Good Documentation is Good Communication Nursing Care Plans - Essay Example

Good documentation is good communication nursing care plans Documentation is any communicable material, which is used toexplain some attributes (preferentially essential) of an object, system or process. Many a times, technical or medical writing skills are taught to the person who seeks to take responsibility of writing documents. However, in the present scenario documentation has become an essential need of people of all professions and from every sphere of life. A well-documented form of communication adds benefit to the confidence of the action and improves ability. The importance of the old saying “if it’s not documented in the medical record it was not done” has been visually and intellectually expressive in the present time of increased law and order in every section aiming for survival. And to this, nursing care plan is no exception. The nursing care plan is a stage of nursing process in which the concerned nurse outlines the nursing care to be provided to the patient. Nursing care plans documents form an essential part of nursing care benefit imparted to the patient. In the absence of the specific, precise, informative and patient care oriented documents delineating the plan of care, important healthcare issues bear the insecurity of being neglected. Care planning documents provide the complete sketch of the means to be followed and actions to be taken in the process of providing the best possible care service to the patient. The nursing care plan is also of value to the nurse in the other shift and to the family members and well-wishers of the patient. Despite so many potential beneficial aspects covered in the nursing care plan, it continues to be regarded as a mere additional burden to work or just a waste of time. It is a sorrow to see this reflection of some experts in the healthcare system. A document as an additional attempt to make more scientific and applicable the care system is the nursing care document. Its preparation, maintenance, usage, application, and respect can certainly add to the good documentation practice. And good documentation practice has always been a preferable and better means of good communication. In an attempt to explain the crucial points for patient’s care, a nurse may be required to depart from much of her on-duty time. This loss of time can also become a cause of less potential care imparted to the patient in the span of specific time. A plan, its document can ease the need of explanation and ensure more specificity and knowledge to the learner (i.e. nurse of the next shift or family member). Nursing Documentation – The essentials for quality communication In order to deliver a high quality skilled and safe care; it is essential to maintain a good quality written documents as means of essential communication. The registered nurses are committed to the duty of care by legal aspects and therefore should not deny the need of documentation. According to the Nursing and Midwifery Council guidelines, 2002, the documentation should be inclusive of the following crucial information: 1. A complete description of the nursing care planned and provided to the patient. 2. Any relevant information about the patient, at any point of time, and how their needs were met or were attempted to meet. 3. Information about the steps taken for the patient care in an attempt to fulfill the responsibilities in hand should be included. 4. A written communication of the arrangements made for the continuing care of the patients. The common documents that hold their valuable presence in most of the hospitals, community nursing service, and care home include nursing care plan. The nursing care plan includes the patient’s needs and problems. Sometimes, the plan also includes the nursing diagnosis. The nursing care plan goal should be set as per the SMART system; i.e. the goal should be specific, measurable, achievable, realistic, and time-oriented. However, there are goals, which cannot be precisely measured by any scale, for example the goal of relieving depression. In such cases, it is a good approach to approach the patient in person and asks in politeness about his feelings of depression, anxiety or say claustrophobia. a. It is also crucial to document the nursing care interventions that are planned with an aim to achieve the goals set. b. It is also of necessity to document the evaluation of progress and the date of review. This shall aim to be inclusive of notes on evaluation, continuation sheet, and plans for discharge of the patient. In certain areas one might use Kardex system for record progress. c. It is also essential to reassess the needs of the patient and bring changes to the nursing care plan with an aim to provide better service. Unlike the physicians and other medical practitioners, the presence of nurses in the care of patients is set for 24 hours in a day. The nurses usually work on the basis of shift, which gives birth to the need for transfer of information from one nursing team to the other. The mechanism followed for the co-ordination forms an important nursing activity and affects greatly the quality of care provided to the patient. The main purpose for nursing documentation includes: a. The documents shall act as the base for patient assessment, nursing care planning, implementation, and evaluation of the care delivered. b. The documents are essential for meeting the statutory requirements. c. The documented material helps in the determination of resource management. d. The documents help in analyzing whether performance indicators were met. e. The documents act as indicators for the ongoing research in nursing practice. The basic guidelines for good documentation and record keeping apply in equality to both the written and the computer records. The NMC 2002 has set the following guidelines to be followed in an attempt to maintain the patient’s record: a. The documents should be correct, consistent, and based on fact. b. The documents should be maintained such that they provide updated information of the patient. In order to keep the document content current it is essential that each step of care taken should be recorded at the earliest possible time. c. The handwriting should be clear and legible and should be written in such a way that it cannot be erased. d. The documents should be such written that any changes or additions are dated, timed, and signed, so that the original entry still is in touch with clarity. e. Accuracy in writing of date, time and sign are essential practices for keeping good and authentic records. f. The documents should not be devalued by including meaningless phrases, irrelevant and offensive statements, etc. The use of abbreviations and jargons should not be made. g. The documents should be written and maintained wherever possible, and should include the involvement of the patient, client, or the relative. h. The terminology used for record and documents should be simple and in a language that the patient understands. i. The document maintenance task should hold continuity and not bear any interruption. j. The documents should include any additional identified problems and the steps followed for the correction of these problems. k. A clear presentation of the evidence of the nursing care planned, the decisions made, and the care delivered, and to clear presentation of the evidence of the nursing care planned, the decisions made, and the care delivered, and the essential information shared should be provided. The first step of the nursing care plan that needs to be included in the documentation prepared is that of accurate and comprehensive assessment. In the case of acute care setting, a complete and confident admission nursing assessment needs to be followed. This can achieve by regular reassessments as and when the need demands. While in the case of the long-term care setting, the Minimum Data Set is the point of beginning for the assessment. For home health, the OASIS assessment is brought to practice. Thus, different settings have set different protocols for initial assessment and ongoing reevaluation. This makes the nursing care planning documentation more scientific in the order of imparting knowledge and more case oriented. Once a precise, concise and confident completion of the initial assessment has been made, one may progress ahead to thee generation of the list of problems. The problem list in its simple form consists of the list of medical ailments which were found to present and the list of diagnosis which were made for the same, However, in its more sophisticated form it involves working through the Resident Assessment Protocol. Process associated with the Minimum Data Set. A better documented nursing care plan aids more to the purpose of imparting knowledge to those concerned. Though time-consuming and bit of a hard work, the documentation act as an essential element of reference and communication. Thus, the best possible steps taken for the better documentation of nursing care plan should be cherished. Once the list of the problem is completed thoroughly, checked for correctiveness and corrected for preciseness, the planning on the presented problems tentative solution should begin. The concerned nurse should apply the course and experience gained knowledge to know whether there is a possible solution to the presented problems and if there is any then which one of them is practically possible and meets the implementation facilities available in the hospital. The nurse can also consult other medical practitioners in her attempt to find the solution of the existent patient problems. Once the solution for the problem is thought, the goal is set to meet the solution at the earliest and most convenient manner. The nurse needs to apply the plan and check for improvement in health in the review period. In the case of acute setting, the review period is short and sometimes insufficient to observe the required responses of gain of health after the application of plan. However, in the case of long-term and home health setting, the deficiency of shorter review period is almost ruled out. It should be noted that in every case the review period should be specific, measurable and attainable. It should however be considered that the nurse plan should not include unrealistic goals. . For example, one cannot keep a goal that the arthritis or diabetes patient would completely recover by the end of next week. Such unscientific goal should not be included in the nursing care plan. The goals that hold a scientific support for attainment and are within the limits of attainment should be specified. Thus, while writing the documents for nursing care plan, it is essential for one to consult ones past knowledge and experience and then reach a practical, feasible and scientific stand for the goal. The goal statement should be specific, precise, scientific and attainable. For example, in the case of diabetes one can write a goal statement somewhat like this- “An attempt to maintain the blood sugar within the normal range shall be made” However, if it is unlikely that the health ailment will show any improvement and health deterioration is inevitable, then step essential for presenting a better quality of life to the patient should be made. This can be the case with cancer or Alzheimer’s disease patients. As we know the practice and concept of euthanasia acceptance is because of the increasingly deteriorating quality of life in the terminally ill patients and this also poses much responsibility on nurses who need to take possible steps to help improve their quality of life. Steps that can help delay the complications or reduce the level of pain and depression experienced because of the present complications need to be taken with strong scientific stand. The document needs to be inclusive of the goal and these essential steps that promote better survival. For all problems, interventions should be as per physician guidance, facility protocol, and accepted standard practices. The facility protocol is determinant of the specificity of the written or documented approaches for nursing care plan. Some facility pose the need of including the exact therapeutic agent, dose and time for administration; while others have more unspecific details. For a document to stand as a good communicating means, it is required to be comprehensive, concise, chronological, complete, descriptive, factual, legible, thorough, correct, revised, accurate, competent and updated. The two attributed that breathe the same air of importance are how it is charted and what is charted. The important ways to create a good document are narrative, SOAP, APIE, PIE, flow sheets, focus charting, and CBE. Some of the important ways of documentation are discussed below. In the narrative system of documentation, the nurse is required to chart in chronological order, the events that occur including the information gathered. The information is usually presented in the sentence form. However, in some cases columns are prepared for the presentation of information. It is a time taking process and it is essential to understand the notes by those reading it. SOAP is an acronym for Subjective data, Objective data, Assessment, and Plan. In some hospitals the acronym SOAPIE is used instead. Here, the word I stand for Implementation and E for Evaluation. Still other acronym is SOAPIER in which Revision has been included as an additional item for increasing the value of documentation even further. APIE is an acronym for Assessment, Plan, Implementation and Evaluation. In this the nursing actions and the expected results of patients care are included in the Plan component. Conclusion It is thus essential to maintain twenty-four hour outcome summaries in documented form. The document should be updated daily in the progress notes by the responsible registered nurse. This nursing care plan document should include any difficulties observed during the process of achieving the set goal. It should also include any changes and or/ deviations that were made in the care plan and family’s contribution in an attempt to achieve the document specified goal. The plans that are required to address an incurable but manageable ailment or symptom should be addressed. Bibliography: 1. Fawcett, T. “Foundations of nursing practice: a nursing process approach.” Journal of Advanced Nursing, 31:4 (April 2000): 980. 2. Allen, D. “Record-keeping and routine nursing practice.” Journal of Advanced Nursing, 27: 6 (June 1998): 1223–30 3. Hansebo, G., Kihlegren M., and G. Ljunggren, “Review of nursing documentation in nursing home wards – changes after intervention for individualized care.” Journal of Advanced Nursing, 29:6 (June 1999): 1463. 4. R. Moloney and C. Maggs, “A systemic review of the relationships between written manual nursing care planning, record keeping and patient outcomes.” Journal of Advanced Nursing, 30:1 (July 1999): 52. 5. G. Hansebo, M. Kihlegren and G. Ljunggren, “Review of nursing documentation in nursing home wards – changes after intervention for individualized care.” Journal of Advanced Nursing, 29:6 (June 1999): 1463. 6. Kirrane, C. “An audit of care planning on a neurology unit”. Nursing Standard, 15:19 (January 2001). Nursing and Midwifery Council (NMC) 2002 Guidelines for records and record keeping. NMC, London. 7. Hoban V. “How to ... handle a handover.” Nursing Times 99(9) (2003) : 54–55. Read More