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8/8/2019 Documentation BSP Oct, 2010
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GOAL of SKMC
In preparation for the JCIA audit visit scheduled early December 2010,
SKMC nursing department aims at
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Goal of BSP
In light of SKMC preparation for the JCIA audit visit on December 2010,
we aim to
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Objectives of BSP Action Plan
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Current Focus
1. Nursing Admission Assessment (NAAF)
2. Nursing Care Plan APIE
3. Ongoing Assessment
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Standard Time Frame
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Document When to Fill Remarks
1. NAAF On AdmissionRegardless of shift Day
or Night
2.APIE
Car Plan
On Admission
For all patients on morning shift
For any identified problem after then
EE
to be done on each
endorsement HAND
IN & Hand OVER oneach shift
3.Ongoing
AssessmentEvery shift for all patients Physical + MHA
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Day ShiftResponsibilities
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3. Write a complete Care Plan using the APIE format.
ForALL patients, whetherNEWLY ADMITTED orEXISTING Patients in the unit.
2. Perform Physical + Mental Health Assessment (MHA).
For allEXISTING Patients in the unit.
1. Write a Complete NAAF
For allNEWLY ADMITTED Patients during day shift.
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Night ShiftResponsibilities
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2. Write a complete Care Plan using the APIE format.
For allNEWLY ADMITTED Patients during Night Shift, and
For anyNEWLY identified DIAGNOSES/PROBLEMS.
1. Write a Complete NAAF
For allNEWLY ADMITTED Patients during Night Shift.
3. Document E ofthe APIE on bothHANDING IN and
HANDING OVER.
ForALL patients, whetherNEWLY ADMITTED orEXISTING Patients in the unit.
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General Guidelines
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2. Assign each problem a NUMBER in a chronological order.
1. Use only oneSK progress note to documentthe APIE and
the carethatYOU renderto your patient during the shift.
3. Enter whateverhappens during the shiftin a chronological
order.
4. ritethe ATE and TIME ofeachentry.
5. SAFE and SIGN OFF eachentry.
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General Guidelines
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6. Ifthe patient develops another problem during the Shift
that was not captured in theinitial APIE, writethe new
problem with a chronological number assigned to it.
7. Never use ABBREVIA IONS.
8. The night staff will do thePHYSICAL and MH assessment
and comparetheiridentified problems withthe ones
identified in the APIE ofthe day shift.
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General Guidelines
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6. Iftheidentified problem(s) is/arealready captured in the
day shift APIE, only write an evaluation ofthe numbered
problem(s).
7. Ifthe problem identified is notyet captured in an APIE
during the day shift, write a complete APIE forthe new
problem and numberit chronologically.
8. Should a patient be admitted on night shift, the nurse will
beresponsible for writing a complete APIE for problems
identified on admission.
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