Record Keeping Jackie Hazeldine Practice Educator Modern Matron

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

Competency framework 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, 2010 a).

Competency framework 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

Competency framework 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.

Competency framework 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.

Competency framework 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.

Competency framework How do we Assess? To undertake an assessment we use: - • ‘Assessment tool’ and • The nursing process

Competency framework An Assessment Tool Provides: • A Systematic Approach • ‘Activities of Living’ and is now integral to the assessment process for Isle of Wight NHS Roper, Logan and Tierney (2000)

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

Competency framework 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

Competency framework However…… • This cannot become a quick tick list

Competency framework Step One • Collect information about the patient's current condition • Identify nursing needs from a critical analysis of the information

Competency framework 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.

Competency framework 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

Competency framework Step Three • Design nursing care to meet the goals

Competency framework 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

Competency framework 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

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

Competency framework 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. • Ensure, those you to whom we delegate, have the appropriate knowledge and skills. RCN 2010.

Competency framework 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

Competency framework 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.

Competency framework 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.

Competency framework Remember Everything you write represents the care you give, therefore ensure it is: Clear Accurate Professional & Ethical

Competency framework And finally…. Any Questions?