NURSING DEPARTMENT

Course No. NCM 114 Lecture

Subject: Care of Older Adult

Yr. Level: BSN 3

Contact Hours/ Credit Units: 2

Chapter 3
Documentation and the Health Care Team

I. Introduction:

Older adults vary greatly in their health and function, from active and independent

to medically fragile and dependent. The comprehensive assessment is more complex,

detailed and time- consuming. If a more thorough assessment is needed, this is usually

performed by a nurse- led interdisciplinary health care team. The assessment is not

complete until it is documented.

II. Learning Objectives:

1. Document health care services rendered to older adults accurately and

comprehensively.

2. Ensure completeness, integrity, safety accessibility and security of information of

older adults.

3. Adhere to protocol and principles of confidentiality in safekeeping and releasing

of records and other information.

4. Ensure intra- agency, interagency, multi- disciplinary and sectoral collaboration in

the care of older adults.

5. Maintain a harmonious and collegial relationship among the members of the

health team for effective, efficient and safe care of the older adult.

6. Collaborate with other members of the health team in the implementation of

nursing care programs and services.

III. Core Content of the Chapter:

A. Documentation for Quality Care

Clinical documentation chronicles support and communicate the results of the

assessment. Good documentation will help the nurse identify, monitor, and evaluate

treatment or interventions. The recorded assessment provides the data needed for

the careful development of the individualized plan of care and the evaluation of

patient outcomes. Documentation also provides the communication needed to

ensure that a person continues to receive continuity of care - from one ship to

another and one caregiver to another and across settings. The nurse who provides

care to a patient for whom the previous nurse did not document knows well the

potential errors that can be made and the added risk to the patient. At the same time,

documentation is the major means for the nurse to demonstrate the quality of care

he or she provides.

B. Documentation Across Healthcare Settings

Documentation begins as soon as the person enters the health care system and the

assessment begins. While the format may change, the purposes do not.

C. Documentations in Acute Care and Acute Rehabilitation Care Setting

Documentation in the acute care setting has undergone significant change in recent

years especially with the mandates for upgrading to the electronic medical record.

Computers can be found at the bedside, in nurses’ pocket, and in strategic locations
 around the unit. Nurses are given passwords that may be more important than their

name tags. Barcodes and even fingerprints are scanned both for access to records,

the administration of treatments and medications and the identification of patients.

The use of checklists, flowsheet, and standardized tools has become the norm, as

has the use of electronic format for everything from the documentation of meals

eaten to vital signs to discharge planning. Care maps are used to predict and

document the care provided within a preestablished trajectory and to anticipate the

day of discharge.

D. Documentation in Home Care

Most of the care that is provided in the home is by informal caregiver’s family

members and others. They will often develop documentation systems of their own

to track appointment, medication administration, and health care provider

instruction. This system increases the continuity of care. Nurses may need to assist

the family in developing and using effective systems.

E. Geriatric Health Care Team

Discipline Role in gerontology

1. Audiologist Hearing assessment including audiometric

studies, evoked potentials, and other

diagnostic procedures, and treatment of

hearing loss.
2. Chaplain/ Priest/ Rabbi/ Minister Provide support to the client/Patient, family,

and others as it relates to spiritual needs. May

assist in identifying resources within

congregation for support or visitation.

3. Client/Patient dietician Expert in their experience assess nutritional

status and implementation of a nutritional plan.

4. Geriatrician Use knowledge of normal aging as part of

assessment. Specialized in the diagnosis and

treatment of the elderly.

5. Occupational therapist Assess and treat functional, sensory, and

perceptual deficits that impact on ADLs.

Assess need for assistive devices. Assess and

treat cognitive deficits. Rehabilitative services

in geropsychiatric.

6. Physical therapist Access mobility and functional capacity of the

elderly. Treatment includes rehabilitation,

strengthening, mobility, and use of assistive

devices.

7. Pharmacist Prepare and dispense medication.

8. Psychiatrist Geropsychiatry evaluation, treatment, and

management of mental health issues faced by

the elderly. Includes pharmacotherapy,

evaluation of cognition, and psychotherapy.

9. Psychologist Geropsychology assessment, consultation,

intervention, and management of conditions

related to adaptation, bereavement,

counseling, and treatment for clinical cognitive

and behavioral needs.

10. Registered nurse Assessment, planning, providing,

coordinating, and evaluating care, which

focuses on health, optimal wellness, disease

prevention, and advocacy.

11. Social worker Assist with coping and problem solving as

individuals and families adjust and face

changes with aging and chronic illness.

12. Speech- language pathologist Assess and treat communication disorders,

which includes speech, language, hearing,

swallowing, and cognitive deficits

Certification in Gerontologic Nursing

Gerontologic Nurse Gerontologic Acute Care Gerontologic Primary Care

Nurse Practitioner Nurse Practitioner

1. Holder of active RN 1. Holder of active RN 1. Holder of active RN

license license license

2. Full- time RN 2 years 2. Master’s, 2. Master’s,

practice postgraduate or postgraduate or

3. Clinical practice of at doctorate degree doctorate degree

least 2000 hours in holder from a holder from a

gerontologic nursing gerontologic acute gerontologic acute

within the past 3 years care nurse practitioner care nurse practitioner

4. Continuing education program accredited by program accredited by

of 30 contact hours Commission on Commission on

applicable to Collegiate Nursing Collegiate Nursing

gerontology within Education (CCNE) or Education (CCNE) or

the past 3 years Accreditation Accreditation

Commission for Commission for

Education in Nursing Education in Nursing

(ACEN) (ACEN)

3. 500 faculty- 3. 500 faculty-

supervised clinical supervised clinical

hours hours

4. Three separate, 4. Three separate,

comprehensive comprehensive

graduate- level graduate- level

courses in the courses in the

following: following:

a. Advance a. Advance

physiology & physiology &

pathophysiology pathophysiology
 b. Advanced health b. Advanced health

assessment assessment

c. Advanced c. Advanced

pharmacology pharmacology

5. Content in:

a. Health promotion

and maintenance

b. Differential

diagnosis and

disease

management

Roles of Gerontological Nurse

1. Caregiver- gives direct, hands- on care to older adults in a

variety of settings.

2. Teacher- focuses on teaching modifiable risk factors and health

promotion.

3. Manager- balances the concerns of the patient, family and

interdisciplinary team.

4. Advocate- acts on behalf of older adults to promote their best

interests and strengthen their autonomy and decision- making.

5. Researcher- uses evidenced- based nursing practices to improve

the quality of patient care in all setting.

I. Activity:

Essay. Answer the question in 200- 250 words. Provide examples and in- text citations.

1. Discuss the importance of documentation to the interdisciplinary team and how it

affects the care of older adults.

II. Bibliography:

Ebersole, P., & Hess, P. (2001). Geriatric Nursing & Healthy Aging. Mosby, Inc. A

Harcourt Health Sciences Company.

Mauk, K. (2010). Gerontological Nursing: Competencies for Care. Jones and Bartlett

Publisher, Inc.

Touhy, T., & Jett, K. (2014). Ebersole and Hess' Gerontologic Nursing & Healthy Aging.

Mosby, Inc.