Leah Bradley August 2016

1. Clinical Handover and Documentation Leah Bradley August 2016

2. Handover and Documentation Today's session Understanding the requirements of Standard 6 Discuss where clinical handover occurs ISBAR-what is it? Bedside handover – The procedure What we need from you the handover champions Documentation for the Registered and Student Nurse

3. Standard 6 – Clinical Handover COLOUR BLUE colour is RGB value: R0 G120B193 FONT Arial Narrowfor normal slide body text, use bold for emphasisonly or subheadings FONT SIZES use your discretion, but try to make use of whitespace (good design principle) suggested sizes – anything from 12 - 24 pts, depending on number of bullet points Next level bullet is created by pressing Enter, then indent Don’t put too much text on one slide, consider inserting a new slide HYPERLINKS Web address links are black and underlined

4. What is Clinical Handover? “The transfer of professional responsibility and accountability for some or all aspects of care for a patient, or group of patients, to another person or professional group on a temporary or permanent basis”.

5. Episodes of Handover • Change of Shift or Responsibility of care • Multidisciplinary Meeting • Bedside handover • Inter-departmental Handover • Escalating Care • Telephone • Discharge from care • Inter-hospital transfer • Internal referrals

6. Practice ISBAR

10. Compare Handover? https://www.youtube.com/watch?v=DbGlwoQ53Gc

11. Documentation Introduction Nursing documentation is essential for good clinical communication. Appropriate legible documentation provides an accurate reflection of nursing assessments, changes in conditions, care provided and pertinent patient information to support the multidisciplinary team to deliver great and safe care. Documentation provides evidence of care and is an important professional and medico legal requirement of nursing practice. Aim To provide a structured and standardised approach to nursing documentation for inpatients. This will ensure consistency and improve clinical communication.

12. General Documentation Guidelines Identification on every page / screen • The following items must appear on every page of the health care record, or on each screen of an electronic record (with the exception of pop up screens where the identifying details remain visible behind): • Unique identifier (eg. Unique Patient Identifier, Medical Record Number). • Patient / client’s family name and given name/s. • Date of birth (or gestational age / age if date of birth is estimated). • Sex. • Address

13. Documentation Guidelines and Compliance • Be clear, Accurate, Legible and Written in English • Use approved abbreviations and symbols • Written in dark ink that is readily reproducible, legible, and difficult to erase and write over for paper based records • Time of entry (using a 24-hour clock – hhmm) • Date of entry (using ddmmyy or ddmmyyyy) • Signed by the author, and include their printed name and designation. In a computerised system, this will require the use of an appropriate identification system eg. Electronic signature. • Entries by students involved in the care and treatment of a patient / client must be cosigned by the student’s supervising clinician.

14. Documentation Guidelines and Compliance • Entries by different professional groups are integrated ie. there are not separate sections for each professional group. • Be accurate statements of clinical interactions between the patient / client and their significant others, and the health service relating to assessment; diagnosis; care planning; management / care / treatment/ services provided and response / outcomes; professional advice sought and provided; observation/s taken and results. • Be sufficiently clear, structured and detailed to enable other members of the health care team to assume care of the patient / client or to provide ongoing service at any time. • Written in an objective way not including demeaning or derogatory statements • Distinguish between what was observed or performed, what was reported by others as happening and / or professional opinion.

15. Documentation Guidelines and Compliance • Made at the time of an event or as soon as possible afterwards. The time of writing must be distinguished from the time of an incident, event or observation being reported. • Sequential - where lines are left between entries they must be ruled across to indicate they are not left for later entries and to reflect the sequential and contemporaneous nature of all entries. • Be relevant to that patient / client. • Only include personal information about other people when relevant and necessary for the care and treatment of the patient / client • Addendum /Additional Entry– if an entry omits details the additional details/documentation must be documented next to the heading ‘Addendum/Additional Entry’, including the date and time of the omitted event and the date and time of the addendum.

16. Documentation Guidelines and Compliance For hardcopy records, addendums must be appropriately integrated within the record and not documented on additional papers and / or attached to existing forms. • Written in error - all errors are must be appropriately corrected. No alteration and correction of records can be made. An original incorrect entry must remain readable. An accepted method of correction is to draw a line through the incorrect entry or ‘strikethrough’ text in electronic records; document “written in error”, followed by the author’s printed name, signature, designation and date / time of correction. For electronic records the history of audited changes must be retained and the replacement note linked to the note flagged as “written in error”. This provides the viewer with both the erroneous record and the corrected record.

17. Documentation Guidelines and Compliance Documentation by nurses and midwives must include the following: • Care / treatment plan, including risk assessments with associated interventions. • Comprehensive completion of all patient / client care forms. • Any significant change in the patient / client’s status with the onset of new signs and symptoms recorded. • If a change in the patient / client’s status has been reported to the responsible medical practitioner documentation of the name/contact details of the medical practitioner and the date and time that the change was reported to him / her. • Documentation of medication orders received verbally, by telephone or electronic communication including the prescriber’s name, contact details, designation and date / time.

18. Format for Documentation and writing Progress NotesSystems Approach • CNS-general appearance, conscious state (alert and orientated, Glasgow Coma Scale Score, pain and analgesia,gaga, level of sedation • CVS- Vital Signs are they within satisfactory parameters for the patient, perfusion and pulses, capillary refill, presence of odema • Respiratory- Maintaining own airways, Rate and pattern of breathing, use of accessory muscles, oxygen requirements, listen to the chest what do your hear? • GIT- Oral mucosa, assessment of mouth, teeth and gums, blleding and infection, diet, insulin requirements, Blood sugar regime, abdomen palpate, bowel sounds, bowel last opened, aperiants, nausea and vomiting? Daily weight

19. Format for Documentation and writing Progress NotesSystems Approach Cont. • Skin Integumentary System- General skin condition, pressure areas, wounds and dressings, intravenous sites, drain tubes, hygiene do they need assistance • Renal-Urinary colour and characteristics, output in regards to fluid balance, diuretics, presence of urinary catheter • Psychosocial-patient response to illness, family situation and support, need for education and discharge planning • Musculoskeletal- mobility, aid, gait, use of appliances, falls risks, how do they transfer in and out of bed

20. Questions ?