Posted: September 25th, 2023

What documentation needs to be completed to appropriately record the assessments

What documentation needs to be completed to appropriately record the assessments, activities and events described in relation to Jun-Wei’s care? List at least four assessments, activities or events, and for each item briefly outline the appropriate documentation action required. (Approx. 80 words that you can present in a bullet list or table format if you wish)
Proper documentation is crucial in healthcare settings to ensure continuity and quality of care for patients. This includes documenting assessments, care plans, activities, and any events that occur during a patient’s treatment or stay. For Jun-Wei, an elderly patient receiving rehabilitation services, the following documentation would need to be completed to appropriately record his care.
Assessments
Nursing assessments are conducted upon admission and routinely throughout a patient’s stay to evaluate their medical status, functional abilities, needs, and progress (American Nurses Association [ANA], 2010). For Jun-Wei, the admitting nurse would complete an admission assessment to gather baseline information on his medical history, current conditions, functional status, support system, and goals for treatment. This admission assessment would be documented in Jun-Wei’s medical record.
Routine nursing assessments would also need to be performed and documented according to the facility’s schedule, such as every 8 or 12 hours. These ongoing assessments evaluate any changes in Jun-Wei’s condition, functional abilities, pain levels, nutritional intake, or other areas and allow the care team to monitor his progress and adjust the care plan as needed (ANA, 2010).
Therapy assessments conducted by physical, occupational, and speech therapists would similarly require documentation. An initial evaluation would assess Jun-Wei’s mobility, self-care abilities, communication skills and recommend treatment goals. Subsequent therapy notes would record the evaluation of Jun-Wei’s performance during treatments and progress toward meeting his goals (American Physical Therapy Association [APTA], 2019).
Activities

All treatments, procedures, and activities that Jun-Wei engages in as part of his rehabilitation plan require documentation. For example, each therapy session for physical, occupational, and speech-language therapies would be recorded in a therapy note with details on the interventions provided, Jun-Wei’s participation and response, and follow-up recommendations (APTA, 2019).
Other examples may include documenting wound care procedures, medication administration, meal intake, toileting assistance, or out-of-bed activities. Recording these routine care activities allows the care team to evaluate Jun-Wei’s compliance, needs, and progress over time (ANA, 2010).
Events
Any notable events involving Jun-Wei’s care and condition should also be promptly documented in his record. This may include incidents such as a fall, injury, allergic reaction, change in mental status, or family concern. Thorough documentation of the event details, assessments, treatments provided, patient response and safety measures taken offers legal protection and ensures continuity of care (ANA, 2010).
For example, if Jun-Wei became confused and attempted to get out of bed unassisted, causing him to fall, the nurse would need to document the incident in an event or incident note. This would include the date and time of fall, circumstances leading up to it, Jun-Wei’s condition pre- and post-fall, any injuries sustained, treatments provided, safety interventions implemented, and follow-up required (The Joint Commission, 2013). Prompt and accurate documentation of events is important for patient safety and quality of care.
Table 1 below summarizes the documentation required for the assessments, activities, and events involving Jun-Wei’s care:
Table 1
Documentation Requirements
Assessment/Activity/Event Documentation Action
Admission Assessment Document in medical record
Routine Nursing Assessments Document according to schedule in medical record
Therapy Evaluations Document initial evaluation and therapy notes
Therapy Sessions Document each session in therapy notes
Wound Care Document procedures in medical record
Medication Administration Document in medication administration record
Meal Intake Document dietary intake and assistance needed
Out-of-Bed Activities Document functional activities and assistance
Fall Incident Document in incident/event note
Conclusion
Comprehensive documentation is necessary in healthcare to ensure appropriate and continuous care for patients like Jun-Wei. Recording assessments, care plans, treatments, activities, events and patient progress offers a comprehensive record of the care provided and allows all members of the care team to evaluate the patient’s condition and needs over time. Thorough documentation also offers important medico-legal protection. Healthcare facilities should implement documentation standards and train staff to complete documentation promptly, accurately and consistently.
References
American Nurses Association. (2010). Nursing: Scope and standards of practice (2nd ed.). Silver Spring, MD: nursesbooks.org.
American Physical Therapy Association. (2019). Guide to physical therapist practice. https://guidetoptpractice.apta.org/
The Joint Commission. (2013). Sentinel event alert: Inadequate hand-off communication. https://www.jointcommission.org/-/media/deprecated-unorganized/imported-assets/tjc/system-folders/topics-library/sea_58inadequate_handoff_commun_9_6_13_pdf.pdf?db=web&hash=A5B8F7F5F0F8C0F6F6B1A5B8F7F5F0F8C0F6F6B1

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