Protect Your Practice –

Helpful tips

Monica Staley – Patient Representative519-254-5577 Ext. 52317Monica_Staley@wrh.on.ca

OBJE

CTIV

ES

REVIEW THE IMPORTANCE OF: * DOCUMENTATIONWhat / Why / How

* COMMUNICATION* PRIVACY* CONFIDENTIALITY

WHA

T W

OULD

YO

U DO

??

ScenarioMrs. S., a 45-year-old woman, is currently an in-patient

receiving chemotherapy for the treatment of a

malignancy. She consented to transfusion with blood

products as part of her treatment and has thus far

received several units of blood products.

West Nile Virus (WNV) nucleic acid testing of donated

blood commenced to prevent transmission of WNV

through the blood supply. Positive donor testing leads to

a recall of the donor’s products.

Unfortunately, only three of eight blood products could

be recalled from a positive donor. The other five units

were transfused to Mrs. S.  Although Mrs. S. remains immunosuppressed from

chemotherapy, she is currently clinically stable and well.

Should it be disclosed to Mrs. S. that she received blood

products that the donor tested positive for WNV?

If so, when?If so, how?If so, by whom?

WHY

DO

CUME

NT?

REFLECTS the client’s perspective

IDENTIFIES the caregiverPROMOTES continuity

of care by allowing other partners in care to access the information

WHY

DO

CUME

NT?

DEMONSTRATES the nurse’s commitment to providing SAFE, EFFECTIVE and ETHICAL care by showing ACCOUNTABILITY for professional practice and the care the client receives and TRANFERRING KNOWLEDGE about the

client’s health history

WHY

DO

CUME

NT?

COMMUNICATES to all healthcare providers :The ‘plan of care’The ‘assessment’The ‘interventions’ necessary

based on the client’s history; and

The ‘effectiveness’ of those

interventions

Is an INTEGRAL component on

interprofessional documentation within the

clinical record

WHY

DO

CUME

NT? DEMONSTRATES that

nurse has applied within the therapeutic nurse-client relationship the nursing KNOWLEDGE, SKILL and JUDGMENT required by professional standards regulations

WHY

DO

CUME

NT?

DEMONSTRATES the nurse’s commitment to providing SAFE, EFFECTIVE and ETHICAL care by showing ACCOUNTABILITY for professional practice and the care the client receives and TRANFERRING KNOWLEDGE about the

client’s health history

WHA

T TO

DO

CUME

NT?

Documentation should provide a clear picture of:The needs/goals of the

client or groupThe nurse’s actions based

on the needs assessmentThe outcomes and

evaluation of those actions

WHA

T TO

DO

CUME

NT? DATA from documentationCan be used to evaluate

professional practice as part of quality improvement processes

Can be used to determine

the care and services required or provided

NOT DOCUMENTED = NOT DONE!!!

INDI

CATO

RS O

N DO

CUME

NTAT

ION

3 STANDARD STATMENTS

1.

COMM

UNIC

ATIO

N Nurses ensure that documentation presents an accurate, clear and comprehensive picture of the client’s needs, the nurse’s interventions and the client’s outcomes

2.

ACCO

UNTA

BILIT

YNurses are accountable

for ensuring their documentation of client care is accurate, timely and complete

3.

SECU

RITY

Nurses safeguard client health information by maintaining confidentiality and

acting in accordance with information retention and destruction processes

and procedures that are consistent with the standards and legislation.

REME

MBER

….

CLEAR, CONCISE, COMPREHENSIVE”

REFLECTS PRIORITY PROBLEM”PATIENT FOCUSED –

what happened; what was done; who was told”FOLLOW UP CARE”

PURP

OSE

OF

COMM

UNIC

ATIO

N CAPTURES essential communication that has occurred within the interprofessional team.

IT S

HOUL

D IN

CLUD

E…

Nursing documentation communicates Assessment planning implementation evaluation client’s response to the care

REME

MBER

…

COMMUNICATE the client’s PREFERENCES and EXPRESSED NEEDS. INCLUDE CLIENT”S PERCEPTION of the care providedSHOW CARE and

CONCERN while communicating with client

DOCU

MENT

S CO

MMUN

ICAT

E TW

O TY

PES

OF D

ATA…

SUBJECTIVE DATAStatements and feedback from client, in quotations“I feel a stabbing pain in

my stomach”OBJECTIVE DATAObserved or measured factsClient was distressed.

Temperature 39oC.

REME

MBER

… INCLUDE IDENTIFIABLE SIGNATURE and DESIGNATON (RN, RPN,NP)KEEP PERMANENT

records

COMM

UNIC

ATIO

N

What is PATIENT-CENTRED

CARE?EMPATHYWALK-IN PATIENT’S SHOES

ADVOCATING for the rights

of VULNERABLE PERSONSKNOW YOUR HIERARCHY TO

ESCALATE & COMMUNICATE!! The law ASSUMES that

people have CAPACITY CONSENT & CAPACITYCAPACITY ASSESSOR

Cons

ent

and

the

Heal

th C

are

Cons

ent A

ct

Must have prior consent to

treatment, and consent must

be informed and voluntary;Common law; now largely

codified in Health Care Consent Act (HCCA);

Person must have capacity to

consent, i.e. able to (i) understand relevant info. &

(ii) appreciate reasonably

foreseeable consequences of

deciding or not (s.4);Emergency exception (s.25)

Capa

city

Health care provider proposing trt. decides re capacity (in first instance)

(s.10);Presumption of capacity (s.4

(2);Capacity can be trt-dependent and come & go

over time (s.15);If patient is incapable, then

substitute decision maker

(SDM) consents to or refuses

treatment.

Subs

titut

e De

cisio

ns A

ct

Power of attorney (POA) for

personal care (made by person concerned; low % of population have one);

Who can make (min. age;

test for capacity);Re health care: POA can say who decides, what to decide, or both;Also, guardianship (court

order).

S.20: Who decides for another:

lists SDMs in order of priority –

appted by ct, person (POA) or

Consent & Capacity Brd (CCB),

then descending degree of

relation; last resort = Public

Guardian & Trustee (PGT);S.21: How to decide for another: (i) follow prior capable

wishes if apply & person was at

least 16; (ii) if none, SDM to act

in best interests;S.5: Wishes: can be expressed

in any form.Subs

titut

e De

cisio

n-Ma

king

in th

e HC

CA:

Guid

ance

Prin

ciple

s

Dete

rmin

ing

Best

In

tere

sts

HCCA

s.21

(2)

SDM shall consider:Prior capable values and beliefs;

Incapable person’s wishes;Treatment factors: Is the trt likely to

Improve condition or well-being;

Prevent deterioration;Reduce extent or rate of

deterioration; +Effect of non-trt on person;Weigh benefit & risk of harm from

trt;Least restrictive or intrusive trt for

this benefit?

Cons

ent &

Ca

pacit

y Bo

ard

Person concerned can challenge practitioner’s finding of incapacity (s.32);

Health care practitioner can

challenge SDM’s compliance

with s.21 (decision making

principles) (s.37);SDM or HCP can apply to CCB

to clarify wish or to disregard

it if likely result much improved from when made

(ss. 35, 36);Further review by court.

PRIV

ACY

& CO

NFID

ENTI

ALIT

Y

PHIPA – Personal Care Information Protection Act

Circle of Care – Are you in

it?Telephone – Who can you

disclose information to?Fax Communication – Are

you permitted to send it?Social NetworkingElectronic AuditsKnow where you are when

you speak