PERL TK. 4.Use an IDE 3. Use the documentation! 2. Experiment. 1.Learn the basics.
Documentation the basics
description
Transcript of Documentation the basics
In this presentation you will learn about:
Types of documentation Handover Basic writing – Progress notes Care planning Aged Care Funding Instrument (ACFI)
To ensure that continuity of resident care
is provided by all health care professionals through professional, accurate and contemporary documentation in keeping with legislative and ethical requirements
Care ReportsACFI, progress notes, incident reports, care
plans etc Other reportsDaily, Hazard and maintenance etc Requisition forms Transfer letters Phone calls
We can communicate what is happening
Funding can be dependent on what is
contained in reported information
Continuity of client care – so that we all are
‘on the same page’ - If a particular worker records
everything accurately in notes and care plans, the next
workers can easily take on the support of the clients, without
missing any details of what has already occurred, what is in
process and what needs to be done
Relevant
Documented
Timely This is a legal requirement Can also become part of an audit process It is generally considered that if something is not documented it is not done!
Extremely important that reports be presented within the appropriate time frame
Plan ahead Negotiate a new deadline if need be Examples: -message re care of resident
-frayed toaster cord -providing a new sharps container
Which is the most urgent?
They are all equally important to be reported to the right person in the right format
Familiarise yourself with all of the types of forms used in your organisation - assessment, admission, care plans, case notes, incident reports, ACFI, Pressure care
Records are always confidential - keep them secure – shut down computer screens, return paperwork to correct storage area, don’t leave identifiable items in public areas
Brief information exchange at the change of a shift
Essential information you need to pass on:◦ details of client preferences◦ details of anything which happened that was out
of the ordinary◦ new treatments, symptoms◦ any information required to provide continuity of
care – Drs appointments, day leave etc
Be factual, concise and accurate- be objective and nonjudgmental
Make sure your writing is neat, clear and legible
Writing should be in blue or black ink
Use exact words when quoting - use quotation marks to show it is a direct quote
Never use whiteout - draw a single line through the error, initial and date the change
Record the date and time - especially when relating incidents that have occurred
Present information in logical sequence
Use abbreviations approved in your organisation
Use correct spelling, punctuation and grammar - use a dictionary !
Edit your report before presenting it - get rid of errors and mistakes
Always sign and date each entry, with your surname printed and designation at the end
Eg: (OTOOLE, PCW)
Make sure you check your organisation’s requirements regarding documentation
Read through this common abbreviation list and undertake the matching activity
Insert hyperlink activity here
Remember that each organisation should have its own accepted abbreviation practice guideline or policy that you will need to abide by
Not necessary to write any entry every day – known as by exception
E.g change in behaviour, visit by GP and commencing new antibiotic
If it is already on the long term care plan there is no need to write another entry as nothing new has happened
If is a new problem then write in the progress notes and be specific- read your entry back to make sure it makes sense to someone who has not cared for the client before
Date Time Designation Written in the correct time sequence Be concise and factual Signature and Name clearly identifiable
What happened – subjective and objective information
What you saw / heard or did What action you took What the result was Subjective
Resident’s description of problem/evente.g. ”Mrs Brown stated she had abdominal pain”
ObjectiveObjective data that can be measured or observed by youe.g. “Mrs Brown pale, holding abdominal area, lying in bed”
AssessmentAssessment of the subjective and objective data availablee.g. “Vital signs recorded – NAD, no vomiting or diarrhoea”
PlanWhat you are going to do/have done about ite.g “ Pain relief given by RN for pain in abdomen, warm gel pack offered. Mrs Brown to remain in bed and review in 2/24”
A full assessment of the health status and care needs of each resident is to be carried out and documented as part of the admission process and an ongoing re assessment of care needs is carried on a continuous basis
This ensures a holistic and individualised approach is undertaken in providing care to each resident, that is meaningful to them
The crucial information that explains what you need to do for a client
Can be in an electronic format
2 TYPESShort term
problems of short duration e.g skin tear
Long termContinuous ongoing problems
e.g. mobility
1. Assessment phase – on each aspect of care
2. Planning phase – write up the care plan3. Implementation – share information with
others, discuss plan of care, implement the care you’ve planned
4. Review – at least monthly if not before, living document; can change as necessary to meet the clients needs
Read these care plan guidelines and look at the examples provided
Identify the issue Statement of the issue/s or problem One per care plan Basis of what you are writing the care plan
about If it is clearly stated it is easy to work out
the interventions
Overall aim of what you want to achieve
What do you want to achieve for the resident?
What does the resident want to achieve? Ideally the resident would be an active
participant in setting the goal/s of their care What does the family want to achieve?
What you are going to do about it
Review the assessment documentation Eg personal hygiene assessment – how
much help does the client need when showering, don’t assume they can’t do anything themselves
Use information recorded in the assessment documentation to work out the content of the care plan
Consideration is to be given to the residents abilities, needs, expectations, choices and preferences, wants and needs in relation to each of the following:
· Residents rights· Personal affairs· Social· Cultural· Spiritual· Physical· Emotional (psychological)
Puts the plan into action – guides your care
Implementation includes the documenting of care in progress notes, treatment sheets, medication charts
Documenting is part of the carer’s direct responsibility, rather than a clerical function, it is a vital part of the professional care practice, providing a permanent record of what you want to achieve, how, when and why you do it
Determines the extent to which goals or outcomes have been met or achieved
Final phase in the process which is an integral part of professional practice, it is ongoing
Based on resident need, facility policy, legal requirements
Could be date or funding driven
Interim Care plan Short Term Care plans Mini Care plans Electronic care plans Community Care plans Mental health plan
Long Term Care PlanFor ongoing total care
Interim Care PlanSnapshot picture on admission
Short Term Care PlanFor problems of short duration
Mini Care PlansSnapshot picture – often found in a client’s wardrobe
Electronic Care Plans“I Care” one example of a computer
generated care plan used on palm pilots
Community Care Plans
Other FacilitiesVary greatly but every facility will have the same basic components, ensure you find out at your orientation how to document care plans properly – particularly if your funding relies on it!
Care Planning is a partnership with residents, it is resident focused not driven by or for staff convenience
ALWAYS engage the client to be an active participant in what is
happening to them