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DOCUMENTATION OF PATIENTS ACCESSMENT

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16 views

DOCUMENTATION OF PATIENTS ACCESSMENT

Uploaded by

sundayprincess06
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PDF, TXT or read online on Scribd
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DOCUMENTATION OF PATIENTS ASSESSMENT

Assessment can be defined as a systematic and continuous collection,validation and


communication of patients data by the healthcare professionals which enables effective plan of
care to be implemented for the patients.

SOURCES OF DATA USED IN PATIENTS ASSESSMENT

Patient( primary source)

Family and significant others

Patients record

Medical history

Laboratory investigations

TYPES OF ASSESSMENT

Initial Assessment: This is done shortly after patient is admitted.

Focused Assessment: the nurse gathers data about a specific problem that has already been
identified.

Emergency Assessment: this is performed when there is physiological or psychological crisis

Timelaped Assessment: this is done to compare patients current status to the baseline data
obtained.

SKILLS IN PATIENT ASSESSMENT

 Observation

 Interview

 Physical examination techniques such as Inspection, palpation, percusion and


auscultation.

DOCUMENTATION OF PATIENTS ASSESSMENT

This is the record of nursing care and is planned and delivered to individual patient by
qualified nurses or other care givers under the direction of a qualified nurse.

It is the principle of maximixing of information to meet professional and legal


requirements as well as vital component of safe, ethical and effective nursing practice
whether done manually or electronically.

Documentation was traditionally done as part of an extensive paper-driven system.


Hospitals around the world doday, are increasinly relying on computer technonoly ton
improve not only efficiency but also accuracy in documentationsystem. Electronic
documentation provides real time access to the patients records, thus the healthcare
wokers can constantly and immediately be aware of the conditions, needs,and problems
as they arise. Most patient information in the clinical setting are now electronic and use
intranet(privatecomputer network within an institution) technology to secure access by
healthcare workers to maintain patient confidentiality.

An electronic health record is a real time patient centred record that makes information
available instantly and securely to authorized users. The most frequent pieces of
information about patient in the EHR are:

 Treatment Administration Record: in most facilities, treatments are documented


in treatment administration record.

 Medication Administration Record: here, the nurse documents the medications


administered.

Diagnostic and laboratory test Record: Patients laboratory investigations and results are
recorded here.

TYPES OF DOCUMENTATION

There are six types of documentation:

 Charting by exemption

 Focused DAR Notes

 Narrative notes

 SOAPIE Notes

 Patient Discharge Summary

 Minimum data set charting

CHARTING BY EXCEPTION: This type of documentation aims at decreasing


the amount of time required for documentation. It contains a list of normal
findings.after performing an assessment, nursesconfirm normal finding on
the list found on the assessment chart and write brief progress notefor
abnormal findings.

FOCUSED DAR NOTE: DAR stands for Data, Action and Response. Focused
DAR Note is commonly used in combination with Charting By Exception.
They are brief notes with each note focusing on one problem for efficiency in
documenting and reading. It is of differet sections namely: DATA section: this
contains informaion collected during patient’s assessment which includes
vital signs and physical examination findings found during the nursing
process. ACTION SECTION: this contains the nursing actions that are
planned and implemented for the patient’s focused problem. It correlates to
the planning and implementation phase of the nursing process. RESPONSE:
Here , patients response to the nursing actions is documented. There is also
evaluation of effectivenessof the planned care. It correlates to the evaluation
phase of the nursing process.

NARRATIVE NOTES: this is a documentation of assessment findings and


nursing activities for the patient throughout the entire shift or visit.

SOAPIE NOTES: This is a type of documentation by nurses and other health


team members. It is an acronym for Subjective, Objective,Assessment, Plan,
Intervention and Evaluation.

Subjective: this includes the patient’s complaint or what he said. It can also
contain information related to patient medical history and the reason for
seeking medical or vnursing care.

Objective: contains the observable and measurable data collected during


patients assessment such as the vital signs, physical examination findings
and laboratory or diagnostic test results.

Assessment: it deals withb the interpretation of what was noted in the


subjective and objective sections such as nursing diagnosisin a nursing
progress noteor medical diagnosis in a progress note of a medical healthcare
provider(doctor)

Plan: this outlines the planof care based on assessment section including
goals and planned interventions.

Interventions: Actions implemented are described here.

Evaluation: it describes the patients response to intervention and determines


wether or not the planned outcome or actions were met or done.

PATIENT DISCHARGE SUMMARY: This is done when the patient is


discharged and includes the following:
Time of discharge from the hospital, condition of the patient at discharge,
discharge instruction on medication, treatment, diet and activity, follow-up
appointment or refferal given.

MINIMUM DATA SET CHARTING: this is a type of additional documentationin


a long term care settingused to provide information for reimbursementby
private insurance. It is federally mandeted assessment tool created by
registered nurses inskilled nursing facilities to track a patient’s goal
achievement.

PURPOSE AND IMPORTANCE OF DOCUMENTATION

 It is used to ensure continuity of care among healthcare team members and


across shift

 It helps to monitor standard of care for quality assurance activities

 It provides information for reimbursement purpose byinsurance companies.

 Documentation is used for research purposes.

 It can also serve as alegal instrumentin court of law.

PRINCIPLES OF DOCUMENTATION

 Documentation should be objective, factual, professional and make use


of proper medical/nursing terminologies as well as correct grammar
and spelling.

 All types of documentation must include date , time and signature of the
person documenting.

 Any type of documentation in the EHR is considered a legal


documentand must be compled in accurate and timely manner.

 Abbreviations must be avoided in legal documentation.

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