Course: Topic: Level of participants: Number of Participants: Date: Time: Duration: Venue: Methodology: Learning Theory:

Clinical Teaching and Assessment Documentation Third year Nursing Students and nurses 30 March 2012 10:30am 45 minutes Inservice Education Department Lecture/Discussion/Demonstration Ausubel: Emphasized the use of advance organizers which he

posited was different from overviews and summaries. His use of an Advance Organizer acted to bridge the chasm between learning new material and existing related ideas. The advanced organizer used, seeks to bridge new knowledge with what was known (sometimes what is known is uncertain and not concrete). Although he specified that his theory applied only to reception learning in school, it was utilized because it introduced the topic and aided the sequence of the information to be imparted. (Ormrod & Rice, 2003) Bruner: Believed that learners are not blank slates but brings past experiences to a situation, he also stated that new information is linked to prior knowledge, thus mental representations are subjective. Bruners Discovery learning is an inquiry-based, constructivist learning theory that takes place in problem solving situations where the learner draws on his or her own past experience and existing knowledge to discover facts and relationships and new truths to be learned. Students interact with the world by exploring and manipulating objects, wrestling with questions and controversies, or performing experiments. As a result, students may be more likely to remember concepts and knowledge discovered on their own (in contrast to a transmissionist model). Models that are based upon discovery learning

model include: guided discovery, problem-based learning, simulation-based learning, case-based learning, incidental learning, among others. The advantages of this theory are: it encourages active engagement, promotes motivation, a tailored learning experience, and promotes autonomy, responsibility, independence, the development of creativity and problem solving skills. (Quinn, 2006). Vygotsky- the teacher and the learner collaborates in a reciprocal relationship where each learns from each other in what is called social interaction. (Quinn, 2006). Bandura- people learn from each other through observation, imitation and modeling. It is often called a bridge between behaviourists and cognitive learning theories since it encompasses memory, attention and motivation. (Ormrod & Rice, 2003). Aim of Activity: To impart the relevance and importance of documentation to Nursing practice and patient care Resources: Registered nurse, computer, white board, charts and Book Scientific Principle: Communication: Kozier et al, 2006 stated, This suggest that there are two roles in any interaction: The communicator (the person sending the message) and the receiver (the person receiving the message) (p. 90). For communication to be beneficial the intent of the message received must be the same as the message sent. (Frisch & Frisch, 2006).

Specific Objectives:

At the end of 45mins interactive session students should be able to: 1. Define the term Documentation as stated by Papathanasiou & Kotrosiou 2. State at least seven of the 14 Guidelines that governs documentation 3. Explain the eight Purposes of Documentation 4. Describe the process of Documenting with the nursing process as a guide on a nursing documentation tool

Evaluation:

Formative, Summative and Return Demonstration. Questions will be asked before and after each objective and followed by a question and answer session and a return demonstration at the end.

References:

Frisch, N & Frisch, L. (2006). Psychiatric Mental Health Nursing. Colorado: Thomson Delmar Learning

Kozier, B., Erb, G., Berman, A & Burke, K. (2006), Fundamentals of nursing: Concepts process and practice, Upper Saddle, River New Jersey: Prentice Hall

Ormrod, J & Rice, F. (2003). Lifespan development and learning. Boston MA: Pearson Publishing. Papathanasiou, I., Kotrotsiou, S & Bletsa, V. (2006). Nursing documentation and recording systems Retrieved on February 05th 2012 from http://www.scribd.com/Dr%5Cmagdabayoumi/22659945-Nursing-documentation-andRecording-Systems.

Quinn, F. (2006). The principles and practice of nurse education. London: Stanley Thornes Sullivan, E & Decker, P. (2009). Effective leadership and management in nursing.Upper Saddle

River, New Jersey: Pearson Prentice Hall

OBJECTIVES ICEBREAKER

CONTENT Have you ever heard the term, if it is inked it is Done?Yohan Blake (world 100 meters sprint champion) inked a deal with LIME recently, it meant the deal was signed, it became official.Your work is not official until written and signedif it is not written it is not done

TEACHERS OBJECTIVES

LEARNERS OBJECTIVE

EVALUATION

Define the term Documentation

Documentation is the written and legal recording of the interventions that concern the patient and includes a sequence of processes.(steps in the nursing process) Documentation is established with the personal record of the patient, which constitutes a base of information on the situation of his health. (Papathanasiou & Kotrotsiou, 2011).

Teacher will ask students to attempt to define Documentation in their own words. Teacher will define Documentation using PowerPoint according to the content.

Students will attempt to define Documentation in their own words.

Students will be able to define Documentation using atleast two

Students will listen attentively and follow on PowerPoint as definition is shown and

specific words from the content such as: the written, legal

stated.

recording of intervention that

Teacher will ask one student seated at the back of class to define Documentation according to content using key words such as: written, legal, recording interventions that concerns the patient

One student seated at the back of class will define Documentation using specific words such as the written legal recording of interventions that concerns the patient

concerns the patient

State at least seven of the 14 Guidelines for Documentation of patient care

The 14 Guidelines for Documentation of patient care are: Dating and time: This is for legal reasons and patients safety. Frequency: Timing is important, thus the frequency of documentation should be insinct with the patients condition and agencys policy and should be done as soon after an assessment or intervention, it should not be done before. Legibility: All entries must be easy to read to prevent errors of misinterpretation. Permanence: All entries made in the patients file should be done in dark ink so that permanence is maintained; dark also reproduces well on microfilm and the photo copying process. Accepted terminologies: Only commonly accepted abbreviations symbols and

Teacher will ask seven students to make an attempt in stating two guidelines each for documentation of patient care.

Seven students will attempt to state two guidelines each for documentation of patient care

Student will be able to state at least seven of the 14 guidelines for documentation of patient care.

Teacher will state the 14 guidelines for documentation using the PowerPoint and a self made book

Students will listen attentively follow on PowerPoint and the Book made by teacher as the 14 guidelines for documenting patient care are stated.

Teacher will ask three

Three students at the

terms that are specified by the agency should be used to document patient care. Correct spelling: Correct spelling is essential in recording, if you are unsure about a spelling, it should be looked up in a dictionary or a resource book. Signature: Each recording on the nurses notes should be signed by the nurse making the recording. The signature includes the nurses name and title. Accuracy: The patients demographic information should be written on each page of his record, always double check to ensure that the chart or nurses note is correct. Dont identify charts by room and bed number only, Check the name as well, because some clients bear the same names. Sequencing: Events should be written down in

students at the back, three in the middle, four on the left and four on the right to state one guideline each for documenting patient care according to the content.

back, three in middle, four on the left, and four on the right will state one guideline each for documenting patient care according to the content

the order in which they occur. Appropriateness: The only information that should be written down are those that pertain to the patients health problem and care. Completeness: The information that is written down should be complete and helpful to the client and health care professional and should reflect the nursing process. Care that is omitted because of the patient condition or refusal must be recorded. You should document why it was omitted and who was notified. Conciseness: Documentation should be brief and complete to save time in communication. You dont need to write the word patient or the patient names again. Each thought or sentence should end with a full stop. Legal prudence: When you document, you do

so with a court of law in mind, thus it should be accurate and complete to protect the nurse, other health care providers, the institution and the patient. (Kozier, Erb, Berman & Burke et al, 2006)

Explain the eight purposes for documentation of patient care

The eight purposes for the documentation of patient care are: Communication: This is to convey information to incoming staff members on the patients condition, to prevent fragmentation (promote continuity of care), repetition and delay in patient care. Planning patient care: Each health professional uses the data from the patients record to plan the required care. For example using a baseline data to evaluate the effective of the nursing plan of care. Auditing: This is the reviewing of the patients records for quality assurance purposes, that is to determine if the health agency is meeting its stated standards (Kozier

Teacher will ask students to attempt to identify the eight purposes of documentation

Students will attempt to identify and explain the eight purposes of documentation in their own words

Students will be able to explain the eight purposes for documentation of patient care

Teacher will explain the eight purposes of documentation according to the content using PowerPoint presentation

Students will sit, listen attentively and follow on PowerPoint presentation as the eight purposes of documentation are explained.

et al, 2006).Types of auditing are, process (how Teacher will ask two care is carried out) outcome (the results of the person in each of four

Two persons seated in each of four rows will

care given) and structure (quality of facility and equipment) audits.(Sullivan & Decker, 2009). Research: The information recorded in the patients file can be used for research purposes, for example, careplan/treatment plans for patients with similar health problems can provide valuable information in treating a particular patient with a similar condition. Education: Students from various disciplines often use patients record as an educational tool, for example in doing a case study, the student can gather the patients illness, treatment modalities and factors that may influence the outcome of the illness. Reimbursement: Documentation can help an agency to receive reimbursement from the

rows to explain two purposes of documentation according to the content

explain two purposes of documentation.

government for care that was given through a private health agency such as Medicare. (In the United States). Legal documentation: The patients file is a legal document and is admissible in a court of law as evidence as to the care that was or was not given in say for example a law suit. Health care analysis: The patients records can assist managers in their planning as it relates identification of the agencies needs, for example the types of services, the amount and types of resources as those that can generate an income or costly. (Kozier et al, 2006).

Demonstrate the process of Documentation for patient care using

These processes according to Kozier et el comprise the nursing process, which is a scientific, systematic and cyclic way of organizing and documenting patient care and

Teacher will ask students to attempt to explain how they would document patient care on a nursing documentation tool (that

Students will attempt to explain how they would document patient care on a nursing documentation tool given by teacher using the nursing process as a guide

Students will be able to demonstrate the process of documentation of patient care using the nursing process as a guide on a nursing

the nursing process involves the following: Assessment: This is as a guide on a nursing Documentation tool

where data is collected, organized validated and will be distributed by documented. Diagnosis: This is where data is analyzed, health problems, risks and strengths of the patients are identified and diagnostic statements are formulized. Planning: This is the stage where problems and diagnoses are prioritized, goals and desired patients outcomes are formulated and nursing interventions are selected. Implementation: The patient is reassessed, the need for nurses assistance is determined, nursing interventions Teacher will demonstrate with the aid of a scenario, white board and PowerPoint how nursing care can be documented on a semi-structured tool using the nursing process teacher) using the nursing process as a guide

Students will listen and observe on white board and PowerPoint as nursing care on a short scenario is documented and explained on a semi-structured

documentation tool

are implemented or carried out, delegation and supervision of activities are done and nursing actions are documented (Frisch et al, 2006, Kozier et al, 2006).

as a guide.

documentation tool using the nursing process as a guide.

Teacher will ask students in each row to form groups and give return demonstration on how patient care can be document on a semistructured nursing documentation tool using the nursing process as a guide, each group will return one completed documentation tool.

Students in each row will form groups and give return demonstration on how patient care can be documented on a nursing documentation tool (semi-structured) using the nursing process as a guide, each group will return one completed

Documentation tool. (8 mins)

QUESTIONS AND ANSWERS

QUESTIONS 1. Define the term Documentation 2. Name at least seven of the guidelines that governs documentation of patient care

True or false 3. One of the major purpose of documenting care done is to protect the agency from losing money 4. Documenting on the semi-structured tool is beneficial to the nurse because it saves time ANSWERS 1. Documentation is the written and legal recording of the interventions that concern the patient and includes a sequence of processes. Documentation is established with the personal record of the patient, which constitutes a base of information on the situation of his health. (Papathanasiou & Kotrotsiou, 2011). 2. Dating and time, Frequency, Legibility, Permanence, Accepted terminologies, Correct spelling, Signature, Accuracy Sequencing, Appropriateness, Completeness, Conciseness and Legal prudence (Kozier et al, 2006) 3. True 4. True