St. Vincent's Hospital Melbourne Information & Guidelines for ...

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DOCUMENTATION GUIDELINESWhen you document in a patient medical record always be brief and factual. Donot use subjective or defamatory statements, and limit the use ofabbreviations. Every entry in the record must be made in a date sequentialmanner and every entry must be dated and signed. When you document youmust clearly print your name next to your signature and print your year leveland University.Progress notes are to be documented daily on the early shift or at any othertime where there is a significant clinical change in a patients' condition, e.g.return to ward post operatively.Under no circumstances should documentation be destroyed or deleted. Anyerrors made in patient medical records must have a single line drawn througheach line of text. The person responsible will write, "Entry made in error" andthen sign in the usual manner.Fluid Balance Charts (FBC)As a general rule of thumb, FBC are required for patients who are receiving IVtherapy; prescribed a fluid restriction or who are unwell. Each clinical area maydiffer as to how they complete the FBC’s. Generally the charts are totalled atmidnight and this data is transferred onto the Thermic Chart.However, it is advisable to subtotal the FBC during your shift to ensureadequate assessment of patient fluid status.Hospital wide fluid measurements:Clear Plastic GlassWhite Tea CupPink Insulated MugSoup BowlJellySpecial Fluids (Clear Plastic)Ice Cream150 mls150 mls250 mls150 mls90 mls200 mls40 mlsYou will need to familiarise yourself with the different charts used in your area,i.e. clinical pathways and special observation charts.14
HANDOVER GUIDELINESThere is only 30 minutes allocated for handover, therefore it is essential thatyou are prepared and know exactly what is relevant and what is not. Your handover should take no longer than 5-6 minutes. Be brief and to the point. There isno need to hand over anything that can be obtained from reading the patientbedside charts. It is the responsibility of the student and buddy/preceptor toassess each patient and read their charts at the commencement of each shift.What to include• Bed number• Patient’s name• Abnormal-Vital signs-Blood sugar levels-Blood results-Oxygen saturation’s• Mobility and ADL status e.g. RIB,transfer with 2, requires feeding• Oxygen therapy• Venous access e.g. IV bung, CVC,PICC line• Incontinence/constipation• NG/PEG feeds• Drain tubes• Wounds• Pain control• Procedure/tests and outcomes• Administration of blood products• NFR orders• Catheters e.g. IDC, ICC• It is enough to state that thepatient is receiving IVantibiotics/fluids• Referrals/consults• Health care problems• Discharge planWhat not to include• Diagnosis• Past history• Age• Normal-Vital signs-Blood sugar level-Blood results-Oxygen saturation’s• Usual medications/treatments• Routine care-Frequency of vital signs-Weighs-Urinalysis• Type, time and rates of IVantibiotics/IV fluidsNB. It is only essential to state patients’ diagnosis and past history if it does notappear on the handover sheet.15
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St. Vincent's Hospital Melbourne Information & Guidelines for ...

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