RSSAll Entries in the "Nursing documentation" Category

Incident Reports: What You Need to Know (Part Two)

Incidents reports are a pain to fill out, but vital for documenting what happened and for protecting yourself and your staff. This week, we’re republishing a popular post full of best practices, provided by Patricia A. Duclos-Miller, MS, RN, CNA, BC.

incident graphic2Yesterday we looked at the purpose of the incident report and the value of documenting facts as well as the patient’s responses to care in the nursing progress notes (see Incident Reports: Part One). Today we’ll look at eight risk reduction recommendations you should follow to limit the number of incidents you face. We’ll also give you a check list of tips for writing incident reports should adverse events occur. (I’ll make the checklist available as a PDF download in a few days, so check back for the link.)

RISK REDUCTION RECOMMENDATIONS FOR NURSE MANAGERS

  1. Be sure that everyone is clear as to who is managing the patient. This is especially critical in complicated cases with numerous consults. One of the major factors in adverse events is fragmentation or lack of clear communication between providers. Therefore, use the medical record as a communication tool for all providers and encourage your staff to read notes from other providers and disciplines.
  2. Be sure staff understand and utilize the chain of command when necessary. They are considered patient advocates and must speak on behalf of the patient to ensure quality patient care. Documentation of the chain of command process should be factual and blameless.
  3. Advise your staff never to create notes at home concerning the event. They should not discuss the event with other care providers without having someone from risk management present, unless the discussion is in a quality-review process or in the presence of the facility’s attorney.
  4. If an adverse event occurs, the staff must know that attention to patient needs is first and foremost. If a patient is injured, nursing and medical interventions take precedence over everything else.
  5. Follow the organization’s policy on medical-event disclosure. It is important that staff understand who is designated to inform the patient/family. Documentation should include who was present during the discussion, what information was discussed, and all of the patient/family responses.
  6. Ensure that the patient/family receives compassionate care and that everyone involved maintains a professional relationship.
  7. If an adverse event occurs, contact the risk manager. Discuss the case discretely, because conversations are not protected under a quality statute or attorney-client privilege, and therefore may be discoverable.
  8. Work with the risk manager. The risk manager can help you and your staff promote patient safety and proactive strategies to avoid injuries.

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Incident Reports: What You Need to Know (Part One)

Incidents reports are a pain to fill out, but vital for documenting what happened and for protecting yourself and your staff. This week, we’re republishing installments of a popular post chock full of best practices, provided by Patricia A. Duclos-Miller, MS, RN, CNA, BC.

incident graphic2If you and your staff think that incident reports are more trouble than they’re worth, you could not be more wrong.

We work in high-stress, fast-paced environments. It is your responsibility as a member of the nursing management team to understand the importance of incident reports, to ensure that your staff completes them, and to investigate incidents to avoid any further occurrences. Your investigation will also provide possible defense if during your investigation you identify a system failure and take the necessary corrective action(s).

The purpose of the incident report is to refresh the memories of both the nurse manager/supervisor and the staff nurse. While the clinical record is patient-focused, the incident report is incident-focused. The benefit to you and your staff is [more]

Don’t Disclose: Peer review confidentiality guidelines download

confidential Recently, I posted an overview of the key confidentiality requirements for
members of the peer review committee. At long last, you can download a copy
of Don’t Disclose here, for the case review committee members in your organization.

Last week’s peer review webcast (presented by Laura Harrington and Marla Smith) was followed by a lively question and answer period. Topics ranged from the meaning of “timely” in terms of completing a review* to the virtues of including a section in your scoring that considers “contributing factors”** … and much more.

You can learn more about the on demand version of the webinar here and the presenters’ nursing peer review book here.

 

 

  * Answer: <90 days

** Answer: Be flexible. If you want to include special factors in scoring, it may help identify process issues to address proactively separate from the review

Reminder: Nursing Peer Review Webcast

Just a few more days left until our Nursing Peer Review webcast, NPR2cloud3afeaturing nursing peer review experts Laura Harrington, RN, BSN, MHA, CPHQ, CPCQM, and Marla Smith, MHSA. These authors of the HCPro book Nursing Peer Review, Second Edition: A Practical, Nonpunitive Approach to Case Review, will pack a 90-minute webcast with answers to these questions, and more:

How do you actually do nursing case review? How do you deal
with the outcomes? And how can you use case review to monitor performance and track and trend data? And what are the core requirements for confidentiality? (See below for Don’t Disclose,
a cheat sheet of guidelines, and look for a notice soon for download instructions.)

Developing a structure to support nursing case review is just the first step. Join us on Thursday, April 16, 2015 at 1–2:30 p.m. Eastern to explore the practical requirements of implementing this important process. To register, click here.

Don't Disclose-Peer Review

 

Improving the image of nursing

Every nurse can play a part in elevating the public perception of the nursing profession. The table below shows you how email, evidence-based research, reasonable work schedules, a diverse workforce, preceptorships, interprofessional communication skills, and name tags can promote the professional image of nursing. This table was adapted from the HCPro book, The Image of Nursing, by Shelley Cohen, RN, MS, CEN and Kathleen Bartholomew, RN, MN.

 imageof nursing table 2

More time working with patients, less time documenting them

What would you be able to accomplish if you had one extra hour in your day? What about if you had several extra hours? Documentation, though a necessary part of healthcare, is potentially eating into hours that otherwise could be spent on patient care. Last month, MIT Technology Review wrote about a system designed by Xerox to automate and streamline some of the time-consuming tasks associated with technology, such as logging into computers, documenting details of patient care, reviewing patient files, and coordinating duties with colleagues.

According to the article, Xerox’s research into nursing documentation was spurred by a 2008 study published in The Permanente Journal that found that more than a third of nurses’ practice time was spent on documentation, with an additional 20% of nurses’ time spent on care coordination. Of the nursing practice time, only 20% was spent on patient care and 7% was spent on patient assessment and reading of vital signs.

We polled readers at StrategiesForNurseManagers.com to find out what percentage of their time was spent on documentation. Nearly half of all respondents (49%) indicated that documentation takes up more than 50% of their time, while another 22% estimated that it took 40%-50% of their time. A quarter of readers responded that 20%-40% of their day was comprised of documentation, and only 6% replied that documentation took up less than 20% of a given shift.

Given that nurses may also be working longer than their scheduled shifts to complete all documentation, and that longer shifts have been linked to nurse burnout and adverse effects on patient outcomes, is not unreasonable to connect the dots and state that less time spent on documentation could potentially improve patient outcomes and patient satisfaction. It seems that nurses would welcome any technology or system that would streamline documentation processes and allow them to get back to providing quality patient care.

Has your organization devised any methods for making documentation more efficient? Please share in the comments section!

Best practices for filling out incident reports

Incidents reports are a pain to fill out, but vital for documenting what happened and protecting yourself and your staff. This week, Patricia A. Duclos-Miller, MS, RN, CNA, BC, provides some best practices.

You and your staff may think that incident reports are more trouble than they are worth-but think again.

We work in high-stress, fast-paced environments. It is your responsibility as a member of the nursing management team to understand not only the importance of the incident report, but also how to ensure that your staff completes them and how to investigate incidents to avoid any further occurrences. Your investigation will also provide possible defense if during your investigation you identify a system failure and take the necessary corrective action(s).

The purpose of the incident report is to refresh the memories of both the nurse manager/supervisor and the staff nurse. While the clinical record is patient-focused, the incident report is incident-focused. The benefit to you and your staff is that years after the event, the incident report will help you and the persons involved remember what happened. [more]