Documentation and Informatics in Nursing Entry Into Professional Nursing Summer 2009

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