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HEALTH EDUCATION REVIEWER

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I.
NURSING DOCUMENTATION
What is Nursing Documentation?
Documentation is a nursing action that produces a written account of pertinent patient data,
nursing clinical decisions and interventions and patient responses in a health record
Documentation is necessary for:
✔ Communication between healthcare providers
✔ Meeting legislative/organizational requirements
✔ Quality improvement
✔ Research
✔ Legal proof of healthcare provided
Principles of Effective Nursing Documentation
1.Document accurately, completely, and objectively, including any errors committed.
2. Note date and time.
3. Use appropriate forms.
4. Identify the client.
5. Write in ink.
6. Use standard abbreviation.
7. Spell correctly.
8. Write legibly.
9. Correct errors properly.
Guidelines for Quality Documentation
Quality documentation means that the elements of the nursing process are evident in
our documentation. It has five important characteristics:
1. FACTUAL
A factual record contains descriptive, objective information about what a nurse
observes, hears, palpates and smells.
2. ACCURATE
The use of exact measurements establishes accuracy and helps you determine if a
patient’s condition has changed in a positive or negative way.
3. COMPLETE
Ensure that the information within a record entry or a report is complete, containing
appropriate and essential information
4. TIMELY (CURRENT)
•Timely entries are essential in a patient’s ongoing care. Delays in documentation lead
to unsafe patient
5. ORGANIZED
Information entered into a medical record facilities communication when it is
documented in a logical order. Documentation is also more effective when notes are
concise, clear and to the point.
II.
Basic leadership and management concepts focused on health
education
Leadership
Leadership has many interpretations, and has been likened to “the abominable
snowman whose footprints are everywhere but who is nowhere to be seen”
It is an influential process, through which groups of people work towards the
achievement of a common goal
Management versus Leadership
Management and leadership are considered just as important as each other in
accomplishing organizational goals. However, there are differences in the functions of
the two roles.
Management produces order and consistency, while leadership produces change and
movement . Management has the responsibility of organizing all elements within the
organization, so that the leader’s vision and goals are successfully achieved.
Leadership Styles in Nursing
● Transformational
● Transactional
● Democratic
● Laissez-faire
● Autocratic
● Servant
Transformational leadership
Transformational leadership involves leadership through the transformation of
individuals or ‘followers’, to work towards a common organizational goal.
Transactional leadership
The transactional model is seen as an authoritative relationship that is transaction
based, where exchanges occur between a leader and follower, once specific goals are
identified or decided upon.
Transactional leaders value order and structure, and have formal authority, with
positions of responsibility within organisations.
Democratic leadership
Democratic leader engages in a shared leadership style in which they use participation
of members of the group to guide decision-making and management. Sometimes, this is
called participative leadership.
Laissez-faire Leadership
A laissez-faire leadership style is a facilitative one in which a leader makes few
decisions. Characteristics of laissez-faire leaders are often reported as “hands off,“
trusting, encouraging and tolerant of innovation as well as error.
Autocratic Leadership
Autocratic leadership is a unilateral style in which the leader delegates to others with
rules and orders.
Servant Leadership
Finally, servant leadership is defined as a supportive style in which the leader provides
team members with skills, tools and relationships they need to perform to the best of
their ability.
Team leadership
More recently, the focus has shifted towards “team leadership”, with distributed
leadership becoming more prevalent within healthcare education, where different
professions share influence
Language of leadership
As already stated, when it comes to leadership, excellent communication skills are a
must. This means that active listening is just as important as active talking. Language
used needs to be :
▪ Clear
▪ Stimulating
▪ Congruent
▪ Include active listening
Note:
▪Titles are not always linked to leadership roles.
• The role of today’s leader requires stepping forward, collaborating and contributing.
• A good leader is a good team player who values and seeks the opinions of others.
• Leadership requires clear, respectful communication that acknowledges the input and
achievements of others.
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