© 2016 Cengage Learning ®. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. Unit 8 Observation, Reporting, and Documentation

© 2016 Cengage Learning ®. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. Objectives Spell and define terms. List the components of the nursing process. Explain the responsibilities of the nursing assistant for each component of the nursing process. 2

© 2016 Cengage Learning ®. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. Objectives Describe two observations to make for each body system. State the purpose of the care plan conference. List three times when oral reports are given. 3

© 2016 Cengage Learning ®. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. Objectives Describe the information given when reporting. State the purpose of the patient’s medical record. Explain the rules for documentation. State the purpose of the HIPAA laws. 4

© 2016 Cengage Learning ®. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. Objectives Describe the difference between an electronic medical record (EMR), an electronic patient record (EPR), an electronic health record (EHR), and a personal health record (PHR). List at least 10 guidelines for computerized documentation. 5

© 2016 Cengage Learning ®. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. Introduction One of the responsibilities of the nursing assistant: –To collect and communicate information about patients Information is collected: –By making observations of the patients 6

© 2016 Cengage Learning ®. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. Introduction Information is communicated to other team members by reporting and documenting Nursing process –The mechanism used to carry out these actions 7

© 2016 Cengage Learning ®. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. Diagnoses Physicians collect information –Make medical diagnoses and treat illness Nurses collect information –Use it to diagnose and treat the human response to illness –Refer to Figure 8-1 8

© 2016 Cengage Learning ®. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. Diagnoses 9

© 2016 Cengage Learning ®. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. Nursing Process Registered nurse –Responsible for achieving patient-focused care by using the nursing process 10

© 2016 Cengage Learning ®. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. Nursing Process Nursing process consists of five steps: –Assessment –Problem identification –Planning –Implementation –Evaluation 11

© 2016 Cengage Learning ®. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. Importance of the Nursing Process Nursing process is a key element in health care delivery Nursing units run more efficiently and effectively if all staff understand and use the nursing process 12

© 2016 Cengage Learning ®. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. If the nursing process breaks down: –Patients are at high risk of injury –Facility and its personnel are at high risk of legal exposure Importance of the Nursing Process 13

© 2016 Cengage Learning ®. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. Understanding and fulfilling your role in the nursing process is an important responsibility Importance of the Nursing Process 14

© 2016 Cengage Learning ®. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. Critical (Clinical) Pathways DRG method of payment has affected many health care practices and shortened hospital stays Many hospitals are using critical (clinical) pathways to direct care 15

© 2016 Cengage Learning ®. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. Making Observations An observation –Information that is obtained by using one’s senses Two types of observations: –Subjective –Objective 16

© 2016 Cengage Learning ®. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. Making Initial Observations To make accurate observations: –You must first know what is expected or normal for an individual –For this reason, baseline information is collected when each patient is admitted to the facility 17

© 2016 Cengage Learning ®. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. Making Initial Observations To make accurate observations: –If you help admit a patient, make observations while you are completing your assignment –It is especially important to note any possible signs of injury or skin breakdown 18

© 2016 Cengage Learning ®. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. Pain It is very important that you be factual in reporting observations of pain and behavior Never try to judge whether a patient really has pain or how severe the pain is 19

© 2016 Cengage Learning ®. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. Pain Pain is never normal Always report patient complaints of pain to the nurse 20

© 2016 Cengage Learning ®. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. Reporting Giving an oral report –One method used to relay information from one person to another Nursing assistant may participate in oral reports several times on a shift 21

© 2016 Cengage Learning ®. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. SBAR Communication A standard structure for concise, factual, effective, and meaningful reporting of patient information S—Situation: What is happening at the present time that has triggered the SBAR communication? 22

© 2016 Cengage Learning ®. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. SBAR Communication B—Background: What are the circumstances leading up to this situation? Put the situation in context. A—Assessment: What do I think the problem is? 23

© 2016 Cengage Learning ®. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. SBAR Communication R—Recommendation: What should we do to correct the problem? How urgent is the situation and when does action have to be taken? 24

© 2016 Cengage Learning ®. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. Documentation In some facilities: –You may be expected to record your observations on the patient’s medical record –The medical record is a document –A document is a legal record 25

© 2016 Cengage Learning ®. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. Documentation In some facilities: –The process of recording a patient’s care, response to treatment, and progress in the patient’s chart is called charting 26

© 2016 Cengage Learning ®. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. Charting Guidelines A patient’s medical record –Legal document that may be used in court as evidence – It is important that everything be correct and legible –All charting and records must be in clear, simple, and accurate language 27

© 2016 Cengage Learning ®. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. Electronic Recordkeeping Electronic health record –A cumulative record containing contact and insurance information, next of kin, a list of medications, etc. –Not a complete medical record 28

© 2016 Cengage Learning ®. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. Electronic Recordkeeping EHR technology may be used only if an EMR system that can communicate with other EMR systems is in place. Information from the EMR contributes to the EHR. 29

© 2016 Cengage Learning ®. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. Electronic Recordkeeping A personal health record (PHR) is an EHR that the patient creates and controls. Most people store these digitally. 30

© 2016 Cengage Learning ®. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. Electronic Recordkeeping An electronic medical record (EMR) is a digital patient record for a single facility or organization. This is an electronic version of the paper medical record. It may also be called an electronic patient record (EPR). 31

© 2016 Cengage Learning ®. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. Point-of-Care Data Capture POCT devices make it possible to obtain information, take action, and document immediately after a change occurs or a procedure is done. 32

© 2016 Cengage Learning ®. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. Point-of-Care Data Capture Point-of-care testing (POCT) is done at the patient’s location at the time care is required. The test result enables a clinical decision to be made, resulting in action or treatment. 33

© 2016 Cengage Learning ®. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. Handheld Computers Personal digital assistants (PDAs) Tablet PCs (TPCs) 34

© 2016 Cengage Learning ®. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. Voice-Activated Systems Voice-activated systems require use of a headset Patients are identified by room and bed number 35

© 2016 Cengage Learning ®. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. Voice-Activated Systems Documentation is done by answering a series of yes/no questions. The responses are immediately sent to the medical record. 36

© 2016 Cengage Learning ®. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. Confidentiality and Privacy Health Insurance Portability and Accountability Act (HIPAA) of 1996 –Increases patient control over personal medical records –Restricts use and disclosure of patient information –Makes facilities accountable for protecting patient data 37

© 2016 Cengage Learning ®. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. Confidentiality and Privacy HIPAA rules: –Require facility to implement and monitor their information release policies and procedures 38

© 2016 Cengage Learning ®. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. Confidentiality and Privacy HIPAA rules: –Protect all individually identifiable health information in any form –Apply to paper, verbal, and electronic documentation, billing records, and clinical records 39