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Nursing

Documentation

General Policies

  • All patient care requires documentation. 
  • A minimum of two (2) unique patient identifiers must be used to verify patients (e.g. patient full name, date of birth, medical record number, health card number).
  • Only hospital approved abbreviations and symbols are to be used.
  • Allergies must be documented immediately in the health record.
  • Correction of errors on electronic notes is done by modifying the current note or by appending the note after discharge. An audit trail is present for all modifications.
  • Entries must be made as close as possible to the time of the occurrence of the event being documented.
  • The person making the entry must have direct personal knowledge of the information being recorded.

Nursing Notes

Nursing notes should be entered at least once every 12 hours for all inpatients and for each of the following events:

  • Admission 
  • Transfer (e.g. unit to unit)
  • Discharge 
  • Treatment or procedure (e.g. procedure requiring consent or unusual treatment)
  • Change in patient’s or family's condition
  • Patient incident (e.g. medication error)
  • Patient or caregiver education

The purpose of the nursing notes is to document the patient response to treatment, illness, and changes in condition, and to provide information and perspective of the professional entering the note. The note is not intended to duplicate what is recorded in other sections of the patient chart, such as flow sheets. Notes should be concise and problem-based. Nursing notes should include the assessment, plan, intervention and evaluation of the care provided to address the issues related to the health of the child and the family. When entering notes in the electronic health record, nursing students should indicate their designation / program of study  (e.g. 2nd year nursing student) and academic institution at the end of all notes.
 

 A.P.I.E. Charting

At SickKids we use a charting format called "APIE" for our nursing  notes. This acronym stands for:

A - Assessment: subjective and objective data. This is your patient assessment, circumstances, conversations, patient/family education needs etc.

P - Planning: Includes nursing plans, and family goals for treatment. 

I - Implementation: What was done

E - Evaluation: Did it work, how it worked, what changes you need to make if it didn’t work. 

Example of a Typical Nursing Note in APIE format: Parent insisting on sleeping in a large bed with their one year old child, rather than placing child in a crib as per hospital guidelines. You are concerned that the child may fall out of the bed, while parent is asleep or when parent has to step away from the bed.

• A: Mom and patient asleep in bed together overnight. Child cries when mom has to leave for any period of time. Patient is connected to a monitor and has multiple IV lines. Mom says “I always sleep with her at night at home.”

• P: Review with mom safe sleep guidelines, rationale and recommendations. 

• I: Discussed safe sleep guidelines for in hospital care. Expressed concerns to parents related to child’s safety, for example if  mother needs to leave bed during the night. Mother states she will continue to sleep with the child. Spoke with charge nurse. Safety report completed. Parents agreed to allow nurses to assess more frequently during the night to ensure safety of patient. Responsible physician notified. Team will speak to parents and discuss strategies to keep child safe.

• E: Patient remained safe overnight. 

Mary Smith, 2nd year Nursing Student, University of Ottawa

Intake/Output section:

  • Hourly IV site and rate check
  • Cumulative IV volume infused hourly
  • Complete description of all IV solutions (solution, name, and concentration of additives), continuous IV infusions (medication name, dose & rate) and parenteral nutrition solutions (e.g. TPN)
Reference: SickKids Policies and Procedures: 
1) Patient Care Documentation
2) Documentation