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Integrative Health Care in the Hospital ModelThe demand for Integrative Health Care services in the hospital setting is growing. IIHI Creates FrameworksIIHI helps Hospitals looking for an expert in Integrative Health (IH) frameworks in the inpatient and outpatient setting. No matter how stressful a situation is, at work or at home there is one sure fire way to let it all go. Good record keeping is a sign of a skilled and safe practitioner and is the hallmark of professional practice ensuring that safe, high quality evidence-based health care is delivered to the patient. Record keeping should inform, update on progress, and instruct personnel on what measures should be followed.
To facilitate interprofessional communication in order that patient receives timely and consistent care. Management plan: Also known as a care plan, this relates to the documentation that identifies the specific actions that need to be taken by the practitioner to resolve the patient’s problem and prevent complications. Evaluation of care: This relates to the entry made in the healthcare record to evaluate the effectiveness of the nursing or therapy treatment. Record keeping: For the purposes of this document this is a generic term relating to the documented evidence of assessment, planning, implementation and evaluation of all aspect of nursing care, figure 1. Strategies to support patient education and engagement should be a fundamental to care delivery. Many healthcare professionals contribute to the patient’s assessment and care planning process during the patients stay in hospital. Adherence to the standards will reduce the opportunity for ambiguity or omission of essential patient information. If information is easily available it avoids patients and colleagues becoming annoyed when asked the same questions.
Similarly rewriting and duplicating information is also frustrating and wastes enormous amounts of time. A well-structured and accurate assessment contains all the information required if it becomes necessary to answer a complaint or medico-legal enquiry. A structured and complete assessment record enables practitioners to monitor national and local standards through the process of audit and review. Good quality record keeping contributes learning by allowing the practitioner to follow the clinical decision making around a patient’s care.
To comply with the professional standards set out in The Code: Standards of Conduct, Performance and Ethics for Nurses and Midwives (NMC 2008). To be able to demonstrate completion of a learning activity in fulfilment of Post Registration Education and Practice (PREP) Continuing Professional Development (CPD) Standard (NMC 2008).
An assessment of the patient’s health status, nursing interventions carried out, and an impact evaluation on patient outcomes.
Information reported to medical teams or other health care provider providing clear evidence of the arrangements provided for future and ongoing care. Records should identify any risks or problems that the patient may develop and the nurse should provide clear written action plans to deal with them. One of the most common reasons for patient complaints is not feeling properly informed about or being involved in their treatment.
On admission to hospital each patient will be assessed by the practitioner to determine any immediate needs and appropriate delegation of the care and objective data collection. The patient’s management plan should be devised by a registered practitioner following assessment. In partnership with the patient care can be delivered by practitioners or nursing assistants.
The person who performs the care or treatment for the patient should document in the healthcare record what has taken place, the patients understanding of their pathway of care including any conversations with the patient or his or her relatives, (Dimond 2005). Evaluation of the effectiveness of the care delivered against the agreed medical and nursing management plan is an essential part of the practitioners’ role.
You should use your professional judgement to decide what is relevant and what should be recorded.
In addition to confirming that care has been assessed, agreed with the patient, planned, delivered and evaluated the following information should also be documented in the healthcare record.

Any conversations with doctors, pharmacists, social workers or physiotherapists that result in a change to the patient’s management should be recorded in the healthcare record.
Record the date and time (using the 24 hour clock) for every entry you make in the patient’s healthcare record and make the entry as soon as possible after the event. The use of acronyms increases the risk that the meaning could be misunderstood or a practitioner could waste time trying to find out the meaning.
If it becomes necessary to correct or delete an entry this should be done with a single line through the text.
Draw a line through any remaining space left on this page to prevent someone else entering a statement before your signature. To ensure that the entry is reliable, never document before a procedure or prior to medication being administered to prevent inaccuracies. Every patient must have a nursing assessment completed within 6 hours of admission to hospital. Every patient must have a current nursing management plan and this must adhere to the current standards for record keeping. Spiritual Dimension The spiritual dimension is characterized by a sense of personal meaning. International Integrative Health Institute offers consulting and turn key operational services for the hospital model. The NMC (2012) annual report highlights that shortcoming’s in nurses’ record keeping was the fourth most common allegation brought before the regulator. When caring for an individual patient the documentation provides a clear picture of the status of the patient, the actions taken by the practitioner and highlights the intervention outcome. Thorough, accurate documentation the potential for miscommunication and errors are reduced.
This will allow the practitioner to determine which interventions are effective and which ineffective, identifying and documenting changes to the management plan as required. Documentation is a valuable method for demonstrating that the practitioner has applied nursing knowledge, skills and judgment according to professional and Trust standards. Whilst considering verbal and nonverbal cues, the assessment involves a patient review of symptoms and signs, medical and social history. It is completed following the initial patient assessment and updated following re-assessment and evaluation.
There should be clear evidence of the care planned, the decisions made, the care delivered and the information shared. Shared decision-making and working in partnership with patients will help them manage their condition and reduce the time spent in hospital.
If discussions and assessments are clearly documented including with whom, about what, when and why, then it will become easier to know who to refer to or call for further advice. Adherence to the standards identified within this policy will increase the probability that the patient’s assessment is accurate, recorded once and made available to all other practitioners involved in the patients care. Duplication of tests such as sending multiple MRSA screens or urine samples is inconvenient for the patient and may expose them to unnecessary harm. When clinically appropriate the nurse must use coaching and prompting interventions to help empower patients to take a more active role in their assessment and care planning.
Delegation of specific aspects of care must be based upon the patient's condition together with the experience and competency of the proposed care giver.
As a result nursing assistants and students will need to document in the healthcare record. If important information has been omitted this can be included at a later time as long as it is recorded that it has been written retrospectively. Usually used by the nursing staff and is good for describing brief interactions or conversations with the patient or other health care providers. When evaluating consider whether the patient’s condition is improving and if not then review the management plan to be delivered.
In addition this should include the information that has been communicated to the patient about the proposed changes. This should include confirmation of their agreement and understanding of the proposed changes.

In 2007 the National Patient Safety Agency and the National Institute for Clinical Excellence (NICE, 2007) identified that verbal or written communication was recognised as being the most common root cause of serious error. If no sticker is available the minimum information required is name, date of birth and NHS number.
If you make the entry a long time after the event you must ensure that the time of the event is recorded along with the time of entry. It is essential that the practitioner does not include abbreviations, jargon, meaningless phrases, speculation or offensive comments in the entry. It is then necessary to add your signature along with the date and time that the correction was made. Lourdes Lorenz is the director will work with Hospitals to create programs to meet their needs for integrative medicine, complimentary alternative medicine and patient experience. Also when a patient’s wishes are clearly recorded it enables all healthcare providers to act in accordance with those wishes when the patient may not be able to speak for themselves. Documentation can therefore be used as evidence in legal proceedings, coroners’ inquests, and disciplinary hearings. Assessment is essential as it provides the information needed to complete a management plan. This guidance has been developed to ensure that practitioners and nursing assistants adopt a unified approach to the assessment and recording of patients’ needs. By encouraging them to become active participant in care they will be better empowered to manage their long term condition, reduce stress and the likelihood of preventable readmission. An accurate assessment that is communicated effectively will also ensure that the needs of the patients are met in a timely fashion and reduce the opportunity for developing complications that may delay the patients discharge. For example a failure to communicate a patients needs to the occupational therapy team may delay a patient’s discharge.
When accessing the healthcare record you should be able to find when an investigation was ordered, when it was taken and the treatment decision made or any actions that have been taken based upon the results.
Whilst it is acknowledged that not all patients want to be involved in choosing a treatment, it is still essential that the nurse informs them of the proposed care plan.
Although aspects of assessment can be delegated to other care givers the registered nurse retains responsibility for interpreting the information and identifying any additional patient care needs. In line with the Royal College of Nursing guidance in 2011, the registered nurse in overall charge of the care episode should countersign the record to confirm that the person documenting it did so within his or her competence and that the care was delivered to the correct standard. Literature would suggest that each time a patient handover occurs, information is lost and transfer between wards is a known risk area.
The purpose of the signature is to identify clearly the practitioner who carried out the assessment so that they can be contacted at a future date if required. Ensure the entry is accurate and complete detailing your observations, interventions, and patient responses. Try to avoid using acronyms unless the meaning is completely understood or has been agreed by the Trust i.e. This document sets out the main characteristics of a holistic assessment and provides the core content of the assessment. You should not document your initials only unless this is in accordance with local policy for example, when documenting dispensed medication on a hospital drug or recording observations on a TPR chart. Be objective so your entries cannot be misinterpreted and where possible state what the patient has said using quotation marks. By agreeing the standards for assessment and record keeping the practitioner will be able to deliver safe and effective care to all patients who are admitted to Salisbury District Hospital .
In line with the guidance from the NMC (2010) and RCN (2011) the following criteria should be met prior to delegating the delivery and documentation of patient care to nursing assistants.

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