Nursing Leadership and Management

NURSING LEADERSHIP AND MANAGEMENT WHAT IS A KARDEX? ● Kardex is a documentation system that enables nurses to write, organise , and easily reference key patient information that shapes their nursing care plan. ● It gives a brief overview of each patient and is updated every shift. It is like having a cheat sheet for nurses to reference that is separate from the patient chart. It is usually kept in a central location, such as the nursing station, for quick access. ● Nurses use kardex to communicate important information about their patients. It is a record of medical and nursing orders of each patient in the ward MAINTENANCE OF NURSING KARDEX ● A Kardex will be maintained for all patients cared for in the ward. ● It will be checked and revised as needed, before giving care and daily after doctors rounds ● Only standard abbreviations will be used in writing orders on the Kardex. ● Do not abbreviate the name of the medications. ● Pencils are used in recording details. ● It is used during endorsement. Method of filling Kardex I. Identification Data: ● Use capital letters to record. ● Name - copy accurately and completely from the admission record ● Diagnosis - Record provisional diagnosis. ● Any changes in the working diagnosis ● Surgical procedure done with date II. Medication: a) Write date, form and the name of the medication, frequency of administration in 24 hours, route of administration if other than oral and specific instructions concerning administration in column marked "medication". b) In a column marked "Dosage" Write the amount to be administered at the time of each administration. c) In the column marked "time" write the hours of administration. d) Stat, P.R.N. and S.O.S. medication orders should not be recorded in the Kardex card but the medicine card should be prepared and should be inserted in the Kardex. e) Alternate day, weekly and bi weekly medications with the pencil the due dates for three consecutive dosage III. Treatments: a) In the column marked "treatment" write: date and name of the treatment, Example I/V, irrigation, diet, therapy, external applications, baking, frequency in 24 hours. And if applicable site, duration, temperature or strength of solutions and instructions. IV. Nursing Care Plan a) Write order relating to needed nursing care plan of the patient such as o Hygienic care: o o o o o o o o o o o o o o o ▪ Special Mouth care ▪ Shampoo Posture and position ▪ Frequency in 24Hrs Activity, rest and exercise. Control of pain Needs for health teaching or nursing care following discharge. Needs for support in relation to emotions or mental attitudes. Food or Fluid - Intake ▪ Type ▪ Amount ▪ Frequency ▪ Elimination Use of comfort devices and safety measures Recreation and diversion. ▪ Plan to meet the spiritual needs ▪ In the "time" column indicate the specific hours for carrying out nursing care if applicable. ▪ Bath Record if bed bath or shower, frequency and if not daily the specific days of week the bath is to be given. T.P.R. - Record the method of taking if other than oral. Diet - Record the type of diet ordered, supplementary feedings, if ordered. ▪ Limitation of food or fluid if applicable. Health education of; Disease General Family Planning Prevention of disease Kardex Management ● Completeness and Integrity: The Kardex must be updated regularly to reflect any changes in the patient’s care plan. Nurses are responsible for ensuring that the Kardex contains accurate and current information to maintain its integrity. In electronic versions, updates can be automatically populated from the Electronic Health Record (EHR). ● Accessibility and Security: Kardex must be easily accessible to nurses during shifts. This is facilitated by electronic systems, which allow information to be accessed quickly on computers. However, strict security protocols are required to protect sensitive patient data, such as implementing user access controls and encryption. ● Safety: Regular audits and compliance checks help ensure that Kardex is being used properly. For electronic Kardex systems, strong cybersecurity measures must be in place to prevent data breaches or unauthorised access. PATIENT’S CHART/ MEDICAL RECORDS It promotes clear communication and facilitates effective decision-making. A well-organised medical chart typically follows a standardised format to ensure consistency and accuracy. Parts of a Patient’s Chart: 1. Demographic Information: The patient's chart should begin with their demographic details to ensure easy identification of the patient, such as name, date of birth, contact information, and insurance information. 2. Chief Complaint: This section helps healthcare providers quickly understand the patient's primary concern and immediate needs. 3. Medical History: Patient background is crucial as it helps healthcare professionals understand the patient’s overall health status by providing insights into their past illnesses, surgeries, allergies, and chronic conditions. 4. Medication List: An up-to-date record of the medications a patient is currently taking, including dosage and frequency. This information helps healthcare providers avoid potential drug interactions and prescribe appropriate treatments. 5. Vital Signs: Tracking a patient's vital signs, such as blood pressure, heart rate, temperature, and respiratory rate, is a crucial part of a medical record when it comes to assessing their overall health status and physiological condition. 6. Laboratory Results: Documenting test results, such as blood tests and pathology findings, is essential for monitoring a patient's health and tracking their progress over time. These results aid in diagnosing and managing medical conditions. 7. Progress Notes: This section details each patient encounter, including subjective information, objective findings, assessments, and treatment plans. These notes serve as a chronological record of a patient's care and enable healthcare providers to track their progress. 8. Consultation Reports: If a patient receives specialized care from other healthcare professionals or specialists, their consultation reports should be included in the medical chart. These reports provide specialized insights and recommendations for the patient's ongoing care. 9. Imaging and Diagnostic Reports: Medical charts should contain a section dedicated to storing imaging reports, such as X-rays, MRIs, or CT scans, as well as other diagnostic reports. These documents provide visual evidence and aid in diagnosing and treating medical conditions. 10. Discharge Summary: When a patient is discharged from a healthcare facility, a comprehensive summary should be prepared. This summary includes details of the patient's hospital stay, diagnoses, treatments, medications, and any necessary follow-up instructions. It helps ensure a smooth transition of care between healthcare settings. Importance of a Patient’s Chart: 1. Continuity of Care: A patient's chart ensures the continuity of care between different healthcare providers. When multiple healthcare professionals are involved in a patient's treatment, the chart provides a centralised repository of information, enabling seamless communication and coordination. 2. Legal and Ethical Considerations: Thorough documentation in a patient's chart protects healthcare providers legally and ethically. It serves as a legal record of the care provided and the decisions made. In case of any legal disputes or medical malpractice claims, a well-documented chart can serve as crucial evidence. 3. Communication and Collaboration: A patient's chart serves as a means of communication among healthcare professionals involved in the patient's care. Accurate and up-to-date documentation ensures that important information is shared effectively, preventing misunderstandings and promoting collaboration. 4. Treatment Planning and Decision-making: A comprehensive patient chart provides healthcare providers with a holistic view of the patient's health history, current condition, and previous treatments. This information is vital for developing appropriate treatment plans and making informed decisions about the patient's care. 5. Quality Assurance and Research: Medical charts play a significant role in quality assurance and research endeavours. Aggregated and anonymized patient data from medical charts can be analysed to identify trends, improve healthcare practices, and contribute to medical research. 6. Billing and Reimbursement: Accurate documentation in a patient's chart supports appropriate billing and reimbursement for healthcare services provided. It ensures that the services rendered are properly coded and documented, facilitating timely and accurate claims processing. MANAGEMENT OF RELEASING PATIENT INFORMATION/RECORD All medical records information is deemed to be strictly confidential and cannot be disclosed to any unauthorised personnel under any circumstances without proper authorization. Certain exceptions which require hospitals to release the medical information of a patient are as follows: 1. The medical record needs to be shared with a different physician or hospital in order to provide better medical treatment of the patient. 2. If a court order for its release is obtained in medicolegal cases such as accidents, medical negligence, etc. 3. If a patient asks for copies of the medical records to seek a second opinion from another physician. 4. A health care power of attorney of the patient has the right to access the medical records as long as the patient has signed a release of records but the extent of access will be limited to those information which will be required to make an informed decision. 5. If a health insurance company asks for medical records for claim settlement. 6. If the patient is a minor, the parents have the right to seek copies of the child's medical records. MANAGEMENT OF RECONSTRUCTING MEDICAL RECORDS: A disaster recovery plan is crucial for every healthcare facility in the event of a failure of the medical records department to preserve the records of the patients. Simple steps that can be taken to safeguard the medical records in an unforeseen circumstance are 4’s: 1. Salvage: Save medical records from being damaged or destroyed. 2. Search: Conduct exhaustive search to locate the missing records. 3. Start reconstruction: If a document is permanently lost, attempt to reconstruct such as reprint or retranscribe. 4. Scribe: If all above fails, the facility should make a documentation of the date on which the disaster took place, number of patient medical records lost, natural or manmade disaster that caused the loss, and possible efforts made to recover the records. DESTRUCTION OF MEDICAL RECORDS 1. Shredding - destruction method of paper-based medical records 2. Incinerating - destruction method of electronic media (magnetic tape, microfilm, floppy disk, CD, or DVD) A simple medical record destruction form would contain the following: 1. Name of the authorizer 2. Period for which the records are destroyed or purged 3. Medical record number 4. Date of destruction 5. Method of destruction 6. Name of the destroyer and witness if any REMEMBER: As the saying goes, “ IF IT WAS NOT CHARTED, IT WAS NOT OBSERVED OR DONE”