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What does effective documentation reflect?
Effective documentation ensures continuity of care, saves time, and minimizes the risk of errors. The quality of patient care depends on your ability to communicate with other members of the health care team.
What are purposes of documentation by members of the health care team?
- -financial billing
- -legal documentation
What are important legal guidelines for documentation in a clients record?
- *do not erase/scratch out errors; single line cross out only
- *no personal/critical comments.
- *promptly correct any found errors
- *record all facts
- *no blank spaces on forms
- *black ink only
- *write legibly
- *if order questioned, write clarity sought
- *no generalized statements
- *chart only your stuff
- *name, date, time every entry
- *no password sharing.
What are elements included in the following guidelines for quality documentation and reporting: factual, accurate, complete, current, and organized?
- Factual: A factual record contains descriptive, objective information about what a nurse sees, hears, feels, and smells. An objective description is the result of direct observation and measurement. For example, B/P 80/50, patient diaphoretic, heart rate 102 and regular. Avoid vague terms such as appears, seems, or apparently because these words suggest that you are stating an opinion, do not accurately communicate facts, and do not inform another caregiver of the details regarding the behaviors exhibited by a patient.
- Accurate: The use of exact measurements establishes accuracy. For example, a description such as Intake, 360 mL of water is more accurate than Patient drank an adequate amount of fluid. Charting that an abdominal wound is 5 cm in length without redness, drainage, or edema is more descriptive than large wound healing well. Accurate measurements help you determine if a patient's condition has changed.
- Complete: The information within a recorded entry or a report must be complete, containing appropriate and essential information. Criteria for thorough communication exist for certain health problems or nursing activities.
- Current: Timely entries are essential in a patient's ongoing care. Delays in documentation lead to unsafe patient care.
- Organized: Communicate information in a logical order. It is also more effective when notes are concise, clear, and to the point. To document notes about complex situations in an organized fashion think about the situation and make a list of what you need to include before beginning to enter data in the medical record.
How do the JCAHO documentation requirements impact nursing documentation?
Current documentation standards require that all patients admitted to a health care facility have an assessment of physical, psychosocial, environmental, self-care, knowledge level, and discharge planning needs. TJC standards require that your documentation be within the context of the nursing process, including evidence of patient and family teaching and discharge planning ( TJC, 2011 ). Other standards such as HIPAA include those directed by state and federal regulatory agencies and are enforced through the Department of Justice and the Centers for Medicare and Medicaid Services.
What are the advantages and disadvantages of narrative documentation?
- easy to write (decreased time spent charting)
- increases willingness to make entries
- new info can be included without difficulty
- notes are in chronological order
- strongly conveys nursing interventions and client responses
- Allow nurses to describe a condition, situation, or response in their own terms, as they understand it
- may be disorganized and documentation may be fragmented
- may be difficult to find information quickly
- may be no evidence of critical decision making by the nurse
- often lengthy
- time consuming to read days & weeks of narrative notes to find a specific problem, its treatment and response
How do the following acronyms relate the progress notes: SOAP, PIE, DAR?
- S Subjective data (verbalizations of the patient)
- O Objective data (that which is measured and observed)
- A Assessment (diagnosis based on the data)
- P Plan (what the caregiver plans to do).
- An I and E are sometimes added (i.e., SOAPIE) in some institutions. The I stands for intervention, and the E represents evaluation.
- P: Problem
- I: Intervention
- E: Evaluation
- The PIE notes are numbered or labeled according to the patient's problems.
- D: Data (both subjective and objective)
- A: Action or nursing intervention
- R: Response of the patient (i.e., evaluation of effectiveness).
- A DAR note addresses patient concerns: a sign or symptom, condition, nursing diagnosis, behavior, significant event, or change in a patient's condition
What does charting by exception mean?
Charting by exception (CBE) focuses on documenting deviations from established norms. This approach reduces documentation time and highlights trends or changes in a patient's condition
How do critical pathways relate to client documentation?
- They provide members of the health care team a way to document their contributions to the client's total plan of care.
- multidisciplinary care plans for the problems, key interventions, and expected outcomes of the client with a specific condition
- all caregivers may use one critical pathway as a monitoring and documentation tool
- a checklist format can be used instead of a narrative format - chart only variances (both positive and negative) from the expected outcomes.
- involves the entire health team
- identifies expected outcomes for each day of care
- may use different symbols in each facility
What documentation is utilized in home health care and long term health care facilities?
- Home care documentation systems provide the entire health care team with the information needed to enhance teamwork. Documentation is both the quality control and the justification for reimbursement from Medicare, Medicaid, or private insurance companies. Nurses must document all their services for payment (e.g., direct skilled care, patient instructions, skilled observation, and evaluation visits). Information in the home care medical record includes patient assessment, referral and intake forms, interprofessional plan of care, a list of medications, and reports to third-party payers.
- Documentation supports an interdisciplinary approach to the assessment and planning process for patients. Communication among nurses, social workers, recreational therapists, and dietitians is essential in the regulated documentation process. The fiscal support for long-term care residents hinges on the justification of nursing care as demonstrated in sound documentation of the services rendered.
What information should be included in a change-of-shift-report?
- Follow a particular order
- Provide basic identifying info (name, gender, medical diagnosis & hx)
- For new clients provide the reason for admission or med diagnoses, surgery, diagnostic tests, and therapies in the past 24 hours
- Significant changes in the pt condition
- Provide exact information
- Report clients need for emotional support
- Include current nurse-prescribed and primary care provider-orders
- Clearly state priorities of care and care due after the shift begins
- From Table 26-4
- Provide only essential background information about patient (i.e., name, gender, medical diagnosis, and history).
- Identify patient's nursing diagnoses or health care problems and their related causes.
- Describe objective measurements or observations about patient's condition and response to health problem; emphasize recent changes.
- Share significant information about family members as it relates to patient's problems.
- Continuously review ongoing discharge plan (e.g., need for resources, patient's level of preparation to go home).
- Relay significant changes to staff in the way therapies are to be given (e.g., different position for pain relief, new medication).
- Describe instructions given in teaching plan and patient's response.
- Evaluate results of nursing or medical care measures (e.g., effect of back rub or analgesic administration).
- Be clear about priorities to which oncoming staff must attend.
How should telephone reports or telephone/verbal orders be recorded?
- A telephone report needs to include clear, accurate, and concise information.
- SBAR: Situation-Background-Assessment-Recommendation. Standardizes telephone communication of significant events or changes in a patient's condition and is a communication strategy designed to improve patient safety.
- Clearly determine the patient's name, room number, and diagnosis.
- Repeat any prescribed orders back to the physician or health care provider.
- Use clarification questions to avoid misunderstandings.
- Write TO (telephone order) or VO (verbal order), care provider and nurse.
- Follow agency policies; some institutions require telephone (and verbal) orders to be reviewed and signed by two nurses.
- The health care provider must co-sign the order within the time frame required by the institution (usually 24 hours).
When would it be important to give a transfer report and what would be the focus of such a report?
- Hand-off reports happen any time one health care provider transfers care of a patient to another health care provider. The purpose of hand-off reports is to provide better continuity and individualized care for patients. Examples of hand-off reports include change-of-shift reports and transfer reports.
- Hand-off communications include up-to-date information about a patient's condition, required care, treatments, medications, services, and any recent or anticipated changes.
- Information during patient hand-off can be given face-to-face, in writing, or verbally such as over the telephone or via audio recording. Regardless of the way hand-off reports are given, it is essential for staff to have an opportunity for last-minute updates, to clarify information, or to receive information on care events or changes in a patient's condition. Properly performed, a hand-off report provides an opportunity to share essential information to ensure patient safety and continuity of care
What is the purpose of an incident report?
- An incident or occurrence is any event that is not consistent with the routine operation of a health care unit or routine care of a patient. Examples of incidents include patient falls, needlestick injuries, a visitor having symptoms of illness, medication administration errors, accidental omission of ordered therapies, and circumstances that lead to injury or a risk for patient injury.
- Incident (or occurrence) reports are an important part of the quality improvement program of a unit
What are the general guidelines to follow when completing an incident report?
- Always contact the patient's health care provider whenever an incident happens.
- Do not mention the incident report in the patient's medical record. Instead you document an objective description of what happened, what you observed, and the follow-up actions taken in the patient's medical record.
- Evaluate and document the patient's response to the error or incident.
What is nursing informatics and what does it facilitate?
- Nursing informatics is a specialty that integrates nursing science, computer science, and information science to manage and communicate data, information, and knowledge in nursing practice.
- It facilitates the integration of data, information, and knowledge to support patients, nurses, and other providers in decision making in all roles and settings.
What constitutes a good information system and what are the advantages?
- A good information system that incorporates principles of nursing informatics supports the work you do.
- Increased time to spend with patients
- Better access to information
- Enhanced quality of documentation
- Reduced errors of omission
- Reduced hospital costs
- Increased nurse job satisfaction
- Compliance with requirements of accrediting agencies (e.g., TJC)
- Development of a common clinical database
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