DOCUMENTATION NURS116

DOCUMENTATION Anything written or printed on which you rely as a record or proof of patient actions or activities Retrieve clinical data, maintain continuity of care, track patient outcomes, reflect current standards, provides detailed account of quality of care.

PURPOSES OF DOCUMENTATION Communication Legal documentation Reimbursement Education Research Auditing and monitoring

CONFIDENTIALITY HIPPA Records may be used for data gathering, research, continuing education, if permission is granted View only the information needed to give safe, quality care As a student, do not use pt identifiers, never print or copy records

STANDARDS Frequency of documentation Pt records become legal evidence Physical, psychosocial, environmental, self- care, knowledge level, and discharge planning needs must all be documented Minimum standards set by The Joint Commission, Center for Medicare/Medicaid

Documentation as Communication Continuing account of health care status Available to all health care team Patient info and demographics Informed consent Admission data Nursing diagnoses and care plan Record of nursing care Medical history (H and P) Medical diagnosis Orders Progress notes Assessment findings Diagnostic study findings Pt education Summary of op procedures Discharge plan and summary

Documenting communication Shift reports Telephone reports between departments Incident reports Laboratory reports Consultations Referrals

Guidelines for Quality Documentation Factual Accurate Complete Current Organized

factual Descriptive, objective information Do not state an opinion Document patient words in “quotes”

accurate Exact measurements Use numbers Avoid abbreviations Learn to spell!!! Use vocabulary appropriately Date, time, sign

complete Appropriate and essential information Includes nursing care and patient response Use narration when flow sheets do not allow enough information

current Don’t delay VS, pain assessment, medications, treatments, pre op or pre test , provider notification re: changes, deaths should be documented IMMEDIATELY Use international (“military”) time in charting

organized Document in a logical order Use SOAPIE or the nursing process to guide your thoughts Think before you write.

LEGAL GUIDELINES DO NOT ERASE OR USE WHITE- OUT DO NOT INCLUDE PERSONAL OPINIONS OR “ATTACKS” ON OTHER PROFESSIONALS CORRECT ERRORS PROMPTLY RECORD ALL FACTS DO NOT LEAVE BLANK SPACES OR LINES BLACK INK CHART ONLY FOR YOU DATE, TIME, SIGNATURE PROTECT YOUR PASSWORD FOR EMR

ELECTRONIC HEALTH RECORDS AKA EMR Provides immediate access Integrates all records Images Provides continuity of care

Narrative Notes Traditional Tells a story Time consuming, repetitious Requires reader to “sort”

SOAPIE notes Subjective Objective Assessment Plan Intervention Evaluation Focuses on ONE problem at a time. Originated from medical records

PIE notes Problem Intervention Evaluation Problems are numbered as identified, then dropped as resolved.

DAR (Focus Charting) Data Action Response Uses the nursing process better, focuses on all concerns, not just “problems”

Charting by Exception Identified norms Reduces documentation Only document when standardized statement on the form is not met Allows tracking, identifying trends or changes

Source records Separate section for each discipline Caregivers can easily locate section in which to make entries Physician Notes Physician’s Orders Nurses Notes MAR Flow Sheets and Graphics Does not show how care is coordinated or how disciplines are related

Flow sheets and Graphics Quickly and easily enter assessment data Vital signs, meals, weights, intake/output Hygiene, ambulation, restraint checks Allows providers to see trends Changes should be followed up with narrative

HAND-OFF REPORTS Transfer of care to another provider Provides continuity, individualized treatment Standardized communication includes: up to date condition required care treatments medications recent or anticipated changes Focus on patient and family (if pertinent to care)

INCIDENT REPORTS Any event that is not consistent with routine operation of a health care unit or routine care of a patient Falls, needlestick injuries, ill visitor, med errors, omission of treatments Circumstances that could lead to injury or risk of injury Analysis of TRUTHFUL reports ID trends that may justify changes, important part of quality improvement

INCIDENT REPORTS Always contact the patients HCP Do not mention the incident report in the patient’s record….document objective findings and follow up, pt response Goal is to prevent further recurrence File with risk management department

Which documentation is correct? A. 0730 patient complains of abdominal pain 9/10. B. patient states he has pain but I don’t think it’s as bad as he says C. patient talks about pain all day D. earlier today, patient said he had bad pain

Which statement does not belong in a hand off report A. “Mrs. Jones is post op day 3 following a CABG” B. “Mrs. Jones’s daughter has been here during physical therapy, and has demonstrated that she can help Mrs. Jones with ADLs” C. “Mrs. Jones is very demanding and has been asking for too much medication” D. “Mrs. Jones is scheduled for a electrocardiogram in the morning” E. “I started a new IV for Mrs. Jones and used chlorhexidine and lidocaine and accessed the antecubital vein.”