Communication and documentation

• What are the learning objectives mentioned in the notes?

  Key principles of good record keeping, when documentation goes wrong, tools for record keeping
• How is communication defined according to Ali (2017)?

  Imparting or exchanging information, thoughts, or ideas using speech, writing, or other mediums
• What is one purpose of communication?

  To convey information
• What are the types of communication listed in the notes?

  Verbal, non-verbal, written, visual
• Why is good record keeping vital in nursing?

  It promotes safety and continuity of care for patients
• What must nursing staff be clear about regarding record keeping?

  Their responsibilities for record keeping in whatever format records are kept
• What are the key principles for good record keeping?

  • Records should be kept at the time or as soon as possible after the event
  • Records must be signed, timed, and dated
  • If digital, must be traceable to the person providing care
  • Must be completed correctly
  • Avoid jargon and speculation
  • If altering is needed, original entry must be visible
  • Be up to date on electronic systems
  • Security and confidentiality must be maintained
  • Records must be stored securely
• Why is record keeping important in nursing?

  It validates care given and maintains patient safety
• What should not be included in record keeping?

  • Personal judgments or opinions
  • Assumptions mistaken as facts
  • Unnecessary information
  • Breaches of patient confidentiality
• What could happen if record keeping goes wrong?

  You could be asked to give evidence in court based on your notes
• What is one of the top reasons for nurses being removed from the NMC register?

  Substandard record keeping
• What should you remember about documentation?

  If it is not recorded, it didn’t happen
• What does poor documentation represent?

  It represents you and will be scrutinized
• How should you write patient notes?

  • Use a standardized form
  • Find a system that works for you
  • Schedule patient notes into your day
  • Document as it happens
• What tools can be used for record keeping?

  • SBAR (Situation, Background, Assessment/Action, Response/Recommendations)
  • ABCDEF (Airway, Breathing, Circulation, Disability, Exposure, Fluids, Family/Social)
  • The nursing process (Assessment, Planning, Implementation, Evaluation)
  • Systems (CVS, CNS, RESP, RENAL, LIVER, GI, SKIN, MUSCULOSKELETAL, ENDOCRINE, IMMUNE, REPRODUCTIVE)
• What does the 'D' in ABCDEF stand for?

  Disability
• What does the 'E' in ABCDEF stand for?

  Exposure
• What does AVPU stand for in the context of disability assessment?

  Alert, Verbal, Pain, Unresponsive
• What is the purpose of a head-to-toe assessment?

  To assess the patient's overall condition