Kozier Ch 15 Documentation

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  1. Discussion
    • •Discussion-
    • –informal conversation

    • •Report-
    • –oral, written, computerized. Ex: end of shift

    • •Record-
    • –written or computer
    • –making an entry on client record (chart) is referred
    • to as charting or documenting, recording
  2. Legal and Ethical
    Standards for Documentation
    • •Client’s record is a legal document
    • •May be used to provide evidence in court
    • •ANA- “duty to maintain confidentiality of all patient
    • information”

    • •HIPAA (Health Insurance Portability & Accountability Act)-
    • –protects health information that it transmitted or
    • maintained in any forms
  3. Maintaining Confidentiality of Records
    • •Restrict access
    • •Ethical codes and legal responsibility
    • •Adhere to policies and procedures to ensure privacy and confidentiality
  4. Security for Computerized Records
    • •Passwords required & should not be shared
    • •Logged in?- don’t leave the computer terminal unattended
    • •Do not leave client information displayed
    • •Shared all unneeded computer-generated worksheets
    • •Know the facility’s policy & procedure for correcting an entry error
    • •Follow agency procedures for documenting sensitive material
    • •Firewalls- protect server from unauthorized access
  5. Purpose of Client Records
    • •Communication
    • •Planning client care
    • •Auditing health agencies
    • •Research
    • •Education
    • •Reimbursement
    • •Legal documentation
    • •Health care analysis
  6. Documentation Systems
    • •Source-Oriented Record (SOR) (traditional chart - each dept makes notes in separate areas of chart - fragmented - have to read all pages to know what's going on)
    • •Problem-Oriented Medical Record (POMR)
    • –SOAP
    • - - narritive charting
    • •PIE
    • •Focus charting
    • •Charting by Exception
    • •Computerized Charting
  7. Source-Oriented Records (SOR)
    • •Traditional client record
    • •Each department/discipline makes notations in a separate section of chart
    • •Information about a particular problem distributed throughout the record
    • –Advantage- easy to locate section/forms
    • –Disadvantage- info scattered through chart
    • •Narrative charting used
  8. Narritive Charting
    • •Notations about
    • –Care
    • –Findings
    • –Problems
    • •Data is organized, systematic

    • 1. What assessment data are relevant?
    • 2. What nursing interventions have I completed?
    • 3. What is my evaluation of the results of the interventions and/or what is the client's response to the interventions?
  9. Problem-Oriented Medical Records (POMR)
    • •Data arranged according to client problem
    • •Members of healthcare team contribute to the problem list, plan of care & progress notes
    • •Uses SOAP, SOAPIE, SOAPIER documentation
    • •Advantages
    • –Encourages collaboration
    • –Easier to track status of problems
    • •Disadvantages
    • –Vigilance required to maintain problem list
    • –Less efficient documentation process
  10. SOAP Documentation
    • •S- subjective data
    • •O- objective data
    • •A- assessment (conclusions drawn)
    • •P- plan to resolve problem
    • •I- interventions performed
    • •E- evaluation of client’s response to interventions or treatment
    • •R- revisions needed
  11. PIE Documentation
    • •Groups information into three categories:
    • –Problem (NANDA, problem gets a #)
    • –Interventions
    • –Evaluation
    • •Consists of client assessment, flow sheet, & progress notes
  12. Focus Charting
    • •Focus on client concerns and strengths
    • •Progress notes organized into format
    • –D- data
    • –A- action
    • –R- response
    • •Holistic perspective of client and client’s needs
    • •Nursing process framework for the progress notes
  13. Charting by Exception CBE
    • •Incorporates flow sheets, standards of nursing care, bedside chart forms
    • •Agencies develop standards of nursing practice
    • •Documentation according to standards involves a check mark
    • •Exceptions to standards described in narrative form on nurses’ notes
  14. Computerized Documentation
    • •Manages large volumes of information
    • •Computers used to
    • –look up data (labs)
    • –chart data
    • –revise care plans
    • –document client’s progress
    • –transmit information from one care setting to another
  15. Documenting Nursing Activites
    • •Admission
    • •Nursing Care Plans
    • •Kardex - important facts, Name, vital signs, main interventions
    • •Flow sheets
    • –Graphic record (VS), I & O, Braden scale, medications
    • •Progress
    • •Discharge/referral summaries
    • •Variance report
  16. Documenting Nursing Activities
    • •Regardless of documentation system used, the client record should show:
    • –Client’s ongoing status
    • –Use of the nursing process
  17. Guidelines for Recording Client Data
    • •Timing
    • •Legibility
    • •Permanence
    • •Accepted terminology
    • •Correct spelling
    • •Signature
    • •Accuracy
    • •Sequence
    • •Appropriateness
    • •Completeness
    • •Conciseness
    • •Legal prudence
  18. Reporting
    • •Change of shift (Box 15-3 & 15-4 p. 263)
    • •Telephone
    • –Report
    • –Orders - some need to be witnessed by second nurse
    • •Care Plan Conference
    • •Nursing Rounds
    • •What information will you report to your nurse at the end of your day?
  19. Guidelines for Reporting Client Data
    • •Should be concise, including pertinent information but no extraneous detail
    • •Follow a particular order
    • •Provide basic identifying information
    • •For new clients provide the reason for admission or medical diagnosis/es, surgery, diagnostic tests and therapies in the past 24 hours
    • •Significant changes in client’s condition
  20. Framework for Communication to a Physician
    • •(S)Situations – What is happening at present time?
    • •(B)Background – What are the circumstances leading up to the situation?
    • •(A)Assessment – What do I think the problem is?
    • •(R)Recommendations – What should we do to correct the problem?
  21. Guideline for Receiving Telephone and Verbal Orders
    • •Know the state nursing board’s position on who can give and accept
    • •Know the agency policy
    • •Ask prescriber to speak slowly and clearly
    • •Ask prescriber to spell out the medication if unfamiliar
    • •Question the drug, dosage, or changes if seem inappropriate
    • •Write the order down or enter into a computer
    • •Read the order back to the prescriber
    • •Use words instead of abbreviations
    • •Write the order on the physician’s order sheet, record date, time, indicate it was a telephone order, and sign name with credentials
    • •When writing a dosage always put a number before a decimal, but never after a decimal
    • •Write out units
    • •Transcribe the order
    • •Follow agency protocol about signing the telephone order
    • •Never follow a voice-mail order
Card Set
Kozier Ch 15 Documentation
Kozier Ch 15 Documentation
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