BSP Nursing

Documentation
Oct., 2010

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 GOAL of SKMC

In preparation for the JCIA audit visit scheduled early December 2010, SKMC nursing
department aims at

Unifying documentation STANDARDS

and PROCESSES
across all SKMC pavilions
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 Goal of BSP

In light of SKMC preparation for the JCIA audit visit on December 2010, we aim to

streamline nurses’ documentation at BSP in

keeping with the SKMC revised
STANDARDS & PROCESSES
2010
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 Objectives of BSP Action Plan

By mid of November 2010, all nurses’ documentation

on the
Admission Assessment Forms (NAAF),

Ongoing Assessment forms, and

“APIE” Care Plans
will be in compliance with SKMC identified guidelines , 2010

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 Current Focus

1. Nursing Admission Assessment (NAAF)

2. Nursing Care Plan “APIE”

3. Ongoing Assessment
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 Standard Time Frame
Document When to Fill Remarks

Regardless of shift “Day

1. NAAF On Admission
or Night”

On Admission E
to be done on each
APIE
2. For all patients on morning shift endorsement “HAND
“Car Plan”
IN & Hand OVER” on
For any identified problem after then each shift

Ongoing
3. Every shift for all patients Physical + MHA
Assessment

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Day Shift Responsibilities

1. Write a Complete “NAAF”

For all NEWLY ADMITTED Patients during day shift.

2. Perform “Physical” + “Mental Health Assessment (MHA)”.

For all EXISTING Patients in the unit.

3. Write a complete Care Plan using the “APIE” format.

For ALL patients, whether NEWLY ADMITTED or EXISTING Patients in the unit.

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Night Shift Responsibilities

1. Write a Complete “NAAF”

• For all NEWLY ADMITTED Patients during Night Shift.

2. Write a complete Care Plan using the “APIE” format.

• For all NEWLY ADMITTED Patients during Night Shift, and
• For any NEWLY identified DIAGNOSES/PROBLEMS.

3. Document “E” of the “APIE” on both HANDING IN and

HANDING OVER.
For ALL patients, whether NEWLY ADMITTED or EXISTING Patients in the unit.
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General Guidelines
1. Use only one SK progress note to document the APIE and
the care that YOU render to your patient during the shift.

2. Assign each problem a NUMBER in a chronological order.

3. Enter whatever happens during the shift in a chronological

order.

4. Write the DATE and TIME of each entry.

5. SAFE and SIGN OFF each entry.

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General Guidelines
6. If the patient develops another problem during the Shift
that was not captured in the initial APIE, write the new
problem with a chronological number assigned to it.

7. Never use ABBREVIATIONS.

8. The night staff will do the PHYSICAL and MH assessment

and compare their identified problems with the ones
identified in the APIE of the day shift.
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General Guidelines
6. If the identified problem(s) is/are already captured in the
day shift APIE, only write an evaluation of the numbered
problem(s).

7. If the problem identified is not yet captured in an APIE

during the day shift, write a complete APIE for the new
problem and number it chronologically.

8. Should a patient be admitted on night shift, the nurse will

be responsible for writing a complete APIE for problems
identified on admission.
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 Example of
Day Shift
Documentation

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 Example of
Night Shift
Documentation

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 Example of
IMPROPER
Documentation

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Questions

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Summary

Thank You
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