QuestionAnswered step-by-stepNURS204 Documentation in Nursing Practice Worksheet Student Name ______

QuestionAnswered step-by-stepNURS204 Documentation in Nursing Practice Worksheet Student Name _______________________________ Instructions: Read Chapter 19 on Documenting & Reporting in Taylor Fundamentals Textbook. Refer to Box 19-1 Documentation Guidelines in the textbook. Review Documentation information below. Complete the scenarios for  documentation practice and bring to Fundamentals lab for review. Be prepared to discuss your documentation in lab.  Nursing documentation is an integral part of clinical documentation and is a fundamental nursing responsibility. Documentation is considered a vital communication tool among healthcare professionals. Good documentation ensures continuity of care, furnishes legal evidence of the process of care and supports evaluation of patient care. Accurate and complete documentation of client’s symptoms and observations is critical to proper treatment and management. Entries documented on a patient’s clinical record are a legal and permanent document.  Definition  ` Nursing documentation’ is any written or electronically generated information that describes the care or service provided to a particular client or group of clients. Throughdocumentation, nurses communicate to other healthcare professionals their observations, decisions, actions and outcomes of care. Documentation is an accurate account of what occurred and when it occurred. Documentation tells your story and reveals the care you gave to your patient(s).:Assists in organizing your thoughts Aids in identifying problem areas, planning and evaluating careOffers a means to communicate with other team membersProvides a way to take credit for what you have observed and doneEnsures reimbursementAffords legal protection to you and your employerMay be used in research, to support decision analysis, and in quality improvement(Lippincott, Williams & Wilkins, 2018) All sources of documentation standards emphasize: • Ongoing assessment• Patient teaching, including the patient’s response to teaching and indication that the patient has learned• Response to all medications, treatments, and interventions• Relevant statements made by the patientDocumentation Responsibilities of the nurseThe nurse understands his/her accountability for documenting on the clinical record the care he/she personally provides to the clients.The nurse documents the care process including information or concerns communicated to another health care provider.The nurse documents all relevant information about clients in chronological order with date and time.The nurse carries out comprehensive, in-depth and frequent documentation when clients are acutely ill, high risk or have complex health problems.The nurse documents timely the care he/she provides.The nurse corrects any documentation error in a timely and forthright manner.The nurse remarks any late entry, if indicated, with both date and time of the late entry and of the actual event.The nurse indicates his/her accountability by adding his/her signature and title as approved by his/her organization to each entry and correction he/she makes on the clinical record.The nurse safeguards the privacy, security and confidentiality of clinical record by appropriate storage and custody.The nurse updates himself/herself with contemporary documentation knowledge.ANA Standards of PracticeANA Scope and Standards of Practice: include expectations concerning documentation and state that nurses document: • Nursing process in a responsible, accountable, and ethical manner• An outcome-focused plan-of-care, stating outcomes as measurable goals• Implementation of the plan-of-care• Evidence for practice decisions and modifications to the plan-of-care• Problems and issues in a manner facilitates evaluation of outcomes• Coordination of care and communication with consumers and team members• Results of evaluation of care and outcomes• Relevant data in a retrievable form• Using standardized language and recognized terminology (American Nurses Association    (ANA, 2010) According to the ANA, high quality documentation is: Accessible Accurate, relevant, and consistent Auditable Clear, concise, and complete Legible/readable (particularly in terms of the resolution and related qualities of EHR content as it is displayed on the screens of various devices) Thoughtful Timely, contemporaneous, and sequential Reflective of the nursing process Retrievable on a permanent basis in a nursing-specific mannerDocumentation Scenario #1 Mr. Ron Brown is a 71 year old gentleman with Type 1 diabetes admitted to hospital for treatment of an ulcer on his right heel. Melanie Smith, RN  was assigned to Mr. Brown and Melanie also provided nursing care to him yesterday. Mr. Brown was alert and oriented to person, place and time. He normally had no problems with ambulation. Mr. Brown wears glasses to read and drive and he has no hearing deficits. He lives alone. Mr. Brown’s discharge plan is to return to his apartment. During her morning assessment, Melanie noted at 0800 that Mr. Brown had some facial grimacing and he limped on his right foot when he walked to the bathroom. When asked, Mr. Brown tells Melanie “I have pain where the ulcer is”. Melanie probed further to determine the characteristics of Mr. Browns’ pain as constant and throbbing, and he rated its intensity as 6 out of 10. Melanie administered pain medication (Tylenol #3- 2 tablets) at 0830. Melanie reassessed Mr. Brown’s pain at 0945 and he rated the intensity at 1 out of 10. Melanie decided to do Mr. Brown’s dressing change at 0950 since Mr. Brown’s pain was controlled. When Melanie removed the old dressing, Melanie noted a moderate amount of fresh watery, bloody drainage with a small amount of green-yellow pus drainage. The ulcer area was round and the size was about 3 cm x 4 cm, the area around the ulcer was red. The ulcer borders were well defined. Most of the wound bed was granulation tissue with a smaller amount of yellow slough. Mr. Brown had decreased sensation to this area of his foot as he could not feel the coolness of the solution or feel when Melanie was pressing down. An adaptive dressing, 2- 4×4 gauze and 1/2 abdominal pad was placed on the wound. Mr. Brown did not complain of any discomfort during the dressing change.  1. Imagine you are Melanie. Document the care you provided to Mr. Brown correctly in the space below:   Time Nursing  Notes                  Documentation Scenario #2 Mrs. Ada Green, an 89 year old widow, lives alone in her two story home. She is recovering from surgery following an “anterior resection” for bowel carcinoma. She was discharged with a Home Nursing Care referral for a home transition assessment and wound healing assessment because she developed a post-surgical wound infection while she was in hospital. At discharge from hospital Mrs. Green was alert and determined to remain independently mobile in her own home for as long as possible. Mrs. Green has Meals on Wheels delivered twice weekly and private home support twice weekly for assistance with personal care. She is on a regular diet and is capable of managing her cardiac, pain and antibiotic medications, which her friend has labelled for her. A neighbor assists with transportation, shopping and social planning. Mrs Green has no family in town. On the morning of October 12 at 0950, three days after being discharged from hospital, Janie Wagner, the Home Care Nurse, found Mrs Green sitting in her chair looking anxious and somewhat unkempt. She was rocking back and forth, clutching her abdomen and moaning. When asked she stated, “I’m in pain” and ” I can’t seem to catch my breath”. Her dressings were in disarray, there was a distinct fecal odor, and she was diaphoretic. She admitted that she had spent the night in her rocker, did not know the time and could not recall when she had last taken her pills or eaten. Janie took her vital signs and they were as follows: Temperature: 100.4 F, pulse 110/ minute and regular, blood pressure 100/70 mmHg, respirations 28 breaths/minute and mildly labored. 2. Imagine you are Janie. Document your assessment of Mrs. Green to this point in the space below. Time Nursing Notes     Self-Assessment Review your documentation above and reflect on the following questions. Did you: Document all clinically significant information using the nursing process?Document care you personally provided to the client?Document in a manner that is clear, concise, factual, and objective?Avoid generalizations and vague descriptors and subjective judgements? Use only approved abbreviations?Document in a chronological and timely fashion?Add your signature and title, or initials as appropriate to each entry made on the health record? Document legibly?_________________________________________________________________________ Case Scenario #1: Rachel  Rachel looked up at the clock – 11am. “Wow,” she thought, “It’s been a busy day and I am not even halfway through yet!” After 5 years in this Extended Care Unit, she had got used to being busy, but today seemed to be ‘one of those days’. She was, as usual, the only RN on today in this 36 bed unit, along with one LPN and four Registered Care Aides. She knew that everyone would be busy: The unit was full and the current client group required a lot of care – and that made for a heavy workload for everyone. She paused for a moment to collect her thoughts and decide on the next thing she needed to do. While her responsibility encompassed all of the clients on the unit, there were four clients that particularly concerned her today. Two were confused and agitated and required close monitoring, another was dying and, with his family at his bedside, needed comfort care and support, and finally Mr. Bell had been short of breath and coughing during the night. When Rachel had looked in on him earlier, he was breathing at 24/ minute, occasionally coughed up yellowish secretions and had a temperature of 101.5 F. Her thoughts were interrupted when Jasmine, an LPN who had worked on the unit for 10 years, stopped beside her and said, “Can you come and look at Mr. Bell? He seems to be worse that he was earlier this morning. I sat him up a bit more and that helped a little, but I am quite concerned about him.” Rachel nodded and they walked down the hallway to Mr. Bell’s room. At first glance it was clear to Rachel that he was worse. His face was slightly diaphoretic and she could hear his coarse cough. When she asked him how he was feeling, he replied, “I feel pretty tired. This coughing is wearing me out.” She nodded and said, “I can see that. If it’s OK with you, I would like to have a closer look at you.” She counted his respiratory rate at 26/minute and then had a quick listen to his chest. She noted that he had coarse crackles in both posterior and anterior lower lung fields. His temperature was 101.5 F. Rachel bent slightly closer to him and spoke gently. “Mr. Bell, I can see that you are not feeling well and that you are tired. Your chest sounds kind of rattly and you have a bit of a fever. I am going to call your family doctor and let him know. I’ll come back as soon as I have done that and let you know what he says.” Rachel called Dr Simms and explained the situation, outlining the change in Mr. Bell’s condition over the previous 24 hours. In response, Dr Simms suggested that Mr. Bell “probably has the flu that’s going around” and instructed Rachel to “keep an eye on him” and to “call him back if she was concerned”. Rachel hung up the phone and pulled Mr. Bell’s chart from the shelf. She made the following entry in his nursing notes: Entry #1Time Nursing Notes 1200 Client seems short of breath. Has a fever. Doctor informed. —–Rachel Mann, RN  Rachel returned to Mr. Bell and, as per the unit’s standing orders, gave him some Tylenol elixir “for comfort”. She also made sure he was well positioned in bed and then left the room to continue with her care for other clients. Over the next four hours, she checked in on Mr. Bell several times and counted his respiratory rate, noting that it was still high. At one point she listened to his chest again, noticing that the crackles had increased. Four hours after her initial phone call, Rachel was quite concerned about Mr. Bell – His respiratory rate was 30/minute, he seemed to be working harder with his breathing, his chest sounded worse, and his pulse oximeter read 92%. She knew that often when clients were sick like this, that they would be send the client to ER at the local hospital, however, Dr Simms had indicated he was happy to be called about his clients, so she decided to call him again and update him. After she had explained the situation, Dr Simms said “I am leaving my office shortly and have to drive past the care facility on my way home, so I will drop in and have a look at Mr. Bell.” Rachel reached hung up the phone, glanced at the clock and realized she has several medications that she was late dispensing. She quickly wrote a note in Mr. Bell’s chart, and then left the office area to attend to the medications. Entry #2Time Nursing Notes 1600 Client’s breathing looks worse. Doctor notified. ———————Rachel Mann, RN  Dr Simms arrived 45 minutes later and assessed Mr. Bell. He then wrote an order to start Mr. Bell on antibiotics and to begin supplemental oxygen via nasal prongs at 3L/minute. Rachel came into the office as he had just completed writing the orders. “Oh Hi, you’re here,” she said. “What do you think is happening?” she asked. He replied, “I think he has the flu, and seems to have a bit of chest infection. I have ordered him some antibiotics and we can start some oxygen therapy and see if that makes him more comfortable. Can you check his pulse oximeter readings every two hours. If they fall below 92%, or if you think he is getting worse, please call an ambulance and send him to the ER.”As Dr Simms left, Rachel reviewed the orders he had written and faxed the prescription for antibiotics to the pharmacy. She also updated the documentation in Mr. Bell’s chart: Entry #3Time Nursing Notes 1700 Dr. in. Orders received.——————————————————Rachel Mann, RN  Answer the following questions related to Case Scenario #1 Review Rachel’s documentation. In what ways does it meet criteria for effective documentation? What documentation errors are present? Where there are errors, describe how Rachel should have documented Mr. Bell’s care in these situations. Provide examples of effective documentation. Entry #1Time Nursing Notes     Entry #2Time Nursing Notes     Entry #3Time Nursing Notes      What factors do you think influenced Rachel’s ability to document appropriately in this situation? What do you think could be done that would assist Rachel to document effectively in future? What are the implications of Rachel’s ineffective documentation for Mr. Bell’s outcomes? Consider the conceptual framework and directives for documentation in nursing practice. What could be the implications of Rachel’s ineffective documentation for herself?Health ScienceScienceNursingNURSING 204Share Question

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