Documentation and Informatics in Nursing Entry Into Professional Nursing NRS 101

Why Document? Accreditation (TJC) Reimbursement (DRG’s, Medicare) Communication (Continuity, education) Legal (Not documented, not done)

Multi-Disciplinary Communication Reports-Oral: End of shift Written Record-Chart: Permanent, legal, healthcare management on-going account Healthteam: All disciplines, nursing, social workers, discharge planning PT, OT, RT

Documentation Anything written or printed that is relied on as a record of proof for authorized persons Reflects quality of care Provides evidence of healthcare team members care rendered

Purposes of Records Communication Legal Documentation Financial Billing Education Research Audits-Monitoring

Guidelines for Quality Documentation & Reporting Factual Accurate Complete Current Organized

Follow TJC Standards Physical Psychosocial Environmental Self-care Client education Discharge Planning Evaluation of outcomes Nursing Process oriented

Types of Documentation Narrative POMR Source records Charting by Exception Critical Pathways Record Keeping Forms Acuity Recording Systems Standardized Care Plans Discharge Summary Forms

Types of Documentation Discharge Summary Forms Home Health Long Term care Computerized

Narrative Traditional type of nursing charting Story-like, repetitive Time consuming

Problem-Oriented Medical Records Data organized by problem or diagnosis Ideally all healthcare team members can contribute to list Coordinated plan of care POMR Components: Database, problem list, NCP, progress notes

POMR Database History and physical Nursing admission assessment On-going assessment Labs Radiology reports Record of each hospital visit

POMR Problem List Holistic needs based on data Chronological list on front of chart Dates when problem resolved or new problem occurs

POMR Progress Notes SOAP/SOAPIE Notes: Subjective data, objective data, assessment, plan, intervention, evaluation PIE Charting: Problem-Intervention-Evaluation Focus Charting/DAR-Data (subjective and objective) Action (intervention) Response of Client (evaluation)

Source Records Chart is so organized that each discipline has own section to record data Sections can be easily located Disadvantage: Not organized by client problems Narrative style notes

Charting by Exception Streamlines documentation Reduces repetition, saves time Short version to document normals, routine care items Based on established standards Progress note when standard not met Assumes all standards are met unless otherwise charted Exceptions must be noted

Critical Pathways Multi-disciplinary care plans used in case management Key interventions, expected outcomes, time frame Variances charted and analyzed

Record Keeping Forms Admission Assessment/Nursing history Graphic Sheets (Vitals, weights, I&O) Nursing Kardex Medication Administration Records

Acuity Reporting Systems Staffing patterns based on acuity of patients Numeric rating for interventions Varies per unit and standard Update every 24 hours and justify

Standardized Care Plans Pre-printed established guidelines Based on health problems Need to modify based on individual assessment, update and use judgement Standards of care are known, promotes continuity, staff knowledge

Discharge Summary Forms DRG’s encourage early discharge, but must ensure good patient outcomes Necessary resources, Client and family involved in process Begins at admission Client education integral to process (food-drug interactions, rehab referrals, medications, disease process)

Home Health Medicare/Medicaid Guidelines 50% of nursing time is documentation Care witnessed by client and family Good assessment skills Health care team focused Direct care in home Use of laptops for documentation

Long Term Care Residents not clients Governmental agencies: Many standards and policies regarding assessments, individualized plan of care Dept. of Health in each state determines frequency of charting Skilled Nursing Units

Nursing Informatics Computer based patient care record Assessments, care plans, MAR’s physician orders Maintain confidentiality with pass codes, looking at other records Nursing Information Systems Clinical Information Systems Electronic Medical Record

Reporting Oral or written Change of shift Nurse to nurse Promotes continuity Report on client health status, care required for next shift, significant facts, head to toe assessment, pertinent labs, priority needs, treatments, family issues

SBAR Technique for Communication S- Situation B- Background A- Assessment R- Recommendation

End of Shift Report Keep professional Avoid judgemental language Include assistive personnel

Telephone Reports Inform physician of changes Client transfers to different units Result reports from lab or radiology Client transfers to different institutions Info needed: When call made, to whom, info given Keep clear, accurate, repeat info if necessary

Telephone Orders Physician to RN Physician must co-sign within 24 hours Nightime, emergency orders Guidelines and procedure per institution Be careful, precise and accurate with order Write order as said by physician, repeat it back

Transfer Reports Unit to unit report Phone or in person All pertinent data about patient Send all belongings with client Review clothing/belonging list prior to transfer Transfer Sheet Documentation

Incident Reports Any event not considered routine (falls, needlesticks, med errors, accidental omissions, visitor injury) Risk Management will analyze trends Changes in policy/procedure, educational programs may be related to findings Notify supervisor, physician of incident Nurse who witnesses makes out report Do not assign blame, be objective, facts only

Tips for Documentation Accurate, timely, thorough, factual, neat Use only approved abbreviations & terms Blue or black ink Always get and give report Focus on a team approach Date, time each entry, do not block chart Document in a timely fashion Follow the nursing process Use appropriate forms

Documentation Tips Correct errors promptly, using proper technique Write on every line, leave no spaces Sign each entry with full signature and correct title Follow institution policy and procedure for charting Military vs standard time