Discussion
Guidelines for Effective Documentation
Documentation
Another aspect of nursing and interdisciplinary team care is documentation.
Written records of client care are important in several ways.
1. Written care plans serve to coordinate and communicate the plan of
nursing care for each client to all team members. Using a written plan
of care maximizes the opportunity for all team members to be
consistent and comprehensive in the care of a particular client.
Ongoing evaluation and revision of the care plan reflect changes in the
client’s needs and corresponding changes in care.
2. A written care plan is an effective, efficient means of communication
among team members who cannot all meet as a group (i.e., who work
on different shifts, float staff, supervisors, etc.).
3. Nursing documentation or charting in the client’s medical record
serves to clearly communicate nursing observations and interventions
to other members of the interdisciplinary treatment team (e.g.,
physicians, social workers, discharge planners, etc.). Information in
the chart is also available as a record in the event of transfer to
another facility, follow-up care, or future admissions.
4. The chart is a legal document, and the written record of nursing care
may be instrumental in legal proceedings involving the client.
5. The documentation of care is important for accreditation and
reimbursement purposes. Quality assurance and utilization review
departments, accreditation bodies, and thirdparty payers depend on
adequate documentation to review quality of care and determine
appropriate reimbursement
A. Privacy and Accountability
Confidentiality refers to the duty to protect privileged information and to
share entrusted information responsibly. It stems from the notion that a
person’s wishes, decisions, and personal information should be treated with
respect. The duty of confidentiality can apply to individuals, organizations, and
institutions. In fields like medicine, the law, and counseling, there are explicit,
professional obligations to keep personal information in confidence, because
the trust is the foundation for meaningful professional relationships.
Privacy
refers to the right to be free from interference. Privacy is supposed to
enable individuals to exert control over their own lives, which includes
deciding who should have access to personal information, and when
and how this information will be disclosed.
Privacy is something most of us value. Healthcare information privacy is
unique in that there are federal privacy laws that must be followed.
Whether you are a family member, or anyone else, a person’s healthcare
information is protected. This is called HIPAA (The Health Insurance
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and Portability and Accountability Act). You have probably seen this
when you have visited your healthcare provider. The portion of the act
that involves privacy dictates that healthcare entities must keep your
health information safe and private.
5 Ways to Protect a Loved One’s Privacy When Working with a Professional
Caregiver
A special bond forms between a client and a valued caregiver. A good
caregiver has knowledge about your family member’s health status. This is
natural, beneficial and allows the caregiver to do their job. But steps should
be taken to protect that information from others. It is better to lay some
ground rules early to prevent a breach of privacy. Some ideas include:
1. Share only health information with a caregiver and care manager that
is necessary for them to do their job. At the time, remind them that this
information is private.
2. Do not leave personal health information or passwords out for anyone
to see. Keep those in a safe and secure location.
3. Caution a caregiver or care team about sharing any personal
information about your loved one. Be specific about if it is ok to share
information with certain people. If your loved one is of sound mind,
they can make the decision about who to share information with.
However, if your family member has dementia, it may be best for the
healthcare power of attorney to make those decisions.
4. There may be occasions when a caregiver is in a healthcare setting
with your loved one. It is important for the caregiver to inform the
provider that health information be shared with a designated family
member and/or the designated care team.
5. Slips may happen. This is no reason to throw the baby out with the
bathwater! We all make mistakes and a breach of privacy is a teaching
moment for a caregiver.
B. Methods and Formats
Geriatric Health Care Team
1. Gerontologist / Geriatrician
Geriatricians
A geriatrician is a medical doctor that specializes in the care of older
adult
are fully trained physicians, M.D.s or D.O.s, who specialize in treating
the health problems of elderly patients. To become a geriatrician, a
doctor must first complete a three-year residency and become board-
certified in either internal medicine or family medicine, according to the
American Geriatrics Society.
Geriatricians diagnose and treat a wide range of conditions and
diseases that affect people as they age, including:
Dementia
Osteoporosis
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Incontinence
Cancer
hearing and vision loss
osteoarthritis
insomnia
diabetes
depression
heart failure
frailty
balance issues
Gerontologists
Gerontologists aren't medical doctors. They're professionals who
specialize in issues of aging or professionals in various fields from
dentistry and psychology to nursing and social work who study and may
receive certification in gerontology.
Gerontologists view aging in terms of four distinct processes:
chronological aging, biological aging, psychological aging, and social
aging
Gerontology is the scientific study of aging, as well as its effect on
individuals and cultures,. It's a multi-disciplinary field, including aspects
of medicine, biology, psychology and sociology and other sciences.
Some gerontologists are researchers, helping to interpret new findings
in microbiology and biochemistry that might unlock the physiological
secrets of the aging process.
Others are caregivers, working directly with elders and their families.
Still others are administrators and policy-makers at the community or
government level. Improving quality of life for seniors, individually or
collectively, is the common goal of gerontologists. According
to California State University, senior roles in gerontology require a
graduate or doctoral degree, though some schools offer baccalaureate
programs for entry-level gerontological work.
2. Nurse Gerontologist
Gerontological nurse, also known as geriatric nurses coordinate medical
treatment for the elderly patients. They give care to the elderly who
usually are in at higher risk of getting diseases such as Alzheimer's,
osteoporosis or cancer and injuries because of their advanced age.
The primary focus for geriatric nurses is to provide preventive care. They
also help the patients and the families to develop coping mechanisms for
specific medical conditions which develop at later stages of life.
GERONTOLOGICAL NURSE WORKING CONDITIONS
Geriatric conditions should be persons who enjoy working with the elderly.
It requires patience; careful listening abilities and balancing skills to
manage the patient needs with family demands that can at times become
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conflicting.
Gerontological responsibilities can vary depending on the needs of a
patient, the attending physician and medical facility. Gerontological nurses
mainly train and work to help patient s who have challenges such as lost
mobility or have impairment in their hearing, speaking or eyesight. Such
patients require supervision for them to enjoy daily lives.
A gerontological nurse who works will perform these functions when
working with patients:
Assess the mental status and cognitive skills
Discuss the common health concerns such as a change in sleep
pattern,
falls, incontinence and other dysfunctions. Frequent discussions help in
understanding the acute and chronic health issues that affect a patient.
Organize medications
Explain how to use medicine, supervise to ensure adherence and
recommend any essential adjustments to a regimen
Educate patients about personal safety and prevention of disease
Link patients with local resources that they may require
GERONTOLOGICAL NURSE PRACTICE SETTINGS
Geriatric nurses work in various practice settings including:
1. Nursing homes
2. Patient homes
3. Hospitals
4. Rehabilitation facilities
5. Senior centers and retirement communities
3. Occupational Therapist
Occupational therapist:
A licensed health professional who is trained to evaluate patients
with joint conditions, such as arthritis, to determine the impact the
disease on their activities of daily living.
Is the only profession that helps people across the lifespan to do the
things they want and need to do through the therapeutic use of
daily activities (occupations).
treat disabled, ill or injured patients with special equipment and the
therapeutic use of daily activities. They help patients improve,
regain and develop the skills needed for day to day life and work.
They may provide long-term patient care and acute patient care
The purpose of Occupational Therapy (OT) is to help people
increase their functional independence in daily life while preventing
or minimizing disability. Often OT is combined with other
treatments, including Physical Therapy
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