Record Keeping
Jackie Hazeldine, Practice Educator &
Modern Matron for Community
Services
December 2013
Competency framework
How do we Assess?
• We assess all the time………..
• We notice a patient’s
Colour
Breathing
Mobility within seconds of our greeting.
• We use all our senses to pick up cues…
• But we do not record all we have intuitively
picked up!
Competency framework
Why we need to Assess?
Nurses need to:–
“...carry out comprehensive, systematic
nursing assessments...” and;
“...plan, deliver and evaluate safe,
competent, person- centred care...”
(NMC, 2010a).
Competency framework
An Assessment is ?
• the gathering of information to make a
decision or plan
• It forms the basis for planning and
implementing care
• It allows us to identify needs and
preferences
• Without it we have no chance of getting it
right
Competency framework
Holistic Assessment
• The term ‘holism’ comes from a Greek
word meaning ‘all’, ‘entire’ and ‘total’.
• The physical, psychological, spiritual and
social aspects of a person’s life are
considered to be closely interconnected.
Competency framework
Approaching Assessment
We need to be:• Adaptable and flexible in a variety of
circumstances.
• The language and terminology used needs
to be appropriate to our audience.
• Accommodate the diversity of individuals,
their beliefs, values and circumstances.
• Inclusive of the views of patients, families
& carers.
Competency framework
Values associated with assessment
• Consent
• Working alongside the patient, family and
carers to make a plan.
• Together identifying problems and needs.
• Together identifying goals of care.
Competency framework
How do we Assess?
To undertake an assessment we use:• ‘Assessment tool’ and
• The nursing process
Competency framework
An Assessment Tool
Provides:• A Systematic Approach
• ‘Activities of Living’ and is now integral to
the assessment process for Isle of Wight
NHS
Roper, Logan and Tierney (2000)
Competency framework
“Activities of living” encompasses:–
–
–
–
–
–
–
–
–
–
–
Communication
Breathing
Eating and Drinking
Eliminating
Personal hygiene and dressing
Controlling body temperature
Sleeping
Mobility
Sleeping
Expressing Sexuality
Dying
Competency framework
Use the Nursing Process
• To identify all the patient’s needs
• And the goals of the care to be provided
• Plan the care to be provided with the
patient, family and carer’s where
appropriate.
• Evaluate the effectiveness of the care
Competency framework
However……
• This cannot become a quick tick list
Competency framework
Step One
• Collect information about the patient's current
condition
• Identify nursing needs from a critical analysis
of the information
Competency framework
Identifying needs
• For every identified need we must ask
WHY?
Explore the underlying causes
• If someone is falling – WHY? explore
footwear, equipment and their medication.
• If someone has a copiously leaking leg
wound –WHY? explore infection, oedema
and Hb.
Competency framework
Step Two
• Using critical thinking and clinical
judgment identify the goals related to
the identified need.
•
These inform the nursing actions to
deliver the care and achieve the
outcomes
Competency framework
Step Three
• Design nursing care to meet the goals
Competency framework
Step Four
• Evaluate the patient's progress towards
or away from goals or desired outcomes
• Evaluate the effectiveness of the care
provided
• Describe and document progress to
date
• Undertake a final evaluation
Competency framework
Working within the multidisciplinary
team
• It is also essential to enable patients are
able to have the right care, from the right
profession at the appropriate time.
• We are responsible and accountable for
making accurate referrals to members of
the multidisciplinary team.
• SBAR supports an effective referral
Competency framework
SBAR (D)
•
•
•
•
•
Situation
Background
Assessment
Recommendation
Decision
Competency framework
Accountability
• Nurses have professional accountability
and responsibility for the assessment,
planning and evaluation of care, and for
delegating work to support staff like
Healthcare Assistants.
• Ensure, those you to whom we delegate,
have the appropriate knowledge and skills.
RCN 2010.
Competency framework
The NMC code states
• You must keep clear and accurate records
of the discussions you have, the
assessments you make, the treatment and
medicines you give and how effective
these have been
Competency framework
Ongoing Process
• Assessment is not a one off activity
• We are responsible and accountable for
making this a dynamic ongoing process
• Encompassing and responding to the
patient’s changing needs.
Competency framework
Accurately Document
• It is equally important that all you
have observed, discussed, planned
and identified as needing further
investigation is accurately recorded
so that it can contribute to effective
compassionate care.
Competency framework
Remember
Everything you write represents the
care you give, therefore ensure it is:Clear
Accurate
Professional
&
Ethical
Competency framework
And finally….
Any Questions?