Protect Your Practice –
Helpful tips
Monica Staley – Patient Representative519-254-5577 Ext. [email protected]
OBJE
CTIV
ES
REVIEW THE IMPORTANCE OF: * DOCUMENTATIONWhat / Why / How
* COMMUNICATION* PRIVACY* CONFIDENTIALITY
WHA
T W
OULD
YO
U DO
??
ScenarioMrs. S., a 45-year-old woman, is currently an in-patient
receiving chemotherapy for the treatment of a
malignancy. She consented to transfusion with blood
products as part of her treatment and has thus far
received several units of blood products.
West Nile Virus (WNV) nucleic acid testing of donated
blood commenced to prevent transmission of WNV
through the blood supply. Positive donor testing leads to
a recall of the donor’s products.
Unfortunately, only three of eight blood products could
be recalled from a positive donor. The other five units
were transfused to Mrs. S. Although Mrs. S. remains immunosuppressed from
chemotherapy, she is currently clinically stable and well.
Should it be disclosed to Mrs. S. that she received blood
products that the donor tested positive for WNV?
If so, when?If so, how?If so, by whom?
WHY
DO
CUME
NT?
REFLECTS the client’s perspective
IDENTIFIES the caregiverPROMOTES continuity
of care by allowing other partners in care to access the information
WHY
DO
CUME
NT?
DEMONSTRATES the nurse’s commitment to providing SAFE, EFFECTIVE and ETHICAL care by showing ACCOUNTABILITY for professional practice and the care the client receives and TRANFERRING KNOWLEDGE about the
client’s health history
WHY
DO
CUME
NT?
COMMUNICATES to all healthcare providers :The ‘plan of care’The ‘assessment’The ‘interventions’ necessary
based on the client’s history; and
The ‘effectiveness’ of those
interventions
Is an INTEGRAL component on
interprofessional documentation within the
clinical record
WHY
DO
CUME
NT? DEMONSTRATES that
nurse has applied within the therapeutic nurse-client relationship the nursing KNOWLEDGE, SKILL and JUDGMENT required by professional standards regulations
WHY
DO
CUME
NT?
DEMONSTRATES the nurse’s commitment to providing SAFE, EFFECTIVE and ETHICAL care by showing ACCOUNTABILITY for professional practice and the care the client receives and TRANFERRING KNOWLEDGE about the
client’s health history
WHA
T TO
DO
CUME
NT?
Documentation should provide a clear picture of:The needs/goals of the
client or groupThe nurse’s actions based
on the needs assessmentThe outcomes and
evaluation of those actions
WHA
T TO
DO
CUME
NT? DATA from documentationCan be used to evaluate
professional practice as part of quality improvement processes
Can be used to determine
the care and services required or provided
NOT DOCUMENTED = NOT DONE!!!
INDI
CATO
RS O
N DO
CUME
NTAT
ION
3 STANDARD STATMENTS
1.
COMM
UNIC
ATIO
N Nurses ensure that documentation presents an accurate, clear and comprehensive picture of the client’s needs, the nurse’s interventions and the client’s outcomes
2.
ACCO
UNTA
BILIT
YNurses are accountable
for ensuring their documentation of client care is accurate, timely and complete
3.
SECU
RITY
Nurses safeguard client health information by maintaining confidentiality and
acting in accordance with information retention and destruction processes
and procedures that are consistent with the standards and legislation.
REME
MBER
….
CLEAR, CONCISE, COMPREHENSIVE”
REFLECTS PRIORITY PROBLEM”PATIENT FOCUSED –
what happened; what was done; who was told”FOLLOW UP CARE”
PURP
OSE
OF
COMM
UNIC
ATIO
N CAPTURES essential communication that has occurred within the interprofessional team.
IT S
HOUL
D IN
CLUD
E…
Nursing documentation communicates Assessment planning implementation evaluation client’s response to the care
REME
MBER
…
COMMUNICATE the client’s PREFERENCES and EXPRESSED NEEDS. INCLUDE CLIENT”S PERCEPTION of the care providedSHOW CARE and
CONCERN while communicating with client
DOCU
MENT
S CO
MMUN
ICAT
E TW
O TY
PES
OF D
ATA…
SUBJECTIVE DATAStatements and feedback from client, in quotations“I feel a stabbing pain in
my stomach”OBJECTIVE DATAObserved or measured factsClient was distressed.
Temperature 39oC.
REME
MBER
… INCLUDE IDENTIFIABLE SIGNATURE and DESIGNATON (RN, RPN,NP)KEEP PERMANENT
records
COMM
UNIC
ATIO
N
What is PATIENT-CENTRED
CARE?EMPATHYWALK-IN PATIENT’S SHOES
ADVOCATING for the rights
of VULNERABLE PERSONSKNOW YOUR HIERARCHY TO
ESCALATE & COMMUNICATE!! The law ASSUMES that
people have CAPACITY CONSENT & CAPACITYCAPACITY ASSESSOR
Cons
ent
and
the
Heal
th C
are
Cons
ent A
ct
Must have prior consent to
treatment, and consent must
be informed and voluntary;Common law; now largely
codified in Health Care Consent Act (HCCA);
Person must have capacity to
consent, i.e. able to (i) understand relevant info. &
(ii) appreciate reasonably
foreseeable consequences of
deciding or not (s.4);Emergency exception (s.25)
Capa
city
Health care provider proposing trt. decides re capacity (in first instance)
(s.10);Presumption of capacity (s.4
(2);Capacity can be trt-dependent and come & go
over time (s.15);If patient is incapable, then
substitute decision maker
(SDM) consents to or refuses
treatment.
Subs
titut
e De
cisio
ns A
ct
Power of attorney (POA) for
personal care (made by person concerned; low % of population have one);
Who can make (min. age;
test for capacity);Re health care: POA can say who decides, what to decide, or both;Also, guardianship (court
order).
S.20: Who decides for another:
lists SDMs in order of priority –
appted by ct, person (POA) or
Consent & Capacity Brd (CCB),
then descending degree of
relation; last resort = Public
Guardian & Trustee (PGT);S.21: How to decide for another: (i) follow prior capable
wishes if apply & person was at
least 16; (ii) if none, SDM to act
in best interests;S.5: Wishes: can be expressed
in any form.Subs
titut
e De
cisio
n-Ma
king
in th
e HC
CA:
Guid
ance
Prin
ciple
s
Dete
rmin
ing
Best
In
tere
sts
HCCA
s.21
(2)
SDM shall consider:Prior capable values and beliefs;
Incapable person’s wishes;Treatment factors: Is the trt likely to
Improve condition or well-being;
Prevent deterioration;Reduce extent or rate of
deterioration; +Effect of non-trt on person;Weigh benefit & risk of harm from
trt;Least restrictive or intrusive trt for
this benefit?
Cons
ent &
Ca
pacit
y Bo
ard
Person concerned can challenge practitioner’s finding of incapacity (s.32);
Health care practitioner can
challenge SDM’s compliance
with s.21 (decision making
principles) (s.37);SDM or HCP can apply to CCB
to clarify wish or to disregard
it if likely result much improved from when made
(ss. 35, 36);Further review by court.
PRIV
ACY
& CO
NFID
ENTI
ALIT
Y
PHIPA – Personal Care Information Protection Act
Circle of Care – Are you in
it?Telephone – Who can you
disclose information to?Fax Communication – Are
you permitted to send it?Social NetworkingElectronic AuditsKnow where you are when
you speak