6. DOCUMENTATION

1. Inpatient

The Standards Based Documentation System (SBD) is utilized at UAMS. Documentation is based on predetermined standards of practice. By implementing and referring to these written standards, the philosophy of charting states that "All standards have been met with a normal or expected response or a documented deviation". It is imperative that the standards be used as a daily reference for the plan of care for the patient and that any deviation from the standard be documented. These standards are meant to provide a minimum standard of practice for each patient. (See Addendum)

http://www.uams.edu/nursingmanual/Policy-addenda/addendum-I1.htm

http://www.uams.edu/nursingmanual/Policy-addenda/addendum-I1a.htm

http://www.uams.edu/nursingmanual/Policy-addenda/addendum-I1b.htm

http://www.uams.edu/nursingmanual/Policy-addenda/addendum-I1c.htm

http://www.uams.edu/nursingmanual/Policy-addenda/addendum-I1d.htm

 

2. Outpatient

Documentation of care is based on a problem-oriented approach. The problem list provides an ongoing summary of diagnosis and conditions, procedures, drug allergies and medications. The list will be reviewed and updated as appropriate. Outpatient Health care providers are required to document teaching on the Multidisciplinary Patient Education Form.

Emergency Department: refer to

http://www.uams.edu/nursingmanual/Guidelines/GuidelineV.htm

7. NURSING STANDARDS

1. The practice of nursing within the University Hospital and Clinical Programs Nursing is directed by practice standards. These standards are congruent with and reflect the Arkansas State Nurse Practice Act, the rules and regulations of the Arkansas Department of Health, the standards set forth by the Joint Commission on Accreditation of Health Care Organizations, Centers for Medicare and Medicaid Services (CSM) and the generic and specialty standards promulgated by the American Nurses’ Association and other professional nursing organizations.
2. The practice standards system is composed of the following groups of standards which encompass the structure, process and outcome of the provision of care to patients:

• Policy
• Job Description/Performance Appraisals
• Procedures
• Protocols
• Guidelines
• Documentation Standards (see Addendum I.1A)
• Precaution Standards (See Addendum I.1B)
• Biophysical Assessment Standards For The Adult Patient (See Addendum I.1C)
• Obstetrical Biophysical Assessment Standards (See Addendum I.1D)

These standards define the level of staff performance or a set of conditions in a unit or patient care area which have been determined to be acceptable by the UAMS Medical Center and Clinical Programs Nursing. Standards are expected to benefit patients through the delivery of improved patient care and are reviewed annually.

c. Development, approval, and review of nursing practice standards is the responsibility of the Professional Nursing Organization whose functions are spelled out in the Constitution, bylaws and rules of the councils/committees of the Professional Nursing Organization.

d.     Quality Improvement Data, nursing research and nationally developed nursing practice standards are utilized to continually improve the quality and efficiency of care delivered to patients.

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