Recording training

Proper nursing documentation will, most importantly, ensure that your patients receive the highest quality and correct care in response to their symptoms. Legally speaking, proper nursing documentation will help you defend yourself in a malpractice lawsuit, and can also keep you out of court in the first place.

General objective This program is designed for nurses for applied quality measures of documentation records. Specific objective At the end of this program the nurses will be able to : 1- Define documentation Program plan: This training program include tow hours theory and two hours practice. The theoretical part: Starts at 10 am 2pm. Tea break at 12md. For 15min. The clinical part: Will last two weeks following the theoretical part Participant : number and position.

Number of participant are 20 nurses , from different positions in the hospital having the head nurse of the ICU unit. Program time table Participants evaluation : The theoretical part: Pre and immediate post program test. Follow up evaluation will be conducted one month after the program. The clinical part: Participants activities during class Implementation of learned activities in their units. Program evaluation: The participants will be requested to fill evaluation format at the last day of the program.

Purposes of client records

1- Communication: The record serves as the vehicle by which different health professionals who interact with a client communicate with each other. 2-Planning client care: Each health professionals uses data from the clients record to plan care for the client. 3-Auditing client care: An audit is review of client records for quality assurance purposes. 3-Research: The information contained in a record can be a valuable source of data for research. 4-Education: Students in health disciplines often use client records as educational tools. 5-Legal documentation: The clients records is a legal document and is usually admissible in court as evidence. 6-Health care analysis: Information from records may assist health care planners to identify agency needs, such as over utilized and underutilized hospital services.

Practice guidelines documentation

Date and time: Document the date and time of each recording, this is essential for legal reasons and for client safety. Timing: Follow the agency's policy about the frequency of documenting. Legibility: All entries must be legible and easy to read to prevent interpretation errors. Permanence: All enteries on the clients record are made in dark ink so that the record is permanent and changes can be identified. Accepted terminology: Use only commonly accepted abbreviations, symbols, and terms that are specified by the agency. Correct spelling: Correct spelling is essential for accuracy in recording. Signature:

Each recording on the nursing notes is signed by the nurse making it. Accuracy: The clients name and identifying information should be stamped or written on each page of the clinical record. Notations on records must be accurate and correct. Accurate notations consist of facts or observation rather than opinions or interpretations. It is more accurate , for example, to write that the client refused medication (fact) than to write the client was uncooperative (opinion) . When a recording mistake is made , draw a line through it and write the words mistaken entry above or next to the original entry with your name .

Do not erase , blot out , or use correction fluid .the original entry must remain visible. Write on every line but never between lines. If a blank appears in a notation raw a line through the blank space so that no additional information can be recorded at any other time or by any other persons, and sign the notation. Sequence: Document events in the order in which they occur. Appropriateness:

Record only information that pertains to the clients health problems and care . Completeness: The information that is recorded needs to be complete and helpful to the client and health care professionals. Nurses notes needs to reflect the nursing process. Care that is omitted because of the client's condition or refusal of treatment must also be recorded . Conciseness: Recordings need to be brief as well as complete to save time in communication . Legal prudence: Accurate , complete documentation should give legal protection to the nurse , the client's other caregivers , the health care facility, and the client. Do's Chart a change in a clients condition and show that followup actions were taken. Read the nurses notes prior to care to determine if there has been a change in the clients condition. Use objective, specific and factual description. Correct charting errors chart all teaching. Record the clients actual words by putting quotes around the words. Chart the clients response to interventions. Review your notes- are they clear and do they reflect what you want to say? Check that you have the correct chart before you begin writing.

 Make sure your documentation reflects the nursing process and your professional capabilities.

Write legibly. Chart the time you gave a medication, the administration route, and the patient's response. Chart precautions or preventive measures used, such as bed rails. Chart patient care at the time you provide it. If you remember an important point after you've completed your documentation, chart the information with a notation that it's a "late entry." Include the date and time of the late entry. Don'ts Don't leave blank space for a colleague to chart later Don't chart in advance of the event (e.g. procedure, medication). Don't use vague terms (e.g. appears to be comfortable). Don't chart for someone else. Don't record assumptions or words reflecting bias Don't chart a symptom, such as "c/o pain," without also charting what you did about it. Don't alter a patient's record - this is a criminal offense. Don't use shorthand or abbreviations that aren't widely accepted. Don't chart what someone else said, heard, felt, or smelled unless the information is critical. In that case, use quotations and attribute the remarks appropriately. Don't chart care ahead of time - something may happen and you may be unable to actually give the care you've charted. Charting care that you haven't done is considered fraud.

IF IT IS DOCUMENTED..................... IT IS DONE & IF IT IS NOT DOCUMENTED.................. IT IS NOT DONE