CHARTING WITH CLARITY, A Documentation Guide For Nurses and Health Professionals, livre ebook

Laws, standards, and regulations dictate the 'WHAT'. This guide will equip you with the 'HOW'. The guide she is presenting today is suitable for all healthcare professionals, especially nurses. It is designed for quick reference and to help you adapt your note writing to current standards. Became a BEST-SELLER after only a few months! Now used as a compulsory book in nursing training in over 85% CÉGEPS, many CFPs and universities. FINALLY. A guide to writing MODERN file notes with online material. A practical format designed for quick retrieval of information. Over 300 pages of tips, vocabulary, examples and practical exercises.
Working in the healthcare sector is under constant pressure. The nursing profession, already burdened by the complexity of care, comorbidities, and an aging population, has undergone numerous transformations in recent years. Recruitment challenges have added to the workload. There are more patients, shorter hospital stays, and consequently, more notes to write—notes that must be thoroughly documented and often written more quickly to keep up with demands. In addition to these new realities, there have been significant changes in the roles and scope of practice of healthcare professionals. Recent legislation on the administrative reorganization of care and the advent of new technologies have had a major impact on many tasks, including the writing of medical notes. Over time, through meetings, visits to healthcare settings in Canada, Switzerland, and Australia, and research, I quickly realized that the need for a documentation guide was shared by nurses everywhere. We all face similar challenges. The laws and regulations are similar. This second edition is therefore tailored to the members of the OIIQ (Québec Nurses Association) but could also be adapted for international use. The quality of the daily work of health professionals is not always reflected in the reading of progress[…] » Extrait de Guide_EN Ce contenu est peut-être protégé par des droits d’auteur.
2. WHAT MUST BE RECORDED “What is written shall be deemed to have been done, and what is not written shall be deemed not to have been done.” This statement is often found in the jurisprudence of courts and ethics committees that have had to judge professional acts. It’s a reminder that the note is essential to attest to the credibility and quality of a service. A rigorous, clear note that respects the treatment plan serves everyone, including the judiciary. Quality clinical content lends credibility both professionally and judicially. This should not obscure the fact that we write only what is relevant. Evidence is easier to establish when the record is rigorously documented. However, proof that an act has been carried out can also be confirmed in other ways, for example by interviewing the nursing staff. During individual inspections, the OIIQ finds that too much data is entered and that the essentials are lost. There’s no point in writing down generalities such as a nursing routine or the details of a technique if they are followed to the letter. The note must be concise, so avoid all those unnecessary words that make you lose sight of the nature and coherence of the interventions. The note should be limited to precise and relevant elements. The best way to achieve this is to place the patient at the centre of the note. There’s no need to note, for example, that a site was disinfected before an injection, a detail that is part of the care protocol. The injection, and its effect on the patient’s health, is the care. Therefore, what is documented and signed is the injection. Continuity of care must be provided at all times. This means that the information needed for safe patient follow-up is communicated to the right person at the right time. This ensures that the care provided is safe and tailored to the patient’s needs. All of this information is contained in the chart notes. Sending an end-of shift report is part of the routine of care and therefore does not need to be recorded. What is communicated in the report should already be documented in the patient’s file. It is important to distinguish between sending an end-of-shift report and ensuring continuity of care. Unnecessary words to avoid / Suggestions for essential information
TABLE OF CONTENTS 1. RECORDING NOTES: AN OBLIGATION 1.1 LAWS AND REGULATIONS 4 1.2 CODE OF ETHICS 6 1.3 NURSES ACT 8 1.4 PROFESSIONAL CODE 11 1.5 CONFIDENTIALITY, PROFESSIONAL SECRECY AND ACCESS TO RECORDS 15 1.6 CONSENT 18 1.7 INCIDENT OR ACCIDENT 22 2. WHAT MUST BE RECORDED 28 2.1 OBSERVATIONS 30 2.2 INTERVENTIONS 35 2.3 THE PERSON’S REACTIONS 35 2.4 WHAT NEEDS TO BE COMMUNICATED 36 3. ELEMENTS OF A QUALITY NOTE 40 4. GENERAL WRITING GUIDELINES 50 4.1 DATE AND TIME 50 4.2 LEGIBILITY OF THE NOTE 51 4.3 CHRONOLOGY 52 4.4 CLARITY AND CONCISION 53 4.5 RELEVANCE 61 4.6 ACCURACY 63 4.7 DANGEROUS ABBREVIATIONS 67 4.8 COMPLETE NOTE 68 4.9 LATE NOTE 71 4.10 CORRECTION OF ERRORS 74 4.11 THIRD-PARTY NOTE 78 4.12 NOTE IN A COMPLAINT PROCESS 81 4.13 PATIENT’S REQUEST FOR CORRECTION 82 4.14 SIGNATURE AND TITLE 83 5. INITIAL AND ONGOING ASSESSMENT 90 5.1 ASSESSMENT OF THE PHYSICAL CONDITION OF A SYMPTOMATIC PERSON 95 5.2 ASSESSMENT OF THE MENTAL CONDITION OF A SYMPTOMATIC PERSON 103 6. TO NOTE A PARTICULAR CONDITION 110 6.1 RESPIRATORY PROBLEMS 113 6.2 MEMORY COMPLAINTS 120 6.3 PAIN 123 6.4 AGITATION 128 6.5 AGGRESSION 132 6.6 SUICIDE RISK 135 6.7 GASTROINTESTINAL PROBLEMS 137 6.8 GENITOURINARY PROBLEMS 143 6.9 INCONTINENCE 146 6.10 FALLS 150 7. NOTING A CARE PROCEDURE 156 7.1 ADMINISTRATION OF MEDICATION 156 7.2 ADMINISTRATION OF A MEDICATION PRESCRIBED AS NEEDED (PRN) 161 7.3 HIGH-ALERT MEDICATIONS 167 7.4 PEOPLE RECEIVING OPIOIDS 168 7.5 VACCINATION 170 7.6 WOUND 175 7.7 MEASURING VITAL PARAMETERS 182 7.8 CARDIAC MONITORING 184 7.9 INTRAVENOUS THERAPY 185 7.10 RESPIRATORY SYSTEM CARE PROCEDURES 186 7.11 GENITOURINARY SYSTEM CARE PROCEDURES 190 7.12 RESTRAINT 195 8. SPECIFIC STEPS OF THE CARE EPISODE 198 8.1 DISCHARGE 199 8.2 REFUSAL OF CARE 201 8.3 CODE TEAM 202 8.4 DEATH 203 8.5 CALL TO A PHYSICIAN AND REFERRAL 205 8.6 TELEPHONE ORDERS 207 8.7 TEACHING 209 8.8 INVOLVEMENT OF RELATIVES 210 9. MONITORING ACCORDING TO THE SECTOR OF CARE ACTIVITY 214 9.1 PREGNANCY MONITORING AND PERINATAL CARE 214 9.2 MENTAL HEALTH 221 9.3 HOME CARE 227 9.4 EMERGENCY DEPARTMENT 234 9.5 INTERVENTION IN THE SCHOOL ENVIRONMENT 240 9.6 OUTPATIENT CLINIC, FAMILY MEDICINE 243 10. METHODS OF WRITING 252 10.1 NARRATIVE 252 10.2 SOAPIE 253 10.3 DIR: 254 10.4 DAR 254 10.5 DEARP 255 10.6 McGill 256 CONCLUSION 257 APPENDIX 1 Dangerous Abbreviations 260 APPENDIX 2 Most Common Abbreviations 261 APPENDIX 3 Useful Vocabulary by System 267 APPENDIX 4 Anatomical Landmarks: Abdomen 270 Anatomical Landmarks: Head 271 Pulse Points 271 APPENDIX 5 Head-to-toe Assessment 272 APPENDIX 6 Glossary of Terms for Mental Health Assessment 273 APPENDIX 7 Standardization Rules and Different Forms 277 APPENDIX 8 High-Alert Medication 279 APPENDIX 9 Switzerland 282 INDEX 286