Documentation PN 103

Introduction The “chart” = health care record – LEGAL record The process of adding written information to the chart is called: – Charting – Recording – Documenting 24 hr record-keeping system To consolidate nursing records

Introduction Good documentation reflects the nursing process Documentation is an integral part of the implementation phase of the nursing process It is necessary for the evaluation of patient care and reimbursement from payor sources

Purposes of Patient Records 1. Provides written communication 2. Permanent record for accountability 3. Legal record of care 4. Teaching 5. Research and data collection

Basic Guidelines for Documentation Hand-out: FON Box 7-1

Legal Guidelines for Documentation Hand-out: FON, Table 7-2

Methods of Recording The Traditional Chart – Divided into sections - eg. Admission sheet, physician orders, progress notes, etc. – Nurses use: flow sheets, graphics, and narrative charting Narrative Charting – the recording of patient care in descriptive form to chart observations, care, and responses – Abbreviated story form – Information obtained from nursing assessment is clustered and organized in a head-to-toe manner

Methods of Recording Problem-oriented Medical Record (POMR) – Database: accumulated information from the medical history, physical exam, and diagnostic tests – Problem list: of active, inactive, potential, and resolved problems – SOAPE documentation

Methods of Recording SOAPE format: – S = subjective information What the patient states or feels – O = objective Information What the nurse can measure or factually describes – A = Assessment A potential diagnosis of the cause of the patient’s problem or need – P = Plan Of care to be given or action to be taken – E = Evaluation And appraisal of the the response and effectiveness of the plan

Methods of Recording Focus Charting Format “DARE”: – D = data Subjective and objective – A = Action Combination of planning and implementation – R = Response and evaluation Of the patient; evaluating the effectiveness of the actions – E = Education and patient teaching As needed

Methods of Recording Charting by Exception = CBE – Will chart per usual at the beginning of each shift : complete physical assessments Observations VS IV site and rate other pertinent data

Methods of Charting Charting by Exception cont. – The only other notes the nurse will make will be: Additional treatments done Planned treatments withheld Changes in patient condition New concerns Notations re: progress or revisions for all active nsg. dx.

Case Study Exercise Index Cards Progress Notes

Record-Keeping Forms P FON “Kardex” – term for a card or paper system used to consolidate patient orders and care needs in a centralized and concise way – Usually kept in the nurse’s station for quick reference

Incident Reports An “incident” refers to: – An event not consistent with the routine operation of a health care unit or the routine care of a patient, or – Other hospital / facility notification form when the patient care delivered is not consistent with the facility or national standards of expected care Eg. Giving an incorrect dosage of a drug or a wrong drug

Incident Reports – Also completed for any unusual event in the hospital or facility: Needle stick Patient/visitor/hospital personnel injury – This information helps the facility risk manager and unit manager prevent future problems through education and other corrective measures

Incident Reports FON P. 150, Fig. 7-9/Table 7-3 When filling out: – Give only objective, observed information – Do not admit liability or give unnecessary information – Do list time, date, care given to the person and name of physician notified (if it was a pt.) – When charting in the progress notes, do not mention that an incident report was made

Acuity Charting 24 hr scoring system Rates each patient by the severity of their illness Helps to determine staffing patterns

Home Health Care Documentation Box 7-4 Documentation Forms Used 50% of nursing time! Documentation has different implications in the home health system: – Fewer witness to the majority of care – Accurate communication to all team members Some forms left in the home; others at the agency – Quality control and justification for reimbursement Computer influence

Computer Influence Communication and assessment via modem linkage – Phone and visual visits – Promotes integration of chart some parts of the chart left in the home; some in the chart Various healthcare disciplines need access Box 7-5 p. 155 FON “Guidelines for Safe Computer Documentation

Long-Term Health Care Documentation MDS – Minimum Data Set – Dictated by Medicare and Medicaid OBRA 1987 – Regulated standards for resident assessment, individualized care plans, and qualifications for healthcare providers

Practice P. 156, 157 FON Practice NCLEX questions SG – Ch. 6 and 7