Below is an actual letter from a hospital administration dealing
with student nurse charting issues. Below is how they addressed
the issue of computerized charting without student access
to the digital charting.
August 2007
In an ongoing effort to align with The Joint Commission’s
patient safety goals, we have been working on improving patient
handoffs and communication. We have adopted the Situation,
Background, Assessment and Recommendation (SBAR) tool. I am
including a DVD and educational materials to share with your
instructors and students to highlight the importance of accurate
handoff/communication. We will be expecting the students to
start to practice this technique in the Fall.
I would also like to take this opportunity to review documentation
guidelines with regards to student nurses caring for patients
in clinical areas that use Meditech. To review an issue that
occurred
recently, I will use the SBAR format:
Situation: Some staff nurses have been under the assumption
that all nursing students document their assessment/observations/vital
signs, etc in the patient’s medical record.
Background: Since [Hospital] conversion to [computer] documentation,
we have not trained the instructors/nursing students to document
in the computer system. [Hospital] has also not supported
the use of “hand-written” student nurses notes.
Assessment: There have been gaps in the documentation of vitals
signs, observations, etc. in the medical record
Recommendation: Starting in the Fall 07, each nursing student
will be required to use the “Daily Nurse’s Notes”
to document their care. At the end of the clinical day, the
student is to review their documentation with their Instructor
and both are to sign the form. When the student is providing
their final report to the staff nurse, they are to review
the documentation and have the staff nurse sign
the note and place in the medical record.
And lastly, [Hopsital] is embarking on an activity study for
all clinical areas. Due to that fact, our CNO has decided
that there are to be no nursing students on the units to skew
the results. So, no nursing
students are to be on the units from Wednesday, September
5th through Thursday, September 13th.
I am sorry for any inconvenience this may cause.
If you have any questions to the above, do not hesitate to
contact me.
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