Practice Expectation Spotlight: Collaboration and Documentation

As an RN, RN(AP) or a RN(NP), we share Practice Expectations regarding Collaborative Care. Two responsibilities found within the Practice Expectations for RNs include:

• Communicating effectively and appropriately with clients, families and other health-care providers in providing for the health care of the client; and
• Documenting the nursing care you provided on the client’s record with enough information for another health-care professional to be sufficiently informed of the care provided.

At the end of this spotlight, you will learn about additional competencies for interprofessional collaborative care. For now, consider how these responsibilities can be demonstrated in this situation:

Kayce Duton RN(NP) reviews a client’s health care record just before he sees a client. Kayce notes that the last four entries by an RN are quite brief – the client had complained of some pain but the documentation was not clear if the pain occurred before or after wound care provision or whether any subsequent treatment was required to manage the pain.

While Kayce knows he will assess the client and gather information from the client about her symptoms and response to treatment, he is also aware that clearer documentation would assist him to improve the management of the client’s overall plan of care. Then, when he met with the client, she protested that the other RN knows how to provide the care better.

All of these choices can work to support the client to get the care she needs, although some may contribute more to sustain collaboration for positive client outcomes within the current team environment. Please read the following explanations.

1. Acknowledging the client’s viewpoint and bringing the situation to the RN’s awareness can support communication within the team although it does not improve quality documentation or care-planning. Additional steps are necessary to improve team collaboration.
2. Listening to and asking questions of the client about her care can continues therapeutic relationship development and care planning with the client. Documentation of this can also serve to improve continuity for other care providers involved with this client. While these are worthwhile steps to take with the client, Kayce may also need to consider connecting with the RN regarding this plan of care to provide feedback on expected documentation.
3. Reaching out to others who are part of the client’s health care team can support greater understanding of the plan of care. Depending how feedback is given and the available resources for skill building, this can be successful to improve documentation for this client’s care.
4. Asking about documentation can be an opening to discuss the client’s plan of care. From here, you can discuss the client’s health condition and updated plan of care to support continuity of quality health care. Appreciative inquiry can be successful for team building; however, a more deliberate approach may also be required for improvement to the system of care.
5. Bringing the situation to management, with the intent to increase the system’s efficiency and effectiveness can build the team’s collaborative processes. From here, Kayce and the Manager would need to bring ideas for improvement to the team then follow up to support any implemented changes. They should also refer to the Interprofessional Collaborative Care Practice Direction to review the competencies regarding interprofessional collaborative care. We encourage you to review these competencies as well.

References

Practice Direction Interprofessional Collaborative Care

Practice Direction Practice Expectations for RNs