Record Keeping Jackie Hazeldine, Practice Educator & Modern Matron for Community Services December 2013

Record Keeping

Jackie Hazeldine, Practice Educator & Modern Matron for Community

ServicesDecember 2013

How do we Assess?• We assess all the time………..• We notice a patient’s

Colour

Breathing

Mobility within seconds of our greeting.• We use all our senses to pick up cues…• But we do not record all we have intuitively

picked up!

Competency framework

Why we need to Assess?Nurses need to:–

“...carry out comprehensive, systematic nursing assessments...” and;

“...plan, deliver and evaluate safe, competent, person- centred care...”

(NMC, 2010a).


An Assessment is ?• the gathering of information to make a

decision or plan• It forms the basis for planning and

implementing care• It allows us to identify needs and

preferences• Without it we have no chance of getting it

right


Holistic Assessment• The term ‘holism’ comes from a Greek

word meaning ‘all’, ‘entire’ and ‘total’.

• The physical, psychological, spiritual and social aspects of a person’s life are considered to be closely interconnected.


Approaching Assessment We need to be:-• Adaptable and flexible in a variety of

circumstances.• The language and terminology used needs

to be appropriate to our audience.• Accommodate the diversity of individuals,

their beliefs, values and circumstances.• Inclusive of the views of patients, families

& carers.


Values associated with assessment• Consent• Working alongside the patient, family and

carers to make a plan.• Together identifying problems and needs.• Together identifying goals of care.


How do we Assess?To undertake an assessment we use:-

• ‘Assessment tool’ and • The nursing process


An Assessment ToolProvides:-• A Systematic Approach• ‘Activities of Living’ and is now integral to

the assessment process for Isle of Wight NHS

Roper, Logan and Tierney (2000)


“Activities of living” encompasses:-– Communication– Breathing– Eating and Drinking– Eliminating– Personal hygiene and dressing– Controlling body temperature– Sleeping– Mobility– Sleeping– Expressing Sexuality– Dying


Use the Nursing Process• To identify all the patient’s needs• And the goals of the care to be provided• Plan the care to be provided with the

patient, family and carer’s where appropriate.

• Evaluate the effectiveness of the care


However……

• This cannot become a quick tick list


Step One

• Collect information about the patient's current condition

• Identify nursing needs from a critical analysis of the information


Identifying needs• For every identified need we must ask

WHY?

Explore the underlying causes• If someone is falling – WHY? explore

footwear, equipment and their medication.• If someone has a copiously leaking leg

wound –WHY? explore infection, oedema and Hb.


Step Two• Using critical thinking and clinical

judgment identify the goals related to the identified need.

• These inform the nursing actions to deliver the care and achieve the outcomes


Step Three

• Design nursing care to meet the goals


Step Four• Evaluate the patient's progress towards

or away from goals or desired outcomes• Evaluate the effectiveness of the care

provided • Describe and document progress to

date • Undertake a final evaluation


Working within the multidisciplinary team

• It is also essential to enable patients are able to have the right care, from the right profession at the appropriate time.

• We are responsible and accountable for making accurate referrals to members of the multidisciplinary team.

• SBAR supports an effective referral


SBAR (D)• Situation• Background• Assessment• Recommendation• Decision


Accountability• Nurses have professional accountability

and responsibility for the assessment, planning and evaluation of care, and for delegating work to support staff like Healthcare Assistants. RCN 2010.

• Ensure, those you to whom we delegate, have the appropriate knowledge and skills.


The NMC code states

• You must keep clear and accurate records of the discussions you have, the assessments you make, the treatment and medicines you give and how effective these have been


Ongoing Process

• Assessment is not a one off activity • We are responsible and accountable for

making this a dynamic ongoing process• Encompassing and responding to the

patient’s changing needs.


Accurately Document• It is equally important that all you

have observed, discussed, planned and identified as needing further investigation is accurately recorded so that it can contribute to effective compassionate care.


RememberEverything you write represents the

care you give, therefore ensure it is:-Clear

Accurate

Professional

&

Ethical


And finally….

Any Questions?


Documents

Record Keeping Jackie Hazeldine, Practice Educator & Modern Matron for Community Services December 2013