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Solutions for project hands : streamlining charting documents to support surgical mission trips Albert, Gillian; Dangerfield, Corrie; Nehra, Ben 2014

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SOLUTIONS FOR PROJECT HANDS Streamlining Charting Documents to Support Surgical Mission Trips  By Gillian Albert, Corrie Dangerfield and Ben Nehra Getting to Know Project HANDS ? Project HANDS (Helping and Nurturing Developing Societies) is a Canadian non-profit organization  ? The organization provides collaborative health care support to rural Guatemalan communities by supplying Canadian health care providers and resources for surgical missions trips  ? Working in small local clinics with the partnership of Guatemalan health care providers, Project HANDS performs general, gynecological, and reconstructive surgeries  Streamlining Charting: Major Goals ? Effective management of the diversity of nursing and medical practices between Canada and Guatemala ? Creating charting documents that reduce confusion and can be easily interpreted by health care providers from both countries  ? Design of documents that accommodate bilingual instructions  ? Reformatting of current documents to enhance clinical precision ? Troubleshooting of potential errors or miscommunication in current charting documents The Background Research ? CRNBC guidelines regarding nursing practice as a component of international development aid indicate that standards of practice must comply with the applicable standards of a nurse?s home practice environment ? As such, documentation practices must be thorough and precise to match those of a typical Canadian clinical setting (such as a hospital)  ? Research by De Marinis et al. (2010) demonstrated that on average only 40% of nursing activities are documented in nursing records  ? Research by Baker et al (1999) suggested that the use of coordinated clinical pathways may prevent deviations from established standards of care  ? Comprehensiveness and accuracy of what occurs in practice need to be evident in the documentation (my note: this is even more complicated when trying to keep documentation simple and uncluttered for purposes of language barriers and difference in nursing practice when in international situations)  ? Improving awareness of the importance of accurate and complete documentation by those who use it may have added benefit to reducing patient safety errors and communicative errors.  ? Document deficiency has the potential to increase communication breakdown and compromise patient safety  Reference Point: Charting by Meds Sans Frontiers (Doctors Without Borders) The Montreal Branch of MSF provided us with exemplars of their surgical guidelines for a picture of typical documentation standards among non-profit organizations. Above: Surgical Safety Checklist Left: Perioperative List Current Charting at Project HANDS Examples of charting documents currently used by health care providers on Project HANDS missions. Above: Discharge Checklist Right: Medication Administration Record Revised Charting for Project HANDS  (a sample) Areas for Further Exploration ? In the context of remote surgical work in rural areas, is electronic charting a feasible option to increase consistency and accessibility? ? Electronic record keeping and charting has been demonstrated to reduce errors (Cowen et al., 2007)  ? What is the most efficient way to document transfer of accountability given this unique clinical setting? ? The College of Nurses of Ontario recommends that health care providers be trained in a standardized form of communicating the parameters around transfer of accountability to minimize errors and missed information (2009)  ? Should document orientation and expectations be  discussed with mission volunteers in a training session prior to providing care?  References Baker, B., Fillion, B., Davitt, K., & Finnestad, L. (1999). Ambulatory surgical clinical pathway. Journal of Perianesthesia Nursing, 14(1), 2-11.  Braaf, S., Manias, E., & Riley, R. (2011). The role of documents and documentation in communication failure across the perioperative pathway. A literature review. International Journal of Nursing Studies, 48(8), 1024-1038.  College of Nurses of Ontario. (2009, April). Transferring Clients Safely: Know Your Client and Know Your Team. Retrieved from http://www.cno.org/Global/docs/policy/TransferringClientsSafelyApril2009.pdf  College of Registered Nurses of British Columbia. (n.d.). Documentation. Retrieved February 11, 2014, from https://crnbc.ca/Standards/PracticeStandards/Pages/documentation.aspx   Healy, K., Hegarty, J., Keating, G., Landers, F., Leopold, S., & O'Gorman, F. (2008). The change experience: how we updated our perioperative nursing documentation. Journal of perioperative practice, 18(4), 163.  Pirie, S. (2011). Documentation and record keeping; Open Learning Zone; Report. Journal of Perioperative Practice.  Rateau, F., Levraut, L., Colombel, A. L., Bernard, J. L., Quaranta, J. F., Cabarrot, P., & Raucoules-Aim?, M. (2011, June). Check-list" Patient Safety" in the operating room: one year experience of 40,000 surgical procedures at the university hospital of Nice]. In Annales fran?aises d'anesth?sie et de r?animation (Vol. 30, No. 6, p. 479)  Acknowledgements  We would like to thank all those who assisted in the research and completion of this project:  Barbara and George Maryniak, Project HANDS Lena Cuthbertson, Project HANDS Sue Binne, RN Tracey Took, RN Benoit Emond, MSF Joel Teurtrie, MSF  

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