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Infection Control & Patient Safety

A New Year Commitment to Documentation

Published January 6, 2014 10:13 AM by Barbara Smith
Hope you had a wonderful holiday and that your New Year is off to an exciting, productive start. On my list of things to do better in 2014, I'm adding getting paperwork completed more quickly.

Many nurses feel we provide excellent care but we are often bogged down with documentation. It's easy to overlook the importance of charting when you have many patients and their families vying for your attention.

From an infection prevention perspective, we need to know that certain key standards of care have been delivered - and the only way to show this is through documentation. Much of my time is devoted to monitoring adherence to these standards.

For example, when was that Foley inserted - and by whom? Is there a valid reason documented why the 60-year-old functional female still needs that catheter? Did your patient have his pre-op chlorhexidine shower? Did you deliver the antibiotics for his surgery on time?

Of course, we want these measures to be documented because it tells us the patient received appropriate care. But they can also tell us what may have been missed if there is an adverse outcome.

My time is also spent intervening when the standards are not being achieved. Working with the staff, we can determine: is it a product problem, a knowledge deficit or is the solution not appropriate to the problem? And of course, all of this is detailed in reports that I hope to disseminate more timely.

How is documentation handled at your job- are you entirely on electronic medical records - or a hybrid version? Has this helped with delivering care?

posted by Barbara Smith

2 comments

Hi Pamela - you are off to a good start.

I would recommend the following:

Check the national APIC website for a wealth of info- www.apic.org.

then

1- connect with the infection preventionist (IP) at your facility -

2- find an issue on your unit related to infection control - and start a simple project  are the alcohol based gels full?-- count for 2 weeks

are your patients' peripheral IVs cared for per protocol?

3- if no IP at your job- work with the quality improvement team

4- contact the local APIC chapter - there are 4 in Illinois

check here --- http://apic.org/Member-Services/Chapters/Chapter-Map/ChaptersByState?state=IL#chapter-section

5- if you are not working now- consider volunteering with the IP at a local hospital or LTC or dep't of health

6- there are a few graduate programs in infection prevention including John Hopkins and Loyola- Chicago

Good luck

Barbara

Barbara Smith January 22, 2014 11:43 PM

Hi,

        I am an RN  licensed in Illinois.  If it's not too much to ask, I had 2 years and 6 months hospital experience  and I want to know more about Infection Control as this is the specialty i want to pursue in the future.  Can you please enlighten me about the procedures or steps/ advice to take to get into being an Infection Control Nurse. The words of wisdom that you will impart to me will be valued and would be grateful for that. Thank You

Pamela Campos, RN January 20, 2014 1:47 AM
IN

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    Occupation: Infection Control Professionals
    Setting: Welch Allyn; St. Luke’s Hospital (Smith)
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