Question

After reading the chapter in your textbook, focus on documentation and informatics. Think about the principles of reporting and documentation. Identify and briefly discuss three challenges a nurse has in ensuring accurate and confidential documentation. Then discuss what actions a nurse can take to overcome these challenges including how informatics might make a difference.

Answer 1

Principles of Documentation and reporting :-

Health workers have a professional obligation to record the details of any
consultation with a patient. The notes should reflect what was said (by the
patient, in her own words) and what was seen and done (by the health worker).
In cases of alleged sexual abuse, the taking of accurate and complete notes
during the course of an examination is critical for the following reasons given below:-

1) As medical records can be used in court as evidence, documenting the
consequences of sexual violence may help the court with its decision-making
as well as provide information about past and present sexual violence.

2) Documentation can provide administrators and policy-makers with an
estimate of the incidence and prevalence of sexual violence that can be used
to guide decisions about allocating resources.

3) Documenting that a patient has been a victim of sexual violence will alert
other health care providers who later attend the patient to this fact and so
assist them in providing appropriate and sympathetic follow-up care.

What should be documented?

In sexual abuse cases, documentation should include the following:
— demographic information (i.e. name, age, sex);
— consents obtained;
— history (i.e. general medical and gynaecological history);
— an account of the assault;
— results of the physical examination;
— tests and their results;
— treatment plan;
— medications given or prescribed;
— patient education;
— referrals given

Storage of records:-

Biological evidence usually needs to be refrigerated or frozen; check with your
laboratory regarding the specific storage requirements for biological specimens.

Epidemiological surveys:-

Medical records of cases of sexual violence are a rich source of data for
surveillance purposes. Information can be used to determine:-
— the patterns of sexual violence;
— who is most at risk for becoming a victim of sexual violence

Photography
If using photography to document findings, the following points are worth
bearing in mind:
• Consider the patient. Many subjects will be uncomfortable, unhappy, tired or
embarrassed.

•Identification. Each photograph must identify the subject, the date and the
time that the photograph was taken.

Providing written evidence and court attendance:-

Health workers may be called upon to give evidence, either in the form of a
written report or as an expert witness in a court of law. When charged with this
task, health care practitioners should be aware of the following pitfalls and
potential problem areas:
— providing opinions which are at the edge of, or beyond, the expertise of
the witness;
— providing opinions that are based on false assumptions or incomplete
facts.

Three challenges of a nurse:-

1) variation in nurse documentation and communication.

2) the absence of a centralized care overview in the patient's electronic health record, ie, easily accessible by the entire care team.

3) rarity of interdisciplinary communication.

Actions taken by the nurse to overcome these challenges:-

Creating awareness about risk involved in patient handling: There are several factors, which make patient handling activities strenuous, thereby increasing the risk of injury. It is, therefore, essential to educate the nurses about these risk factors, and their consequences. The following measures can reduce patient handling risks to a great extent:

a) Technological advancements and assistive devices help nurses in their task of patient movement and mobility. They also help reduce risks of injury to the staff.

b) Competence-based employee education on the use of safe patient handling and mobility devices, and associated work practices is crucial. Both, new hires and the permanent staff, who have the responsibility to handle patients, should be given proper education and rigorous training to improve their efficiency.