I. NURSING DOCUMENTATION What is Nursing Documentation? Documentation is a nursing action that produces a written account of pertinent patient data, nursing clinical decisions and interventions and patient responses in a health record Documentation is necessary for: ✔ Communication between healthcare providers ✔ Meeting legislative/organizational requirements ✔ Quality improvement ✔ Research ✔ Legal proof of healthcare provided Principles of Effective Nursing Documentation 1.Document accurately, completely, and objectively, including any errors committed. 2. Note date and time. 3. Use appropriate forms. 4. Identify the client. 5. Write in ink. 6. Use standard abbreviation. 7. Spell correctly. 8. Write legibly. 9. Correct errors properly. Guidelines for Quality Documentation Quality documentation means that the elements of the nursing process are evident in our documentation. It has five important characteristics: 1. FACTUAL A factual record contains descriptive, objective information about what a nurse observes, hears, palpates and smells. 2. ACCURATE The use of exact measurements establishes accuracy and helps you determine if a patient’s condition has changed in a positive or negative way. 3. COMPLETE Ensure that the information within a record entry or a report is complete, containing appropriate and essential information 4. TIMELY (CURRENT) •Timely entries are essential in a patient’s ongoing care. Delays in documentation lead to unsafe patient 5. ORGANIZED Information entered into a medical record facilities communication when it is documented in a logical order. Documentation is also more effective when notes are concise, clear and to the point. II. Basic leadership and management concepts focused on health education Leadership Leadership has many interpretations, and has been likened to “the abominable snowman whose footprints are everywhere but who is nowhere to be seen” It is an influential process, through which groups of people work towards the achievement of a common goal Management versus Leadership Management and leadership are considered just as important as each other in accomplishing organizational goals. However, there are differences in the functions of the two roles. Management produces order and consistency, while leadership produces change and movement . Management has the responsibility of organizing all elements within the organization, so that the leader’s vision and goals are successfully achieved. Leadership Styles in Nursing ● Transformational ● Transactional ● Democratic ● Laissez-faire ● Autocratic ● Servant Transformational leadership Transformational leadership involves leadership through the transformation of individuals or ‘followers’, to work towards a common organizational goal. Transactional leadership The transactional model is seen as an authoritative relationship that is transaction based, where exchanges occur between a leader and follower, once specific goals are identified or decided upon. Transactional leaders value order and structure, and have formal authority, with positions of responsibility within organisations. Democratic leadership Democratic leader engages in a shared leadership style in which they use participation of members of the group to guide decision-making and management. Sometimes, this is called participative leadership. Laissez-faire Leadership A laissez-faire leadership style is a facilitative one in which a leader makes few decisions. Characteristics of laissez-faire leaders are often reported as “hands off,“ trusting, encouraging and tolerant of innovation as well as error. Autocratic Leadership Autocratic leadership is a unilateral style in which the leader delegates to others with rules and orders. Servant Leadership Finally, servant leadership is defined as a supportive style in which the leader provides team members with skills, tools and relationships they need to perform to the best of their ability. Team leadership More recently, the focus has shifted towards “team leadership”, with distributed leadership becoming more prevalent within healthcare education, where different professions share influence Language of leadership As already stated, when it comes to leadership, excellent communication skills are a must. This means that active listening is just as important as active talking. Language used needs to be : ▪ Clear ▪ Stimulating ▪ Congruent ▪ Include active listening Note: ▪Titles are not always linked to leadership roles. • The role of today’s leader requires stepping forward, collaborating and contributing. • A good leader is a good team player who values and seeks the opinions of others. • Leadership requires clear, respectful communication that acknowledges the input and achievements of others.
