Saint Mary’s University

Bayombong, Nueva Vizcaya

School of Health & Natural Science
CHAPTER 2
GUIDELINES FOR EFFECTIVE DOCUMENTATION

I. Introduction: Documentation helps ensure consent and expectations. It helps to tell the
narrative for decisions made, and how yourself or the client responded to different situations.
In this same manner, it is important to record information that can help support the proper
treatment plan and the reasoning for such services.
II. Learning Objectives:
● To understand the importance of documentation in different care system aside from
hospital setting
to determine the
● Identify and enumerate geriatric health care team
severity of illness,
● Identify different courses offered that focus on gerontology the intensity of
III. Core Content of the Chapter: services, and the
so for example yung quality of care
kapalitan mo sa duty, he or
she claiming na ginawa niyaA. Documentation for Quality Care provided
‘tong intervention na ‘to
pero hindi naman nakalagay
Clinical documentation chronicles, support, and communicate the results of the
sa documentation niya ano assessment. Good documentation will help the nurse identify, monitor, and evaluate
pwedeng mangyari, for
example nagtake na pala treatment or interventions. The recorded assessment provides the data needed for the
siya ng ganitong gamot pero careful development of the individualized plan of care and the evaluation of patient
hindi siya nag countersign
so ikaw na next shift outcomes. Documentation also provides the communication needed to ensure that a
nagbigay ka kasi wala ka person continues to receive continuity of care - from one ship to another and one
nakitang countersign, so
naibigay mo ulit eh yung caregiver to another and across settings. The nurse who provides care to a patient for
gamot is OD=Once a day.
Pero syempre dapat
whom the previous nurse did not document knows well the potential errors that can be
gamitan mo rin ng common made and the added risk to the patient. At the same time, documentation is the major
sense, always ask and
check, dahil no means for the nurse to demonstrate the quality of care he or she provides.
documentation no so the more maganda ang documentation, mas magandang
intervention given. quality of care ang kaya mong ibigay
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.
so kung itatagalog lang naman naten siya, nagsisimula ang assessment and documentation once yung pasyente pumasok sa for examplesa ER

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 scan 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 pre-established trajectory and to anticipate the day of discharge.
sila yung pinaka the best
source mo when it comes to
assessment other than the D. Documentation In Home Care
patient him or herself since
sila yung mostly kasama The majority of the care that is provided in the home is by informal caregiver’s family
nila, at nagaalagay pero
minsan syempre hindi pa
members and others. They will often develop documentation systems of their own to
rin enough na sila lang track appointment, medication administration, and health care provider instruction. This
yung
magpoprovide ng care sa system increases the continuity of care. Nurses may need to assist the family in
pasyente kaya meron developing and using effective systems. Common sa philippines ang anak, or kamag anak lang yung nag aalaga
tayong GERIATRIC
HEALTH CARE TEAM
E. Geriatric Health Care Team
Discipline Role in gerontology
1. Geriatrician Use knowledge of normal aging as part of
assessment
Specialized in the diagnosis and treatment of the
elderly
2. Psychiatrist Geropsychiatry evaluation, treatment, and
management of mental health issues faced by the
elderly

Includes pharmacotherapy, evaluation of cognition,

and psychotherapy
 Saint Mary’s University
Bayombong, Nueva Vizcaya
School of Health & Natural Science
3. Psychologist Geropsychology assessment, consultation,
intervention, and management of conditions related
to adaptation, bereavement, counseling, and
treatment for clinical cognitive and behavioral needs
4. Registered nurse Assessment, planning, providing, coordinating, and
evaluating care, which focuses on health, optimal
wellness, disease prevention, And advocacy
5. Client/Patient dietician Expert in their experience assess nutritional status
and implementation of a nutritional plan
6. Audiologist Hearing assessment including audiometric studies,
evoked potentials, and other diagnostic procedures,
and treatment of hearing loss
7. Speech- language pathologist Assess and treat communication disorders, which
includes speech, language, hearing, swallowing, and
cognitive deficits
8. Occupational therapist Assess and treat functional, sensory, and perceptual
deficits that impact on ADLs

Assess need for assistive devices

for example yung patient na stroke Assess and treat cognitive deficits

Rehabilitative services in geropsychiatric

9. Physical therapist Access mobility and functional capacity of the elderly

Treatment includes rehabilitation, Strengthening,

mobility, and use of assistive devices
10. Pharmacist Prepare and dispense medication

Clinical consultation and dedication for patient and

geriatric team
11. 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,
Visitation, Or respite
12. Social worker Assist with coping and problem solving as individuals
and families adjust and face changes with aging and
chronic illness

Provide counseling and psychotherapy

Certification in Gerontologic Nursing

Gerontologic Nurse
1. Holder of active RN license
2. Full- time RN 2 years
practice
3. Clinical practice of at least
2000 hours in gerontologic
nursing within the past 3
years
4. Continuing education of 30
contact hours applicable to
gerontology within the past
3 years
Gerontologic Acute Care Nurse
Practitioner
1. Holder of active RN license
2. Master’s, postgraduate or
doctorate degree holder
from a gerontologic acute
care nurse practitioner
program accredited by
Commission on Collegiate
Nursing Education (CCNE)
or Accreditation
Commission for Education
in Nursing (ACEN)
3. 500 faculty- supervised
clinical hours
4. Three separate,
comprehensive graduate-
level courses in the
following:
a. Advance physiology &
pathophysiology
Gerontologic Primary Care Nurse
Practitioner
1. Holder of active RN license
2. Master’s, postgraduate or
doctorate degree holder
from a gerontologic acute
care nurse practitioner
program accredited by
Commission on Collegiate
Nursing Education (CCNE)
or Accreditation
Commission for Education
in Nursing (ACEN)
3. 500 faculty- supervised
clinical hours
4. Three separate,
comprehensive graduate-
level courses in the
following:
a. Advance physiology &
pathophysiology
 Saint Mary’s University
Bayombong, Nueva Vizcaya
School of Health & Natural Science
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

Courses/Organizations in the Philippines that focus on Care for Older Adults:

● Organization: Gerontology Nurses Association of the Philippines (GNAP)
● Philippine Society of Geriatrics and Gerontology (PSGG)
● Course: Master of Arts in Nursing Major in Gerontology and Geriatrics Nursing

References:
https://www.addictionacademy.com/2017/03/the-importance-of-documentation/