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GUIDELINES AND PROTOCOLS IN DOCUMENTATION - Hce

Nursing documentation provides an accurate reflection of patient care and is essential for clinical communication between the multidisciplinary team. Guidelines are provided for a structured approach to nursing documentation including assessing patients at the beginning of each shift, planning care in collaboration with patients, documenting care in flowsheets, and evaluating outcomes through real-time progress notes. Consistent documentation ensures safe patient care and supports the nursing process of assessment, planning, implementation and evaluation.

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Roshin Tejero
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430 views

GUIDELINES AND PROTOCOLS IN DOCUMENTATION - Hce

Nursing documentation provides an accurate reflection of patient care and is essential for clinical communication between the multidisciplinary team. Guidelines are provided for a structured approach to nursing documentation including assessing patients at the beginning of each shift, planning care in collaboration with patients, documenting care in flowsheets, and evaluating outcomes through real-time progress notes. Consistent documentation ensures safe patient care and supports the nursing process of assessment, planning, implementation and evaluation.

Uploaded by

Roshin Tejero
Copyright
© © All Rights Reserved
Available Formats
Download as PDF, TXT or read online on Scribd
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GUIDELINES AND PROTOCOLS IN DOCUMENTATION

INTRODUCTION

Nursing documentation is essential for good clinical communication. Appropriate


documentation provides an accurate reflection of nursing assessments, changes in
clinical state, care provided and pertinent patient information to support the
multidisciplinary team to deliver great care. Documentation provides evidence of care
and is an important professional and medico legal requirement of nursing practice.

Aim
To provide a structured and standardised approach to nursing documentation for
inpatients. This will ensure consistent clinical communication processes across the
RCH.

Definition of Terms

• EMR: electronic medical record


• EMR Review: process of working through the EMR activities to collect pertinent
patient details
• Real time: nursing documentation entered in a timely manner throughout the
shift.
• Required documentation: minimum documentation required to reflect safe
patient care. On admission and at the commencement of each shift, all ‘required
documentation’ must be completed to comply with the National Safety & Quality
Health Service Standards. There is an expectation that shift required
documentation is completed within 3 hours of shift start time.
Process
Nursing documentation is aligned with the ‘nursing process’ and reflects the principles
of assessment, planning, implementation and evaluation. It is continuous and nursing
documentation should reflect this.
Fig 1. Nursing Process
Assess
At the beginning of each shift, a ‘shift assessment’ is completed as outlined in
the Nursing Assessment Guideline. The information for this assessment is gathered
from handover, patient introductions, required documentation (safety checks and risk
assessments, clinical observations) and an EMR review and is documented in relevant
the ‘Flowsheets’.

Review of the EMR gives an overview of the patient. To complete an EMR review, enter
the patients’ medical record and work through the key activities in order. These tabs can
be customised to meet the specific needs of your patient group (EMR tip sheet link -
coming soon). It is recommended that each ward standardises the layout of their activity
bar based on their patient population.
The EMR review should include (*indicates essential);

• *Storyboard - age, bed card, gender, FYIs, infections, allergies, isolations, LOS,
weight
• *IP Summary - Medical problem list, treatment team, orders to be acknowledged
• *ViCTOR Graph - observations trends, zone breaches
• *Notes - e.g. admission, ward round, any other useful details (mark all as not
new)
• *Results Review - recent and pending results (time mark)
• *MAR - overdue medications, discontinued, adjust due times for medications
• Fluid Balance- input/output and balance
• Avatar- review lines/drains/airways/wounds, including, location, size, date
inserted
• *Orders:

• review all active, continuous, PRN and scheduled, discontinue expired,


• nursing orders create and manage as required for patient care
• Flowsheets - document specific information, ‘last filed’ will show most recent
entries, review and manage unnecessary rows e.g. ‘complete’

Patient assessments are documented in the relevant flowsheets and must include the
minimum ‘required documentation’. To ensure required documentation for each patient
is complete, use the summary side bar link (EMR Req Doc tip sheet link -- coming
soon).

Plan
With the information gathered from the start of shift assessment, the plan of care can be
developed in collaboration with the patient and family/carers to ensure clear
expectations of care.
The nursing hub is a shift planning tool and provides a timeline view of the plan of care
including, ongoing assessments, diagnostic tests, appointments, scheduled
medications, procedures and tasks. The orders will populate the hub and nurses can
document directly from the hub into Flowsheets in real-time. Orders are visible by the
multidisciplinary team.
Management of orders is crucial to the set up and useability of the hub. It must be
‘cleaned up’ before handover takes place - too many outstanding orders is a risk to
patient safety.
For more information on how to place and manage orders, click on the following
link: https://www.rch.org.au/Nursing_Hub.aspx
Additional tasks can be added to the hub by nurses as reminders. All patient
documentation can be entered into Flowsheets (observations, fluid balance, LDA
assessment) throughout the shift. Clinical information that is not recorded within
flowsheets and any changes to the plan of care is documented as a real time progress
note.
This may include:

• Abnormal assessment, eg. Uncontrolled pain, tachycardic, increased WOB, poor


perfusion, hypotensive, febrile etc.
• Change in clinical state, eg. Deterioration, improvements, neurological status,
desaturation, etc.
• Adverse findings or events, eg. IV painful, inflamed or leaking requiring removal,
vomiting, rash, incontinence, fall, pressure injury; wound infection, drain losses,
electrolyte imbalance, +/-fluid balance etc.
• Patient outcomes after interventions eg. Dressing changes, pain management,
mobilisation, hygiene, overall improvements, responses to care etc.
• Family centred care eg. Parent level of understanding, participation in care, child-
family interactions, welfare issues, visiting arrangements etc.
• Social issues eg. Accommodation, travel, financial, legal etc.

Implement and evaluate


Progress note entries should not simply list tasks or events but provide information
about what occurred, consider why and include details of the impact, outcome and plan
for the patient and family.
All entries should be accurate and relevant to the individual patient - non-specific
information such as ‘ongoing management’ is not useful.
Duplication should be avoided - statements about information recorded in other
activities on the EMR are not useful, for example, ‘medications given as per MAR’.
Professional nursing language should be used for all entries - abbreviations should be
used minimally and must be consistent with RCH standards, for example, ‘emotional
support was provided to patient and family’ could be documented instead of ‘TLC was
given’.
Real time notes should be signed off after the first entry and subsequent entries are
entered as addendums.
Example of real time progress note entry:
09:40 NURSING. Billie is describing increasing pain in left leg. FLACC 7/10.
Paracetamol given, heat pack applied with some effect. Education given to Mum at the
bedside on utilising heat pack in conjunction with regular analgesia. Continue pain score
with observations. (Progress Note, sign at the end)
10:15 NURSING. Episode of urinary incontinence. Billie quite embarrassed. Urine bottle
given. (Addendum)
14:30 NURSING. Routine bloods for IV therapy taken, lab called- high K+ (?
Haemolysed). Medical staff notified, repeat bloods in 6/24. Encourage oral fluids and
diet, if tolerated. IV can be removed. (Addendum)

***REFERENCES:
https://www.rch.org.au/rchcpg/hospital_clinical_guideline_index/nursing-documentation-
principles/

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