302 Documentation

Documentation

• Facilitate patient care
• Serve as financial and legal record
• Help in clinical research
• Support decision analysis

Patient Record

• Specifies that nursing care data be implemented into the patient record.
• Patient assessment
• Nursing diagnosis
• Patient needs
• Nursing interventions
• Patient outcomes 

• žAim: complete, accurate, concise, current, factual, and organized data communicated in a timely and confidential manner to facilitate care coordination and serve as a legal document.
•    Content
•    Timing
•    Format
•    Accountability
•    Confidentiality

• *Avoid words such as "good, aerage, normal, or sufficient"
• *Record patient findings NOT opinions
• *Avoid generalizations (ie: "feels comfortable")
• *Note problems IN THE ORDER they occur
• *Chart precautions or preventive measures used
• *Document medical visits
• *Document in legally prudent manner
• *Document nursing response to questionable medical orders/treatment

• *Chart in a timely manner
• *Date and time of entry and time of observations/interventions
• *Military time
• *NEVER document before carrying out an intervention
• *Write a progress note for:
•    --admission, transfer to another unit, discharge
•    --when procedure is performed 
•    --receiving a patient postoperatively
•    --upon speaking w/ physician about critical patient info
•    --ANY change in patient's status

• *make sure you have the correct chart
• *as designated by agency policy
• *legible writing in dark ink (use standard terminology)
• *Date/Time each entry
• *never skip lines

• *Sign your fist initial, last name and title to each entry
• (ex: K, Davis)
• *Do not use dittos, erasures, or correcting fluids
• *Identify each page of the record with the patient's name and ID number
• *recognize that the patient record is permanent

• *Patients have a moral/legal right to expect that the information contained in their patient health record will be kept private
• *Most agencies allow students access to patient records for educational reasons

• žCrucial Omissions
• žMeaningless repetitious entries
• žInaccurate entries
• žLength of time

• žProblems
• -Undermine nurse’s credibility as a professional discipline
• -Cause legal problems for the nurse responsible

žAll info about patients is considered private or confidential.

• Written on paper
• Saved on computer
• Spoken out aloud
• Names
• Address
• Telephone number
• Fax number
• Social security
• Reason person is sick or in the hospital, office, or clinic
• Treatment
• Information about PMH

Patient medical record

Computer systems

Telephone calls

Voice mails

Fax transmissions

E-mails that contain patient info

Conversations about patients between clinical staff

ž**Workers must undergo HIPPA training and sign confidentiality agreements

žPatients have a right to:

See and copy their health record

Update their health record

Get a list of the disclosures a healthcare institution has made independent of disclosures made for the purposes of treatment, payment, and healthcare options

Request a restriction on certain uses or disclosures

Choose how to receive health info

žEveryone who has access to the record (direct caregivers) is expected to maintain its confidentiality

žMost agency grant nursing students access for education purposes….must hold info in confidence…Never use patient’s name when preparing written or oral reports

žAgency policy indicates which personnel are responsible for recording on each form in the record…

žPolicy also indicates order of chart

žPolicy may indicate frequency to record entries

žWhat to record

• žManner to identify self :
• Kelli Shugart, RN, GBCN Faculty
• Sally Cabbage Patch, SN, GBCN

1. Communication with other workers

2. Diagnostic and therapeutic orders

A.Verbal orders-order must be given directly by the physician, or nurse practitioner to a registered nurse or registered pharmacist

B.The only circumstance in which an attending physician, nurse practitioner, or house officer may issue orders verbally is in a medical emergency, when they are present but unable to write the actual order.

4.Care Planning

5.Quality review

6.Research

7.Decision analysis

8.Education

9.Legal documentation

10.Reimbursement

11.Historical documentation

žThe RN who receives the order will:

1.Record the orders in the medical record

2.Read the order back to verify accuracy

3.Date and note the time

4. Record V.O. (verbal orders), name of the MD who issued the orders, followed by the nurse’s name and title

• žExample:
• žGive 0.25mg po lanoxin Daily, starting in Am 9/18/09  V.O. Micheal Smith, MD/Kelli Shugart, RN

žIt is the responsibility of the physician or nurse practitioner who issued the verbal order to:

1.Review the order for correctness

2.Sign the orders with his or her name, title, and pager number

3.Date and note the time he or she signs the orders

žIt is the responsibility of the unit secretary and/or the registered professional nurse to see that the orders are transcribed according to procedure

žAgency policy must be followed

žEvery T.O. must be repeated back to ensure that the nurse correctly understands what was ordered.

žMust be on an order sheet

žCo-Signed by physicians within a specific time

žFax orders must be legible and issued from a credentialed and privileged individual

žFollow similar protocol as V.O. (1-3)

4.Record T.O. (telephone order) and the full name and title of the physician or nurse practitioner (NP) who issues the orders.

5.Sign the orders with name and title

žIt is the responsibility of the physician or NP dictating the orders to sign them as soon as practical. With exception of orders for narcotics, anticoagulants, and antibiotics, which must be signed within 24 hours.

1.Source oriented Records

žTable 17-3 p. 336

• -Advantage
• -Each discipline can easily find and chart data
• -Disadvantage
• -Data fragmented

2. Problem-Oriented Medical Record- (POMR)

• žExample Box
• 17-4 p. 337

Advantage

• -Entire health team works together to determine list of problems
• -Collaborative plan of care
• -Progress notes clearly focus on patient problems

3.PIE charting system- Problem, Intervention, Evaluation- originated from nursing

• žExample figure
• 17-2 p. 338

• -Does not develop separate plan of care
• -At beginning of each shift patient problems are identified, numbered and documented in progress notes, and worked up using PIE format
• -Resolved problems are dropped

• žAdvantage
• -Continuity and saves time (no separate Plan of Care)

• žDisadvantage
• -Nurses have to read all nursing notes to determine problems and planned interventions

4.Focus charting

• žFocus may be on a patient's:
• Strength
• Problem
• Need

• žTopics may include
• -Patient concerns and behaviors
• -Therapies and responses
• -Changes in condition
• -Significant events
• -Narrative section uses the Data, Action, Response (DAR) format- example figure 17-3 p.339

• žAdvantage
• -Holistic emphasis on patient
• -Ease of charting

• žDisadvantage
• -Some nurses argue that the DAR categories are artificial and not helpful when documenting care

5.Charting by exception (CBE)- figure 17-4

• žAdvantages
• Decreased charting time
• Greater emphasis on significant data
• Easy retrieval of significant data
• Timely bedside charting
• Standardize assessment
• Greater interdisciplinary communication
• Better tracking of important patient responses
• Lower cost

• žDisadvantage 
• -limited usefulness in response to negligence claims against nurses

ž6.Case Management Model

• žAdvantages
• -Collaboration
• -Communication
• -Teamwork among disciplines
• -Efficient use of time increases quality

• žDisadvantage
• -Works for “typical” patient 
• -Collaborative Pathways/critical pathways/care mapping –
• Variance Charting
• žPersonal Health Records (PHRs)

• -Defined database
• -Problem list
• -Care plan
• -Progress notes- BOX
• 17-4 p. 338 narrative progress notes follows the SOAP format

The Acronym SOAP (Subjective, data, Objective data, Assessment, Plan)

Progress Sheet

Focus Example

Calls up admission assessment tool

Develop plan of care using computerized care plans available (NANDA list)

Adds to patient database as new data are identified and modifies the plan of care

Receives a work list showing the treatment, procedures, medication necessary

Documents care immediately using bedside computer

Never share passwords

Don’t leave computer unattended

• Follow protocol when correcting errors, “mistaken entry” add correct info, date and initial entry.
• If wrong chart, write “mistaken entry – wrong chart”.

Never create, delete or change entries

Back up files

Don’t leave info about patient for others to see

Never use email to send protect health info

Follow policy for documenting sensitive material

1.Initial nursing assessment- Database

2.Kardex and Patient Care Summary p. 343

3.Plan of Care- student example chapter 14

• Diagnosis
• Goals
• Expected outcomes
• Interventions

4.Critical/collaborative pathways-chapter 14, Abbreviated case management plan

ž

• Nursing History and Physical Assessment
• **Provides baseline for later comparison as the patient's status changes

Kardex

There purpose is to inform caregivers of the progress a patient is making toward expected outcomes.

The method used to record the progress depends on the documentation system used.

Narrative nursing notes

SOAP notes

PIE notes

Focus charting

Charting by exceptions

 Flow sheets

See Table 17-5 for advantages and disadvantages

Graphic (clinical) Record

24 Hour Fluid Balance Record

Medication Record

• 24 Hour Patient Care
• Record and Acuity Charting Forms

ž

• Specified by Resident Assessment Instrument (RAI)
• Helps staff gather information on strengths and needs, and addresses these in individualized plans of care.

• 4 components:
• 1.Minimum data set

2.Triggers

3.Resident assessment protocols

4.Utilization guidelines

Statutory law, federal regulations, and Health Care Financing Administration specify how the RAI is implemented. 

• *not in accordance with progessional organization standards
• *content does not include descriptions of situations that are out of the ordinary
• *content overgeneralizes patient assessment or nursing interventions
• *content does not include appropriate medical orders
• *content implues attitudinal bias

• *lines between entries
• *countersigning documentation
• *tampering
• *different handwriting or obliterations
• *Illegibility
• *Sloppiness (some lawyers infer sloppy care from sloppy charting)
• *Dates & times of entries omitted or inconsistently documented
• *Improper nurse signature or unidentifiable initials
• *Transcription errors

• Advantages:
• Message can be delivered immediately
• Nonverbal messages are readily conveyed
• Message can be clarified; reciever's questions can be raised & answered

• Disadvantages:
• Both the communicating and the receieving people must be available at the same time, in the same place
• *Ordinarily, there is no permanent record for later use

• Advantages:
• *Message can be delivered immediately
• *Message can be clarified; receiver's questions can be raised and answered
• *Two parties need not be present in the same place

• Disadvantages:
• *Only the tone of voice and voice inflections can be communicated- no nonverbal messages
• *Ordinarily, there is no permanent record

• Advantages:
• *message can be exchanged at times convenient for the people involved
• *Record is available
• *Time-efficient if message is understood

• Disadvantages:
• *Message usually cannot be validated with the sender

• *Message can be exchanged at times convenient for the people involved
• *Record is available
• *Time-efficient if information communicated is complete

• Disadvantages:
• *Message usually cannot be validated with the sender

• Advantages:
• *Message can be delivered immediately even to those at ta great distance
• *Parties need not be present in the same place
• *Two-way communication is possible by email
• *Record is available
• *Many people can participate in exchange

• Disadvantages:
• *No nonverbal messages can be communicated
• *Privacy concerns remain an issue

• S- Situation
• B- Background 
• A-Assessment
• R- Recommendation

žBasic identifying information about each patient

žCurrent appraisal of each patient’s health status

(Changes in medical conditions and patient response to therapy... Where patient stands in relation to identified diagnoses and goals)

žCurrent orders (nurse and physician)

žSummary of each newly admitted patient

žReport on patient transferred or discharged

1.Consultations and Referrals

2.Nursing and Interdisciplinary team Care Conferences

3.Nursing Care Rounds