Tiêu đề NCM 114 SEMI FI ✅

NCM 114 SEMI FI BY TONS and MADS WEEK 8: GUIDELINES FOR EFFECTIVE DOCUMENTATION & GERIATRIC HEALTH CARE TEAM Nursing Documentation ➔ record of nursing care that is planned and delivered to individual patients by qualified nurses or other caregivers under the direction of a qualified nurse ➔ principal clinical information source to meet legal and professional requirements ➔ Vital component of safe, ethical, and effective nursing practice whether done manually or electronically. ➔ should fulfill the legal requirements of nursing care documentation Due to the multiple chronic illnesses, older adults are likely to see several health care practitioners and to move from one health care setting to another. Providing consistent, integrated care across specific care settings, sometimes called continuity of care, is thus particularly important for older patients. Communication among primary care physicians, specialists, other health care practitioners, and patients and their family members, particularly when patients are transferred between settings, is critical to ensuring that patients receive appropriate care in all settings. Electronic health records may help facilitate communication. Geriatric interdisciplinary teams consist of practitioners from different disciplines who provide coordinated, integrated care with collectively set goals and shared resources and responsibilities. The overarching goal is to improve the patient experience and provide high quality and safe care at a lower cost. Engaging with patients and families to become partners in care leads to more meaningful person-centered care and more effective prevention and treatment plans with better outcomes. Practitioners need to coordinate care among patients' various health care settings and communicate effectively with other practitioners, as well as patients and their families. Additionally, geriatric practitioners need to work with communities to create and implement best practices that incorporate prevention strategies with a goal of keeping patients and populations healthier. Lastly, health care professionals and staff, academics, and researchers must work with policymakers to make health care more affordable. Because older adults tend to have multiple chronic disorders and may also have cognitive, social, or functional problems, they have higher health care needs and use a disproportionately large amount of health care resources Guidelines for Effective Documentation and Geriatric Health Care Team VIDEO: https://youtu.be/618nVHXBIuA - not transcribed DOCUMENTATION AND RECORD KEEPING ➔ a vital part of registered nursing practice. ➔ The quality and coordination of client care depends on: ◆ Communication between different health-care providers ◆ formal, legal documents PRINCIPLES OF EFFECTIVE DOCUMENTATION 1. Document accurately, completely, and objectively, including any errors. 2. Note date and time 3. Use appropriate forms 4. Identify the client 5. Write in ink 6. Use standard abbreviations WHAT SHOULD YOU INCLUDE IN YOUR DOCUMENTATION? ● Quality Documentation Indicators: Reflects the application of the nursing process. ● Timely Documentation. ● Documenting in Higher-Risk Situations. ● FACTS: Factual, Accurate, Complete and Timely 9 TYPES OF NURSING DOCUMENTATION ERRORS 1. Sloppy or illegible handwriting 2. Failure to date, time, and sign a medical entry 3. Lack of documentation for omitted medications and/or treatments 4. Incomplete or missing documentation 5. Adding entries later on 6. Documenting subjective data 7. Not questioning incomprehensible orders 8. Using the wrong abbreviations 9. Entering information into the wrong chart Use Of Technology And Documentation Electronic Records ➢ PROTECTION OF E RECORDS: Password ➢ WHAT IF YOU MAKE AN ERROR IN E- DOCUMENTATION ○ Correct errors promptly. ○ Record date and time. ○ Policy on making corrections. ○ Do not change/edit another Staff member’s entries. Geriatric Health Care Team ➔ Geriatric Care: team-based approach. ➔ Team members: ◆ Geriatrician/Gerontologist 2