NurChat 17/01/17 6pm - What does good documentation and care planning look like?
On this one occasion, we’re moving the time of the #Nurchat to 18:00 – 19:00 because I’ll be with our clinical team in Bristol. It’s a great opportunity for us to share all the benefits of #NurChat with some of the newer members and I hope you’ll join me in welcoming them to the Twitter community.
In this #NurChat we’ll be talking about the importance of accurate record keeping, care planning and documentation.
A few years ago, The RCN estimated that nurses spent as many as 2.5 million hours a week on non-essential paperwork and admin tasks, and that the volume of general administrative tasks had increased. Indeed, nurses have previously been described as ‘drowning in a sea of paperwork’ by the media.
But good documentation, frequently updated with the appropriate level of detail is not only central to ensuring people get the care they need, but also providing a written record of care given, decisions made and changes in a individual’s health. It’s such a core part of nursing that the requirement for timely, accurate record keeping runs throughout the NMC Code of Practice.
Documentation shouldn’t be an afterthought, nor should it be so onerous that patient care is sacrificed for it. In some instances, paperwork can be delegated to those with appropriate skills, but how do we as nurses make the judgement who is suitable? Appropriate supervision, the right level of knowledge and skills are all essential, but how can you ensure the accuracy of the record-keeping that is ultimately your responsibility?
A factual account of every intervention is essential, but may not always be sufficient to fully record the outcomes. It can omit vital clues as to the wellbeing of the person. A list of facts may not be enough for the reader to build a picture of the intervention and determine whether or not the patient received the right care. If your care plans and notes were examined by a third party, would they give a clear and accurate picture of the wellbeing of the individual?
There have been efforts to simplify and reduce the paperwork burden with technological solutions, some of which have had tangible impacts. For instance, the use of handheld devices over paper charts significantly reduced the mortality rate at two large hospitals. Combined with a software package that used the data to calculate if someone was deteriorating, lives were saved. So, what if this could be applied to all care plans, and an intelligent use of the notes and data made a real impact on the outcomes for those in our care?
We’re discussing everything about record keeping, care planning and documentation, so come along with your thoughts and experiences and let’s see what practice we can share and learn from.
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Some pre-chat reading:
Read back over the discussion here: