Name: Michael Andre R.

Coros
Course: BSN I-A
1. Compare and contrast different documentation methods utilized in two hospitals
worldwide.

The Royal
Children’s
Hospital in
Melbourne

- 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.
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’.
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/careers 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.
 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.

REFERENCES

 Australian Commission on Safety and Quality in Health Care (2017). National Safety and Quality
Health Service Standards: Guide for Hospitals (2nd Ed.). Sydney: ACSQHC.
 Blair, W., & Smith, B. (2012). Nursing documentation: Frameworks and barriers. Contemporary
Nurse, 41(2), 160-168
 Collins, S. A., Cato, K., Albers, D., Scott, K., Stetson, P. D., Bakken, S., & Vawdrey, D. K. (2013).
Relationship between nursing documentation and patients’ mortality. American Journal of Critical
Care, 22(4), 306-313.
 De Marinis, M. G., Piredda, M., Pascarella, M. C., Vincenzi, B., Spiga, F., Tartaglini, D., Alvaro,
R., & Matarese, M. (2010). ‘If it is not recorded, it has not been done!’? consistency between
nursing records and observed nursing care in an Italian hospital. Journal of Clinical Nursing, 19,
1544-1552.
 Häyrinen, K., Lammintakanen, J., & Saranto, K. (2010) Evaluation of electronic nursing
documentation—Nursing process model and standardized terminologies as keys to visible and
transparent nursing. International Journal of Medical Informatics, 79 (8), 554-564.
 Jefferies, D., Johnson, M., & Griffiths, R. (2010). A meta‐study of the essentials of quality nursing
documentation. International journal of nursing practice, 16(2), 112-124.
 Johnson, M., Jefferies, D., & Langdon, R. (2010). The Nursing and Midwifery Content Audit Tool
(NMCAT): a short nursing documentation audit tool. Journal of nursing management, 18(7), 832-
845.
 Kargul, G. J., Wright, S. M., Knight, A. M., McNichol, M. T., & Riggio, J. M. (2013). The hybrid
progress note: Semiautomating daily progress notes to achieve high-quality documentation and
improve provider efficiency. American Journal of Medical Quality, 28(1), 25-32.
 Hospitals in the
Philippines

ASSESSMENT

- person-centred and aims to develop a database of subjective and objective information

relating to an individual's physical, developmental, emotional and psychosocial health.

CLIENT’S HEALTH HISTORY

-
NURSING DIAGNOSIS

- Established from the recognition of patterns in the assessment data, comparison of trends
to normal standards and developing reasoned clinical judgements relating to an individual's
needs, protective factors, concerns or health problems.

PLANNING

- Planning involves critical thinking to priorities individual's problems and develop a set of
measurable goals and expected outcomes. The main purpose for developing goals and
expected outcomes are to provide direction for individualized nursing intervention and set
standards for determining the effectiveness of interventions. The development of goals of
care forms the creation of a nursing care plan.

IMPLEMENTATION

- Implementation involves carrying out the pre-determined interventions to achieve, or

progress towards the identified goals of care in the nursing care plan. Implementation
requires cognitive, interpersonal and psychomotor skills to identify the most appropriate
method, provide theoretical rationale and technically perform the intervention.

EVALUATION

- Evaluation involves consideration of responses to nursing interventions implemented and

determining the effectiveness in progressing towards or achieving identified goals and
promoting wellbeing. Evaluation is a dynamic and changing process depending on revision
of the condition, needs and changing abilities of the client.

Overall, whether in the Philippines or in abroad, all of the hospitals believe that good documentation is
important to protect your patients. Good documentation promotes patient safety and quality of care.
Complete and accurate medical recordkeeping can help ensure that your patients get the right care at
the right time. At the end of the day, that's what really matters.

REFERENCES

(Petablackburn, 2021). Module 3 the nursing process. Retrieved from

https://quizlet.com/au/496812995/module-3-the-nursing-process-flash-cards/ .