Feidhmeannacht na Seirbhise Sirume
Health Service Executive
HSE-WEST (MWRH-Nursing Limerick) Policy on
Documentation and Report Writing
Document
Reference
Number
Revision
Number
NP 01108
Document
Drafted By
Julie Wade, CPC
03
Document
Approved By
Maura Fitzgerald
AlDirector of Nursing
Gerardine Kennedy.
Nurse Practice
Development
Coordinator
Approval
Date
Revision
Date
~q,~- ~ (<99 . Responsibility
For
Implementation
January 2012
Responsi bility
For Evaluation
And Audit
Nurse Practice
Development Unit.
Registered Staff
Nurses and Midwives
Gerardine Kennedy
NPDC1ADON
Julie Wade CPC
Pages
7
HSE-WEST( MWRH-Nursing, Limerick) Policy on Documentation and Report Writing:
Nursing PPPG Documentation aud Report Writing Ol109/.doc
Page 1 of7
Table of Contents
1.0 Policy Statement
3
Page 3
3.0
4.0 Definitions
Page 3
3
5.0 Roles and Responsibilities
Page 3
6.0 Procedure.
Page 3
7.0 Implementation
4
8.0 Evaluation and Audit
4
5
Appendix
Signature Sheet
6
Page 7
HSE.WEST( MWRH-Nursing, Limerick) Policy on Documentation and Report Writing:
Do.:urrumltatil)n and Report
Ol109/.doc
Page 2 of7
1.0
POLICY STATEMENT
1.11t is the Policy of the Mid-Western Regional Hospital that all patients must
have an
2.0
legal record of care.
PURPOSE
2.1 The
of this policy is to ensure that
registered nurses and midwives
use comprehensive written documentation and
a written plan care
is evident for all patients/clients. The Quality of record keeping should be
such
the continuity care
a patient is always supported.
"Incomplete, inaccurate or non- existent documentation, regardless of
may
be considered negligence", (Plaweki & Plawelkj,
2007).
IJcnJ';:)V'
3.0
SCOPE
Applies to all Registered Nursing and Midwifery
under supervision.
4.0
including
ulUluel
DEFINITIONS
4.1 When caring for the patient, (which may include the
family), the
nurse's documentation provides a clear picture of
state of the 1"'I!:'II'I:C>l"'It
the actions of
nurse,
the
outcome in a care plan reflecting
the needs and goals of the patient, (An Bord Altranais,
CRNB
wetislte 2008).
5.0
ROLES AND RESPONSIBILITIES
Each nurse should establish a patient focused plan of care
holistic, clear
current patient records within a
professional framework, (An Bord Altranais,
S.2A nurse making a referral or consulting with another member of the
by name the person in the record.
healthcare team should clearly
5.3 The standard of record
of student nurses and student midwives
clinical area should
monitored by
supervision in
Nurse/Midwife charged with the responsibility for their supervision. This
skill
instruction/supervision, as a student nurse cannot
held
totally accountable for
record while under supervision, (An Bard
Altranais, 2002, p13)
6.0
PROCEDURE
6.1 All narrative notes must be individualised, accurate, up to date, factual and
unambiguous.
RS'F/"~\lE!~T( M\VRlEl-l"uN~in£!
Limerick) Policy on Documentation and Report Writing:
DO(~Umien~:atic)D and Report Writing Ol109/.doc
6.2 Black ink
used for all records.
6.3 Notes must be written as soon as possible
the event in chronological
order using
24hour clock.
6.4 Late entries are
provided they are clearly documented as
6.5The patient's name and hospital number must be written on each
S.6AII
must be dated, timed and
by
nurse making
6.7 Nursing records must
complete.
6.SAII written records
be leQIOle.
6.9Nurses should sign their name as entered on the
of Nurses and
Midwives maintained by An Bord Altranais.
6.10
made in error should
bracketed
have a single line drawn
through them so that the original entry is still legible.
6.11
should
signed,
6.12
fluid should never be
6.13 Do not attempt to
or erase the error.
6.14 Once written, reports must not be
or added to, as they are a
legal record of care.
6.15 Only abbreviations approved by the National Hospital Office (2007) are
permitted.
6.16 All decisions to take no immediate action but to review the situation
later must be clearly documented.
S.17 Each patient must have an individualised plan of care in place and this
care
reviewed daily or more often if required.
6.18 All documentation must reflect the condition of the patient and any
deterioration or improvement.
6.19 All nurses and midwives must document relevant patient education,
discharge planning and discharge advice.
7.0
IMPLEMENTATION PLAN
7.1 The approved policy will be distributed by the NPDU to Nurse Managers
to the ADON office the
in clinical areas at MWRH, Copies will be
Regional Orthopaedic Hospital, Croom and to
ADOM office the
Regional Maternity Hospital Limerick.
policy.
are
to
and sign that they have
7.2This is a
done so,
Signature Sheet). The information is essentially the same
but updated with references. If further education sessions are required the
manager should contact the author.
7.3A tracking
recording distribution of
policy and withdrawal the
previous edition will
monitored by the author or delegate and this
will be kept in NPDU.
8.0
EVALUATION AND AUDIT
S.1 This policy will be
within six months by the auditor with the Nurse
Appendix 1
Practice Development Coordinator and
HSE-WEST( MWRH-Nursing,
Policy on DocumentatioD and Report Writing:
Nursing
Documentation and Report Writing 01/09/.doc
Page 4 of7
REFERENCES AND BIBLIOGRAPHY
An Bard Altranais (2002) Recording Clinical Practice Guidance to Nurses and
Midwives, Dublin: An Bord Altranais
An Bard Altranais (2000) Scope of Nursing and Midwifery Practice, Dublin: An Bard
Altranais
An Bard Altranias (2000) The Code of Professional Conduct for each Nurse and
Midwife, Dublin: An Bard Altranias.
CRNBC (2008) www.crnbc. caJNursingPractice-Reguirements.aspx accessed on
nd
22 December 2008
Mid-Western Regional Hospital Limerick, (2008) Nursing Care Plan Guideline.
National Hospital Office Code of Practice for Healthcare Records Management,
(2007) The National Hospital Office Code of Practice for Healthcare Records
Management, Dublin
National Hospitals Office Code of Practice for Healthcare Records Management
(2007) Abbreviations, Barnaville Print and Graphics Ltd.
Plaweki, L.& Plaweki, H. (2007) Your choice documentation or litigation, Journal of
Gerontological Nursing, 32(1)
HSE-WEST( MWRH-Nursing, Limerick) Policy on Documentation and Report Writing:
Nursing PPPG Documentation and Report Writing Ol/09/.doc
Page 50f7
Appendix 1
AUDIT
HSE ..WEST (MWRH-Nursing LIMERICK) Policy on
Documentation and Report Writing Audit Template
1.
all narrative
a. Up to date?
b.
c.
Unambiguous?
2. Is black ink
for all
r<=>I"'·l"\r..~e'}
notes written as soon as possible
3.
Are late entries
5. Is the
('I~:::UIV
the
the
in chronological
documented as such?
name and hospital number written on
6. Are all entries dated, timed and signed by
page?
nurse making
entry?
7. Are nursing records complete?
8.
written records legible?
9.
the Nurse
their name as entered on the Register of Nurses
maintained by An Bord
1O. Have entries
11. Are errors
12.
Altl"~n<llle')
in error been bracketed
so that
original
<:.il"lI'I~ri
Midwives
have a single
drawn through
is still legible?
and dated?
erasure fluid (forbidden) should
used?
~th"ml"lt
13. Is the documentation clear of
to alter or erase
error?
14. Not Applicable
15. Are abbreviations as approved by
16. Are
National Hospital
(2007).
decisions to take no immediate action but to review the situation later been
clearly documented?
17.
each
n::ltlijl:>nt
an individualised plan
i. Is
care in
daily or more often if required?
care plan must
Does documentation must reflect the condition of the natilAnt
19. Does documentation show
i. Relevant
n!:lt •.::.nt
education?
ii. Discharge planning?
Discharge aO\lrlce
20. Are ...::ofl:l."I"~1 consultations cleJ=lrlv identified by name?
. Is student documentation supervision
Was a copy of the policy
23. Is
a signature
to
monitoring evident?
ward?
in use?
MWRH-Nursing, Limerick) Policy on Documentation and Report Writing:
Documentation and Report Writing Ol109/.doc
Signature Sheet:
J have read, understand and agree to adhere to the attached Policy, Procedure,
Protocol or Guideline:
Print Name
Signature
Area of Work
Date
HSE-WEST( MWRH-Nursing, Limerick) Policy on Documeotation and Report Writing:
Nursing PPPG Documentation and Report Writing Ol109/.doc
Page 7 of1