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  1. Why document?
    • Communication between providers
    • Educational tool
    • Legal documentation of care
    • Quality assurance 
    • Research
    • Reimbursement
    • The old adage
    •  “if it wasn’t documented it wasn’t done” 
    • still rings true.
  2. Justifying care and decisions
    • Why the patient/resident needs care
    • What care was given
    • How the patient/resident responds
    • Why the patient/resident continues to need care, and
    • When he or she is ready to move to another level of care or go home.
  3. Types of documentation
    Image Upload 1
  4. Basic principles of documentation
    • The clinical record must be:
    • Timely: you have time to document when the info is still fresh. You do. Seriously.
    • Accurate
    • Complete
    • Legible
    • Easily retrieved
  5. Narrative nursing notes
    • Orderly
    • Tells a story
    • Dated and timed
    • Signed by you. Line out extra spaces to prevent others from adding to your notes
  6. Focus Charting
    • Data (symptom)
    • Action
    • Response
  7. Charting by exception
    • You only chart what is outside the norms or expected parameters
    • What do you think the problems might be with this charting? No baseline. 
    • What are the advantages of this type of charting? Faster
  8. Flow sheets
    • Record routine aspects of care (hygiene, turning)
    • Document assessments; usually organized according to body systems
    • Track client response to care (wound care, pain, intravenous fluids) 
    • Graphic records - used to record vital signs
    • Intake and output record
  9. Nursing Admission Assessment
    • Patient history, allergies, etc.
    • Sometimes done several times
    • Who is present when questions are being asked. May be a good idea, but only if pt wants/permits it.
    • Baseline
    • May determine where the care is going…..
  10. KARDEX or client care summary
    • Demographic data
    • Medical diagnoses
    • Allergies
    • Diet/activity orders 
    • Medications
    • Safety precautions
    • Treatments
    • May be different depending on the unit
    • Usually in a different location than the main patient chart
  11. Integrated plans of care
    • Combined charting and care plan form
    • Maps out on a daily basis, from admission to discharge 
    • Client outcomes, interventions, and treatments for a specific diagnosis or condition 
    • Laboratory work, diagnostic testing, medications, and therapies included in the pathway
  12. Reporting
    • Informing other caregivers about the client condition
    • Nurse to nurse; nurse to physician
    • Passage of vital information related to the client’s status/plan of care
    • I-SBAR-R – make sure report is organized and concise – this is not a soap opera report
    • ISBARR: Identification, Situation, Background, Assessment, Recommendation, Readback.
  13. What is I-SBAR-R?
    Look at the handout!
    • Call Dr. 
    • I-Who are you, who is the patient? 

    • Situation
    • Background
    • Assessment
    • Recommendation 

  14. What is a Sentinal Event
    • A medical error that resulted in death or severe psychological damage. 
    • So severe, they should never happen.
  15. Handoff Reports
    • Verbal (conversational)
    • Taped (not preferred)
    • Written
    • Walking rounds
    • Charge nurse to charge nurse
    • SBAR or PACE (PACE is actually IPPPAACCCE)
  16. Standardized approach to handoff communications
    • Shift-to-shift, transfers, breaks, therapist-to-therapist
    • Up-to-date information regarding care, treatment, condition, recent/anticipated changes
    • Must allow opportunity for questions between the giver and receiver
    • Read back or repeat back as applicable
    • SBAR format
    • Approach may be customized, but must use SBAR
  17. Stuff that should be in handoff report
    • Client demographics and diagnoses
    • Relevant medical history
    • Special directives
    • Significant assessment findings
    • Treatments
    • Pertinent or upcoming diagnostics or procedures
    • Restrictions
    • Plan of care for the client
    • Concerns
    • Discharge plan
    • Concise and pertinent information only! Emphasis is on being concise without omission.
  18. Discharge summary
    • Patient education
    • Check-list 

    • Time of departure and method of transportation
    • Name and relationship of person(s) accompanying client at discharge
    • Condition of client at discharge
    • Discharge instructions
    • Follow-up appointments or referrals given
  19. Verbal/telphonic orders
    • Verbal orders
    • Spoken to you; often during a client emergency
    • Should be made for critical change in patient condition.
    • If can be spoken, should be written.
    • Telephone orders
    • Received by phone and transcribed onto chart order sheet 
    • Both have an increased risk for errors
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