N210 Week 2 Lab Documentation & Reporting

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  1. A. State at least 4 different uses of documentation in a medical record and recognize when documentation is used inappropriately.
    • 1. Documentation: written or electronic legal record of all pertinent interactions with the patient: assessing, diagnosing, planning, implementing, and evaluating.
    • 1. Contain data used to facilitate quality
    • 2. Evidence based patient care
    • 3. Serve as financial and legal records
    • 4. Help in clinical research
    • 5. Support decision analysis
    • 6. Information specialist: aim to create an environment that supports timely, accurate, secure, and confidential recording and use of patient-specific information
    • 2. Used inappropriately
    • 1. Meaningless repetitious or inaccurate entries
    • 2. Although these errors might go undetected and have no effect on the patient, they might also seriously affect the care the patient receives
    • 3. Undermine nursing’s credibility as a professional discipline
    • 4. Cause legal problems for the nurses responsible
  2. B. Define and apply the following types of nurse’s notes documentation (narrative, SOAPIE, Focus [DAR], PIE, and charting by exception)
    • 1. Progress notes: Notes written to inform caregivers of the progress a patient is making toward achieving expected outcomes
    • 2. Narrative notes: progress notes written by nurses in a source-orientated record and address routine care, normal findings, and patient problems.
    • a. They also include a description of the status of the problem, related nursing interventions, patient responses, and needed revisions to the plan of care
    • 3. SOAPIE: (Subjective data, Objective data, Assessment [the caregiver’s judgment about the situation] Plan Intervention, Evaluation)
    • a. Is used to organize entries in the progress notes of the POMR (problem orientated record)
    • b. Caregivers select numbered problems from the master list and then “SOAP it” on the progress sheet
    • c. Some nurses believe that it focus’ too narrowly on problems
    • 4. PIE charting (Problem Intervention Evaluation) this plan is incorporated into the progress notes, which identify problems by number (in the order that they were identified)
    • a. This document is filled out in the beginning of each shift using preprinted fill-in-the-blank assessment forms.
    • b. Patient problems identified in these assessments are numbered, documented in the progress notes
    • c. Resolved problems are dropped from daily documentation following the nurse’s review
    • d. Continuing problems are documented and numbered each day
    • e. Advantage: promotes continuity of care and saves time because there is no separate plan of care
    • f. Disadvantage: nurses need to read all the nursing notes to determine problems and planned interventions before initiating care
    • g. PIE has a nursing origin
    • 5. Focus charting: purpose is to bring the focus of care back to the patient and the patient’s concerns
    • a. Topics may include patient concerns and behaviors, therapies and responses, changes of condition and significant events such as teaching, consultations, monitoring, management of activities of daily living or assessment of functional health patterns.
    • b. DAR (Data Action Response): holistic emphasis on the patient and the patient’s priorities
    • 6. Charting by Exception (CBE): is a shorthand documentation method that makes use of well defined standards of practice; only significant findings or “expections” to these standards are documented in narrative notes
    • a. Advantage: less time needed for charting, a greater emphasis on significant data, easy retrieval, timely bedside charting, standardized assessment, greater interdisciplinary communication, better tracking of important patient responses and lower cost
  3. C. Discuss the pros and cons of using flow sheets for documentation
    • 1. Flow sheets: are documentation tools used to efficiently record routine aspects of nursing care
    • 2. Pros: Allows nurses to quickly document the routine aspects of care that promote patient goal achievement, safety, and well-being.
    • 3. Cons: not good for recording unusual events, overuse of the form can lead to incomplete documentation, if not consistent with progress notes it can lead to legal problems, it fails to reflect needs of patient and documentation needs of nurses
    • 4. Always a possibility of duplication of documents
  4. D. Name the components and use of a nursing care plan
    • 1. Patient records must communicate the patient’s problems or diagnoses; related goals, outcomes, and interventions and progress or resolution of the problems
    • 2. May be written separately or incorporated into a multidisciplinary plan
    • 3. Traditional plan of nursing: are written for each patient
    • 4. Standardized plans of care: identify common problems and related care for select patient groups
    • 5. Contains an overview of valuable patient information such as documentation, lab and test results, orders and medications
  5. E. Discuss the pros/cons of computerized charting
    • 1. Pros
    • a. Improved data accessibility
    • b. Faster
    • c. More efficient
    • d. Legible notes to read
    • 2. Cons
    • a. Displayed information viewed by unauthorized users
    • b. Sending confidential email messages can be read by unauthorized users
    • c. Sharing printers among units with differing functions and information
    • d. HIPPA
    • e. crashing of computers
  6. F. Apply the “Golden Rules” of documentation
    • 1. Make sure you have the right chart and the page is stamped with the identifying information
    • 2. Write legibly
    • 3. Use a black ink pen only
    • 4. Don’t document it, until you do it
    • 5. Document as soon as possible
    • 6. Be precise, accurate and thorough
    • 7. Always date and time every entry. If a late entry, also write “late entry”
    • 8. Use abbreviations appropriately (only those approved)
    • 9. Sign (in script, not print) legibly every entry with appropriate signature
    • 10. Draw a line through unused space
    • 11. Only document information you gather through your five sense: see, hear, smell and touch
    • 12. Document objectively, no interpretations
    • 13. If an error is made, make one line through the words. Write “mistaken entry” initial and date entry. There is no “white out in nursing” Don’t write “mistake, accident or error”
    • 14. Omit “patient” since it is assumed you are speaking about the patient
    • 15. Easier if you start sentences with action verbs (Capitalize first word)
    • 16. Omit articles “the, an, a, is, and are”
    • 17. Write a practice entry and check it with your instructor before writing a chart entry note
    • 18. Never chart for someone else

    G. Recognize and utilize medical abbreviations, both approved and from the “Do Not Use” list. (Ch. 16, Pg. 345-349)

    • H. Convert traditional time to military time
    • http://www.aaamath.com/meats2m.htm
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N210 Week 2 Lab Documentation & Reporting
2015-10-12 17:42:35
N210 Week Lab Documentation Reporting
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