Documentation

What Is It? Written record of everything done for a patient Medications Treatments Activities Education supplies

Purpose Accreditation Reimbursement Legal Communication To prove meeting prescribed standards Reimbursement To show what was used Legal Shows condition of patient before, during and after treatment Communication Within the health team

Special Considerations Confidentiality Only for those with “need to know” Must be accurate and thorough Must be legible

Characteristics Factual Accurate Describe findings, not what “seems” or “appears” Use exact patient statements, put in “ ---” Accurate Precise measurements No unnecessary words Only pertinent details Correct spelling

More Characteristics EACH ENTRY MUST BE: Timed Dated Signed At the time of activity ** Dated Signed By the person recording **exceptions: after shift Team effort

Signatures First name or initial Full last name Title (ADNS) At least once per page Then may use initials Signature Initials S.Manning, RN, MSN SM

Still more characteristics Completeness Thoroughly describe events using details of Quality Quantity Duration Measurements Rating scales

yet more characteristics Current Up to the minute Don’t ‘wait til later’ Organized Use a logical method Make & review notes before writing in record

Legalities NEVER: ALWAYS Erase use white-out scratch or scribble out Omit critical commentary Completely record FACTS Record clarification efforts Write legibly, use black ink Correct errors promptly

IMPORTANT If it isn’t written, it wasn’t done

Malpractice Issues Incorrect time of when events occurred Not recording verbal orders Not getting verbal orders signed Charting actions in advance Documenting incorrect data

Types of Records Facility designates which format of documentation SOAP Subj, obj, assess, plan PIE Plan, implement, evaluate DAR Data, actions, responses

Discharge Planning Begins at time of admission Must educate the patient Throughout hospital stay Diet, meds, treatments, rehab, community resources Continuity between health teams

End of Shift Reports Report facts Obj & subj data Info about family, prn Responses to care or treatments Occurrences

Telephone or Verbal Orders Listen carefully Write down on notepad Ask questions if necessary Read back to physician Document on order page Sign after order: T.O. Dr.Fry/N. Nurse, RN V.O. Dr. Oar/N. Nurse, RN