Documentation is an essential component of effective communication. As student

Documentation is an essential component of effective communication. As student Registered Nurses and Registered Nurses, we need to ensure that relevant, accurate, finished and up-to-date information about a patient’s care is documented, and members of the health care team have access to the right information to make safe clinical decisions and to deliver safe, high-quality care. Case Study: Elena Karagiannis, DOB 10/02/1940, Resident ID 7865456-09 In this case study, you are a Registered Nurse working at a rural Aged Care Centre. The person you have been asked to see is Elena Karagiannis. Elena has arrived back to the Aged Care Centre, ten days after undergoing a left total knee replacement Elena has now settled back into her room, and you have been asked to undertake a full assessment, review her postoperative wound and undertake a dressing change. Elena moves from the bathroom to the chair in her room, Elena is wincing in pain, frowning and limping with a walking stick. You start the interaction by welcoming Elena home and taking a full set of vital signs. RR- 24, BP- 110/70, HR- 88bpm, regular Temp- 38.4 degrees Celsius, Oxygen saturations- 98%, RA GCS- 15/15, Pain- 3/10 when resting, localised to the surgical site . 8/10 when mobilising, radiating upward from the surgical site. As you are assessing Elena, you notice her voice is clear and her breathing appears unlaboured. Elena is orientated to time, place and person. It looks like both sides of her chest are rising and falling equally. Elena explains that she hasn’t been eating or drinking much lately because she is in too much pain with her knee. She hasn’t had her bowels open for several days and is passing a little bit of urine which is straw coloured. She is passing flatus regularly. You continue with your assessment: Height- 165cm, Weight- 75kg Bilateral pedal pulses present, equal and strong Capillary refill less than 2 seconds to all extremities As you auscultate Elena’s lung fields there is air entry to all fields and no wheeze or crackles present Elena’s abdomen is soft, she has no pain to the abdomen while you are palpating. There are bowel sounds present in all quadrants. Elena’s oral mucosa is quite dry. You refer to the notes in the system and can see Elena’s Medical History: Osteoarthritis, Allergy- Aspirin, Left Total Knee Replacement (TKR) ten days ago, Previous smoker, No ETOH Partial Hysterectomy (1987), Vegetarian diet And current medications: Current Medications: Panadol Osteo 1200mg, Q6H Vitamin D 600 IU daily, Vitamin B12 2.4mcg daily New: Endone 5mg Q4H as needed for postoperative pain Wound Assessment: Exudate has completely soaked through the current primary and secondary dressings. The exudate is green and has an offensive smell. The surrounding tissue is fragile, hot to touch and very tender. It does not appear that the incision from surgery is healing together with the sutures in place as the wound edges are not joined. Elena explains that the knee has been throbbing and burning, especially at night while she is resting. Further characteristics of the wound and wound size can be ascertained from the below image of the wound: Surgical wound, mild maceration You call Elena’s regular General Practitioner (GP) to notify them that Elena has returned home. The GP asks that you complete the documentation and they will come and review Elena later this afternoon after the clinic closes. Please refer to the case information provided in the subject site. The case information includes a primary and secondary survey and an image of a wound. This task asks you to review the case information and do the following: Clinical Progress Note A structured framework should be applied to support the Clinical Progress Note. Guiding principles for high quality documentation as outlined in the subject learning modules should be incorporated: person-centred, compliant, complete and accurate, integrated and up to date, accessible, readable and enduring. References would not usually be expected in this section. Document a clinical progress note that applies a systematic and evidence-based framework, and includes the following information: Document all the findings of the primary and secondary survey in the form of a typed Clinical Progress Note Document the findings of a focused pain assessment using PQRST Document the findings of a focused wound assessment, including: Aetiology and duration of wound Anatomical location Dimensions (length x width x depth, estimated based on image) Wound appearance Tissue type Wound edges Condition of skin surrounding wound Exudate: amount and type Odour Signs of infection, foreign bodies, debris and dressing remnants if present Justification Underneath your Clinical Progress Note, describe how your Clinical Progress Note complies with legal and professional requirements. This should include how the notation includes the guiding principles for high-quality documentation: person-centred, compliant, finalized and accurate, integrated and up to date, accessible, readable and enduring. References should be included throughout this section to support the discussion.

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