process (i.e., assessment,diagnosis, planning, intervention andevaluation).


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Accurate, timely documentation reflects careprovided; meets professional, legislative andagency standards; promotes enhanced nursing

care; and facilitates communication, betweennurses and other healthcare providers.

nursing documentation must be bothcomprehensive and flexible enough to obtain

critical data, maintain quality and continuity ofcare, track client outcomes, and reflect currentstandards.


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Cont.

Documentation also reflects the application ofnursing knowledge, skills and judgment,establishes accountability, and conveys the

unique contribution of nursing to health care. The current trend toward interdisciplinary

documentation is intended to eliminateduplication, enhance efficient use of time, andenrich client outcomes through teamcollaboration


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Registered nurses are legally and ethically

required to practice nursing in accordance with

the Registered Nurses Act and the code of

Ethics for Registered Nurses. According to the Standards, a nurse is expected

to record andmaintain documentation that is

clear, timely, accurate, reflective of observations,

permanent, legible and chronological

Nurses need to be familiar with agencies

policies, standards and protocols.


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Documentation refers to written or

electronically generated information about a

client, describing the care or services provided

to that client (e.g., charting, recording, nurses

notes, or progress notes).

In other words, documentation is an accurate

account of events that have occurred andwhen they occurred.


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Individual Clients

Nursing documentation for individual clients

provides a clear picture of the status of a

client, the actions of the clients nurse, the

clients health outcomes, and information

about or from the clients family.


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Nursing documentation for an individual client, shoulddescribe:

an assessment of the clients health status

a care plan or health plan reflecting the needs and goals of

the client nursing interventions carried out

the impact of these interventions on client outcomes

any proposed or needed changes to the care plan

information reported to a physician or other healthcare

provider and, when applicable, that providers response

advocacy undertaken by the nurse on behalf of the Client .


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Documentation in ICU

The intensive care nurse has to be highly

skilled today due to technological advances

and complex care of the critically ill patients.

Also the documentation and care required are

complex and time consuming


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The current process of documentation in theintensive care unit involves one chart withmany areas:

Vital signs respiratory observation ,neurological

observation stool chart ,pain chart,nursing

management chart ,daily fluidbalance,problem sheet ,ECG collection,biochemistry/haematology


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Cont.

This flow chart should fulfil the following criteria:-

decrease the amount of time required for

charting by: -

avoiding unnecessary repetition of patient data,

condensing patient observations onto one main chart;

be relatively easy for all nursing and medical staff

to use decrease the amount of paper required for

charting;


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be cost effective and compatible with

ecological principles.

allow more time for patient care at the

bedside

provide accurate documentation of patient

care for medico-legal reasons, to fulfil hospital

requirements and to facilitate continuity of

care.


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Purposes of Documentation

Communications and Continuity of Care

Quality Improvement and Risk Management

Risk management is a system used to identify,

assess, and reduce, where appropriate, risks toclients, visitors, staff, and organizational assets.

Risk management entails good documentation,

and client health records may be used for audits,ethical and disciplinary reviews, accreditation

surveys, legislated inspections and board

reviews, and ongoing risk management analysis


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Purposes cont..

Professional Accountability

Registered nurses are expected to follow the

Standards for Nursing Practice and Code of

Ethics for Registered Nurses when

documenting information related to the health

status of clients, related

situations/circumstances, and care provided.


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Legal Records

In a court of law, a health record serves as the legal record

of care or service provided, and documentation is often usedas evidence in legal proceedings.

Nursing care and the documentation of that care is measured

according to the standard of a reasonable and prudent nursewith similar education and experience in a similar situation.

Consequently, thorough and accurate documentation is one

of the best defenses against legal claims and the bestdefence if a lawsuit actually ensues.


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Cont..

Funding and Resource Management

Documentation is one source of data that can be usedby administration in making funding and resourcemanagement decisions.

Health records are proof of care provided, and third-party insurers sometimes use documented clientoutcomes for the approval of insurance claims.

Workload measurements, client classification systems,derived as a consequence of client documentation, areused by some agencies to help determine theallocation of staff and/or funding


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Research

Health records serve as a valuable and major source

of data for nursing and health related research

Data obtained from health records are also used inhealth research to assess nursing interventions,

evaluate client outcomes, and determine the

efficiency and effectiveness of care


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What should be documented?

Relevant and client-focusedinformation

environmental factors (e.g., safety, equipment, allergies),self-care, and client education

significant events during a client care episode, clientoutcomes, including a clients response to treatments,teaching or preventive care

discharge assessment data. Discharge documentationshould note whether a client and his/her family hadadequate preparation prior to discharge (e.g., contentand outcome of education sessions).

more comprehensive, in-depth and frequent notationsfor clients who are seriously ill, considered high-risk, orhave complex health problems


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Collaboration/Communication with Other Healthcare Providers

Nurses collaborate with other healthcare providers in person, bytelephone, meetings or other electronic means. In these situations,record significant communications in the clients health record,noting:

o date and time of the contact

o name(s) of the people involved in the collaboration

o information provided to or by healthcare providers

o responses from healthcare providers

o orders/interventions resulting from the collaboration

o the agreed upon plan of action


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Medication Administration

actual times medications are administered

names of medications

routes medications administered

sites of medication administration (when

appropriate)

dosage administered nurses signature/designation.


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Cont..

Verbal Orders

Giving and receiving verbal orders is

considered a high risk activity and should be

carried out only in situations in which it is

deemed to be in a clients best interest.

However, any miscommunication or lack of

communication could lead to negative

implications for the client.


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Telephone orders should be co-signed by the

physician involved at the first availableopportunity or within the time frame indicated in

the policy Errors in recording telephone orders can occur,

and there is always the question of who madethe error: the physician in the ordering or the

nurse in recording. Despite these concerns, thereare times when telephone orders may be thenext best option for the client.

documentation practice in icu

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