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ملتقى التمريض يهتم بجميع امور التمريض التثقيفية

Documentation

[align=center] Documentation Outline :  Objectives  Introduction  Definition of documentation  Purpose and goal of documentation  Documentation systems  Types of records

ملتقى التمريض
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  #1  
قديم 09-08-2009, 10:26 PM
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رانـيـه ج will become famous soon enough


[align=center]Documentation



Outline :

 Objectives
 Introduction
 Definition of documentation
 Purpose and goal of documentation
Documentation systems
 Types of records
 Guide line of quality of documentation
 Types of Reporting
 Summary
 References






Objectives

At the end of this seminar all students will be able to :

- understand the definition of documentation
- identify the purpose of documentation
- identify most important documentation systems
- know that guide line of quality of documentation
- know the legal consideration of documentation
- identify traditional source record
- identify different types of reporting







Introduction :

Accurate documentation of patient symptoms and observations is critical to proper treatment and recovery. Entries written on a patient's medical record are a written, legal, permanent document. If documentation is poorly or inaccurately entered into a medical record, patient may receive improper or potentially harmful care. What you document as fact in a medical record, is directly used by physicians, nurses, and physician assistants to plan, implement, and evaluate their patient's course of treatment.

Effective communication among health professionals is vital to the quality of client care. This type of communication can take many forms between the health care personnel; such as discussion: which is informal oral consideration of a subject by two or more health care workersto identify a problem or establish strategies to resolve a problem.




Definition of documentation :

It`s anything written or printed that is relied on as a record of proof for authorized persons

The collection of documents that describes the requirements, capabilities, limitations, design, operation, and maintenance of a system, such as a communications, computing, or information processing system.
The act or an instance of the supplying of documents or supporting references or records.
The documents or references so supplied.
The collation, , and coding of printed material for future reference.



Purpose of documentation

Communication - a means of communicating and sharing information on the patient's status throughout the hospitalization with health care team members , the recod serves as the vehicle by which different health professional who interact with a client communicate with each other, this prevents fragmentation, repetition, and delays in client care.


Patient care planning - each professional working with the patient has access to the patient's baseline and ongoing data. Patient responds to the treatment plan from day-to-day is documented. Modifications of the plan of care are then based on this data

Audit - patient records may be reviewed to evaluate the quality of care received and to improve the quality of care as indicated

Research - patient records may be studied by researchers to learn how best to recognize or treat health problems , The information contained in a record can be a valuable source of data for research. The treatment plans for a number of client with the same health problems can yield information helpful in trearing a particular client.


Education - clinical manifestations of particular health problems, effective treatment methods, and factors affecting client goal achievement are documented


Financial billing :to show the service and care and procedures , diagnostic tests made for the patient

Legal documentation : accurate documentation is one of the best defense for legal claims associated with nursing care (care not documented not done)


Documentation systems


Narrative documentation:

Is the traditional method for recording nursing care. It is simply the use of a storylike format to document information specific to client conditions and nursing care.

Source-Oriented Record:
Is the traditional client record. Each person or department makes notation in a separate sections of the client chart. For example, the admission department has an admission sheet, a doctor’s has history sheet, order sheet; the nurses use the nurses’ note, and so on.
This type is conenient because care providers from each discipline can easily locate the forms on which to to record data and it is easy to trace the information specific to one’s discipline. The disadvantage is that information about a particular client problem is scattered throughout the chart.

Problem-oriented medical records ( POMR ):

Is a method of documentation that places emphasis on the client's problem. Data are organized by problem or diagnosis.
The POMR has the following major sections: database, problem list, car plan, and progress notes.



Database:

the database section contains all available assessment pertaining to the client.

Problem list:

after data are analyzed, problems are identified and a single list is made. The problems include the client's physiological, psychological, social, cultural, spiritual, developmental, and environmental needs.

Ng. care plan:

a care plan is developed for each problem by the disciplines involved in the client's care.

Progress notes:


SOAPIE , SOAP , PIE
focus charting or DAR : Intended to make the client and client concerns and strengths the focus of care.consists of three columns for recording: date and time, focus, and progress notes→ which organized into data (D), action (A), and response (R).
The focus charting system provides a holistic perspective of the client needs


Source record ( insert table )

Is the traditional client record. Each person or department makes notation in a separate sections of the client chart. For example, the admission department has an admission sheet, a doctor’s has history sheet, order sheet; the nurses use the nurses’ note, and so on.
This type is conenient because care providers from each discipline can easily locate the forms on which to to record data and it is easy to trace the information specific to one’s discipline. The disadvantage is that information about a particular client problem is scattered throughout the chart.





common record-keeping forms :

- nursing history: this form guide the nurse through complete assessment to identify relevant nursing diagnosis . data in this record consider as baseline that can be compared with changes in the client's condition.

- graphic sheets and flow sheets: ( benefits )

- Ng. cardex.

- Acuity recording systems.

- Discharge summary forms.


Home health care documentation
Long-term health care documentation
Computerized documentation: This system developed as a way to manage the huge volume of informations, nurses use computers to store the client’s database, add new data, create care plan.





Guidelines for quality documentation and reporting

Factual
A record contains de******ive, objective information about what a nurse sees, hears, and smells.

Accurate
The use of exact measurements ensures that a record is accurate.

Complete
The information within a recorded entry or a report needs to be complete, containing concise, appropriate and through information about a client’s care.

Current
Timely entries are essentials in the client’s ongoing care.

Organized
The nurse communicates information in a logical order.



GUIDELINE FOR RECORDING:

Date and Time:
Essential not only for the legal reasons but also for client safty.

Timing:
According to the agency policy about the frequency of documenting.

Legibility & permanence:
All enteries must be easy to read and permanent by using dark ink.

Accepted terminology:
Use the only common accepted abbreviations, symbols, and termsthat are specified by the agency.

Correct spelling.

Signature:
Include the name, and title.

Accuracy & sequence.

Appropriatteness& completeness.

Conciseness & legal prudence


Types of Reporting:

Report: is oral, written or computer-based communication intended to convey information to other. For example, nurses always report on clients at the end of a hospital work shift. A

Change-of-shift reports

Telephone reports

Telephone orders

Transfer reports

Incident reports


Summary :
It`s important for the nurse to have adequate information about documentation to protect himself and the patient
Nursing documentation can have an impact on the quality of care.
Poor quality documentation can impact on informed treatment decision-making.
The completion of a particular nursing documentation system will depend on the attitude and satisfaction of the staff, if they are very satisfied and comfortable with the system, nursing documentation is more likely to be completed.
The information provided within nursing documentation has a direct influence on the level of care a resident will receive.The completion of a particular nursing documentation system will depend on the attitude and satisfaction of the staff, if they are very satisfied and comfortable with the system, nursing documentation is more likely to be completed.


References :

Kozier b, 2000: fundementals of nursing, sixth edition.
Denis S. 1994, Philadelphia : nursing documentation : charting , recording , and reporting
http://www.gnu.org/copyleft/fdl.html

http://****.sun.com/developer/codesamples/index.html
[/align]


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من مواضيعي : رانـيـه ج
رد مع اقتباس
  رقم المشاركة : [ 2 ]
قديم 09-09-2009, 02:32 AM
مشرف سابق
 

B.S.M will become famous soon enough
افتراضي

[align=center]رانية

يعطيك العافية على النقل و الطرح الجميل

إخترتي فنقلتي فأبدعتي

تمنياتي لك بالتوفيق [/align]
من مواضيع : B.S.M
B.S.M غير متواجد حالياً   رد مع اقتباس
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قديم 09-10-2009, 04:29 AM
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white dream will become famous soon enough
افتراضي

يعطيك العافيهـ
white dream غير متواجد حالياً   رد مع اقتباس
  رقم المشاركة : [ 4 ]
قديم 10-03-2009, 11:54 PM
مثقفة مرضى السكر
 

رانـيـه ج will become famous soon enough
افتراضي

[align=center]الاستاذ بندر المحمادي
white dream
اشكركم كل الشكر على مروركم
نورتوا صفحتي
[/align]
من مواضيع : رانـيـه ج
رانـيـه ج غير متواجد حالياً   رد مع اقتباس
  رقم المشاركة : [ 5 ]
قديم 10-08-2009, 11:10 PM
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غصون الغامدي will become famous soon enough
افتراضي

[align=center]يسلموو الله يعطيك العافيه
قمه في الابداع والتميز
على روع ــة طرحك .. وابداعك الملحوظ..
آعجبني ما تسطرهـ يمينك ..
لاآ عدمنـــا روع ـــة قطفك ,,
ودي مع عطر وردي ..
غصون..
[/align]
من مواضيع : غصون الغامدي
غصون الغامدي غير متواجد حالياً   رد مع اقتباس
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قديم 10-09-2009, 11:21 PM
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رانـيـه ج will become famous soon enough
افتراضي

[align=center]اختي غصون
اشكرك على مرورك
وكلماتك العطرة
نورتي صفحتي
[/align]
من مواضيع : رانـيـه ج
رانـيـه ج غير متواجد حالياً   رد مع اقتباس
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قديم 01-14-2010, 01:55 PM
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hamad999 will become famous soon enough
افتراضي

"Thank you very much"
On your effort
Receptive greetings
hamad999 غير متواجد حالياً   رد مع اقتباس
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قديم 01-04-2011, 04:11 AM
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سمير11 will become famous soon enough
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يعطيكي العاافيه لا خت راااانيه ولا ترحرمينا من جديد
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