Nursing Documentation 101 101zzzzzzzzzzzzzzzzzzzzzzz This module is intended to support the continuing education of Alberta’s Licensed Practical Nurses. Copyright © College of Licensed Practical Nurses of Alberta 2014 – 2018 All rights reserved. The reproduction, storage in a retrieval system or transmission in any form or by any means (including electronic, mechanical, photographic, photocopying or recording) of any part of this publication without the prior written permission from the College of Licensed Practical Nurses of Alberta is an infringement of copyright law. College of Licensed Practical Nurses of Alberta 13163 146 Street NW Edmonton, Alberta T5L 4S8 CANADA Phone: 780-484-8886 Toll Free: 800-661-5877 Fax: 780-484-9069 www.clpna.com Table of Contents Module 1: Introduction .................................................................................................. 1 Purpose ........................................................................................................................ 1 The need ...................................................................................................................... 1 Course content ............................................................................................................. 1 Learning components .................................................................................................... 2 Strategies for effective learning ...................................................................................... 3 Module 2: The Importance of Accurate Documentation .............................................. 4 Specific learning outcomes ............................................................................................ 4 Introduction .................................................................................................................. 4 The health care environment ......................................................................................... 5 Who’s looking .............................................................................................................. 5 Methods of communication ........................................................................................... 6 Purposes of documentation ............................................................................................ 6 Perceptions of documentation ......................................................................................... 7 Challenges of documentation ......................................................................................... 7 Standards of documentation .......................................................................................... 9 Your employer’s role .................................................................................................... 10 Consequences of inaccurate documentation ................................................................. 10 Reflective questions ..................................................................................................... 11 Key points ................................................................................................................... 11 References .................................................................................................................. 12 Module 3: Essential Elements of Accurate Documentation ....................................... 13 Specific learning outcomes .......................................................................................... 13 Documentation deficiencies ......................................................................................... 13 Spelling and grammar – who cares .............................................................................. 15 Abbreviations .............................................................................................................. 16 The nursing process ..................................................................................................... 16 For review.................................................................................................................... 18 Objective and subjective data ....................................................................................... 20 Inaccurate terms ......................................................................................................... 20 Other strategies .......................................................................................................... 22 Documentation methods ............................................................................................. 23 Advantages and disadvantages ................................................................................... 23 Progress notes ............................................................................................................ 24 Adverse events ............................................................................................................ 25 Key points ................................................................................................................... 26 Table of Contents Nursing Documentation 101 page i Table of Contents References .................................................................................................................. 26 Module 4: Legal Issues – Your Documentation is Evidence ...................................... 27 Specific learning outcomes ........................................................................................... 27 Introduction ................................................................................................................ 27 The legal process ......................................................................................................... 27 The players ................................................................................................................. 28 Problem areas of documentation according to the lawyers ............................................ 29 Electronic documentation ............................................................................................. 30 Tips for improving the legal status of your documentation ............................................. 30 When a lawsuit proceeds ............................................................................................. 31 Key points ................................................................................................................... 31 Reflective questions ..................................................................................................... 32 References .................................................................................................................. 33 Module 5: Applying Documentation Knowledge and Principles ............................... 34 Specific learning outcomes .......................................................................................... 34 Admission ................................................................................................................... 34 Consent to treatment or procedure ............................................................................... 36 Refusal of treatment ..................................................................................................... 37 Physician or health care professional notification .......................................................... 37 Telephone calls and messages ..................................................................................... 39 Physician telephone orders .......................................................................................... 39 Post-operative care ...................................................................................................... 40 Discharge from care .................................................................................................... 42 Discharge against medical advice ................................................................................. 43 Health literacy .............................................................................................................. 44 Client teaching ........................................................................................................... 44 Family interactions ...................................................................................................... 45 Client meetings ........................................................................................................... 46 Medications ................................................................................................................ 46 Medication errors ......................................................................................................... 47 Client falls .................................................................................................................. 47 Client transfers ............................................................................................................. 48 Cardiac arrest .............................................................................................................. 49 Key points ................................................................................................................... 49 Take away thoughts .................................................................................................... 50 References ..................................................................................................................