Module 7: Optimizing Health Systems in LTC
175 7.4.1 Integrated Documentation
NPs working in LTC may be expected to document. Poor documentation practices in LTC:
- May contribute a delayed response to a change in health status
- May negatively affect a resident’s safety, health, and wellbeing
- May negatively affect patient health outcomes
- Contribute to critical incidents
The Medical Record may include:
- Advance Care Plan
- Medical history
- Medications
- NP/MD progress notes
- Progress notes by team
- Documented physical exams
- Care plans
- Consult notes from specialist
- Diagnostics – labs and imaging
- Admission and discharge summaries
- Resident Assessment Instrument (RAI) Assessments
- Comprehensive assessments
Effective documentation facilitates:
- Health care providers having the right patient health information at the right time to guide decision making
- High quality comprehensive care that is resident centered, holistic, and inclusive
- Continuity of care and safe transfers in care amongst rotating staff
- Effective individualized care plans
- Interdisciplinary team mobilization to effectively meet a resident’s needs
- Accurate data to facilitate quality RAI assessments
- Effective infection control practices
LTC National Standards: Individualized Care Plan
- Ongoing documentation of needs
- An accurate problem list that captures active issues and their treatment plans
- Residents’ goals of care, preferred level of medical information, needs, and preferences
- Team members involved in care
- Safety plans – risk for elopement, substance use, aggression