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Discharge Protocol from ITU and Record Keeping

Discharge Protocol from ITU and Record Keeping. Julia Moser, Charlotte Farron and Natalie Ashwood. ITU discharge Protocol.

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Discharge Protocol from ITU and Record Keeping

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  1. Discharge Protocol from ITUandRecord Keeping Julia Moser, Charlotte Farron and Natalie Ashwood

  2. ITU discharge Protocol • Apatient is discharged from ITU when the condition, which led to referral, has been adequately treated and reversed, or when the intensive care consultant considers that the patient can no longer benefit from the treatment available.

  3. Discharge cont.. Discharge can be considered when the patient: • No longer requires ventilation and/or multi organ support. • No longer requires acute renal replacement therapy. • Is no longer able to benefit from the available treatments. • The patient requires palliative care. • The patient of sound mind requests discharge.

  4. Discharge Protocol Aim: To facilitate the transfer of patients from ITU to wards to provide a seamless service of care.

  5. Discharge Protocol Procedure: • Anticipate discharge of patients to wards wherever possible, notifying the bed manager in advance. • Consider any special needs of patients and most appropriate area for them to be discharged. This includes oxygen, suction, and infusion pumps. • Arrange a visit of the ward staff if appropriate to assess patient/dependency work load.

  6. Discharge Protocol Cont.. • Notify the Outreach Team of the intended discharge, so that they can be reviewed on the new ward. • Prepare patient and family by keeping them informed of the likely transfer. • Ensure that the doctors’ discharge summary is completed and patient case notes and X-Rays accompany the patient to the new ward. Remove any lines that are not needed, eg. Arterial or central lines. However this is not essential.

  7. Discharge Protocol Cont.. • Complete the nursing discharge summary. Ensure patients care plan, evaluation, fluid balance chart and observation charts are all up to date. This includes the documentation of the PAR and MEWS scores. • List patients property. • Ensure that a full and comprehensive handover is given to the receiving ward staff.

  8. Record Keeping… • … is an integral part of professional nursing, not an optional extra. • It is a tool of professional practice that should help the care process.

  9. Guidelines for Records and Record Keeping Good record keeping helps to protect the welfare of patients and clients by promoting: • Continuity of care. • High standards of clinical care. • Better communication and dissemination of information between members of the inter-professional health care team. • An accurate account of treatment and care planning and delivery. • The ability to detect problems, such as changes in the patient’s or client’s condition, at an early stage.

  10. The law • The approach that courts of law adopt, tends to be ‘if it is not recorded, it has not been done.’ • All records should be retained for as long as stipulated in local policy, (McGeehan, 2007). • In order to protect you……Records should contain a full account of the assessment and subsequent care planned and provided which should include……information about the patient's condition, from any given time, along with the measures taken to respond to the patient's needs at that time.

  11. Professional Issues • Nurses should use professional judgement to decide what is relevant in documenting patient events. • The NMC does not provide rules or law but advises to use professional judgement when record keeping. • Records are an integral part of patient care and part of the ‘professional duty of care owed by the nurse to the patient’.

  12. Nursing Process Model Assessment ▼ Diagnoses and goal ▼ Planned interventions ▼ Implementation ▼ Evaluation (Yura and Walsh, 1988)

  13. Implications for Poor Record Keeping • According to the literature the most common barrier to accurate record keeping is time constraints.(Cited by Owen 2005). • Consequences of poor record keeping include: • Patient care being compromised. • Nurse and employer losing protection against negligible claims. • The nurse breaching the professional code of practice.

  14. Not forgetting!!... Confidentiality The Data Protection Act 1998 and the Human Rights Act 1998 protect the confidentiality of patient information.

  15. Just for Fun… Good practice in record-keeping is important to: • Ensure high standards of care. • Promote continuity of care. • Protect the welfare of patients. • All of the above.

  16. (D) All of the above

  17. Question 2 The nurses' organisation that currently rules on professional conduct issues about record-keeping is the: • British Medical Association. • General Medical Council. • Nursing and Midwifery Council . • The UK Central Council.

  18. (C) Nursing and Midwifery Council

  19. Question 3 What could be a good defence in a clinical negligence claim? • Ambiguous notes. • Incomplete records of nursing interventions. • Meticulous records of the care given. • Unsigned and undated records.

  20. (C) Meticulous records of the care given

  21. Question 4 Alterations to a patient's notes should include: • The original entry. • The date and time. • A signature. • All of the above.

  22. (D) All of the above

  23. Question 5 After an event, when should notes be made in a patient's record? • As soon as possible. • One day later. • One week later. • Within one month.

  24. (A) As soon as possible

  25. Question 6 Patient records should be: • Written in such a way that text can be erased. • Written so that the first entry is not visible. • Written in red ink only. • Readable on any photocopier.

  26. (D) Readable on any photocopier

  27. Question 7 Failure to maintain reasonable standards in record-keeping will not lead to: • Civil court action. • Disciplinary action. • Enhancement of professional status. • Professional misconduct proceedings.

  28. (D) Professional misconduct proceedings

  29. Question 8 A useful tool to help improve the quality of record-keeping is: • Braden score. • Audit. • Weber's test. • Visual analogue scale.

  30. (B) Audit

  31. Question 9 Good record-keeping can be improved by: • Consistency. • Abbreviation. • Subjective statements. • Jargon.

  32. (A) Consistency

  33. Question 10 Which of the following handles clinical negligence claims against member bodies? • Clinical Negligence Scheme for Trusts. • NHS Confederation. • Nursing and Midwifery Council. • Strategic health authorities.

  34. (A) Clinical Negligence Scheme for Trusts

  35. Simon…Discharge and Records. Examples: • Discharge. • Simon was well enough to be transferred. • His infection had cleared. • His peak flow was back up to 400..no longer needed ventiliation. • Record Keeping. • In A+E resperations were not recorded at one point…bad record keeping!

  36. References • http://www.nmc-uk.org/aFrameDisplay.aspx?DocumentID=1120 • McGeehan, R. (2007) Best Practice in Record Keeping. Nursing Standard. 21(17), p 51-55. • Nursing Standard. (2007). 21(17), 3 January 2007, p 58. • Owen, K. (2005) Documentation in nursing practice. Nursing Standard. 19 (32), 48-49. • Yura, H. and Walsh, M. (1988) The nursing process. Assessing, planning, implementing, evaluating. 5th ed. Norwalk, CT: Appleton & Lange.

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