Transcript Document

Documentation Competency
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
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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.
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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.
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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.
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How do we Assess?
To undertake an assessment we use:• ‘Assessment tool’ and
• The nursing process
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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)
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“Activities of living” encompasses:–
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Communication
Breathing
Eating and Drinking
Eliminating
Personal hygiene and dressing
Controlling body temperature
Sleeping
Mobility
Sleeping
Expressing Sexuality
Dying
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Outcomes of an Assessment
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Supportive ~ assisting in self expression
Restorative ~ maximising independence
Educative ~ health promotion
Life enhancing ~ improving daily living
Managerial ~ care delivery
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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
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However……
• This cannot become a quick tick list
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Step One
• Collect information about the patient's current
condition
• Identify nursing needs from a critical analysis
of the information
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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.
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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
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Step Three
• Design nursing care to meet the goals
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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
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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
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SBAR (D)
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Situation
Background
Assessment
Recommendation
Decision
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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.
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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
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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.
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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.
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Remember
Everything you write represents the
care you give, therefore ensure it is:Clear
Accurate
Professional
&
Ethical
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And finally….
Any Questions?