Communication is Vital! Technology is your friend!

 Accurate:  Observations only  Do not use subjective words  Correct spelling, grammar & med terms  Complete:  New or changed information  S/S, clients behavior  Nursing interventions  Meds given  Physicians orders carried out  Client teaching and response to therapy

 Consistent  Concise and brief using approved abbreviations  Objective  Important when documenting psychosocial and mental health issues  Legible  Writing must be clear and easily read by others  Line out errors: 100 cc clear yellow urine from foley  Organization  Use nursing process  Timelines  Document care, treatments, procedures and medications as soon as possible

 Purpose of documentation:  Communication  Assessment  Care planning  Quality assurance  Reimbursement  Legal documentation  Research  Education

 Technology in healthcare is advancing  Information will be managed electronically  Outcomes:  Safe patient care  Patient centered care  Improved outcomes  Ease of access to information  Workflow

 Forms use a standardized language  Radio buttons, drop-down boxes  Data driven  Mandatory fields  Charting by exception  Increases compliance  Alerts to abnormal findings  Able to document all aspects of nursing care

 EHR/EMR  Monitoring  Imaging  Medication administration  Pharmacy  Clinical Decision Support Systems  ADT  CPOE  Central supply ordering systems

Elements that reduce human error:  CPOE  Bar Code  High Alert Medication Documentation  Point of Care Documentation  Mandatory Fields  Smart Pumps  Communication Tool

 Admission History and Assessment  Discharge Form  Nursing Care Plans  Flow Sheets/graphic sheets  Kardex  Clinical Pathways  Medication Administration Records (MAR)  Nursing Progress Notes  Patient education form  Acuity charting  Incident report Does NOT go in pt chart!

HIPAA

Purpose Techniques Content

Situation  Pt name  Age  Physician’s name  Diagnois  Hospital day/POD # Background  What brought them to the hospital  Past medical history

Situation Background Assessment Recommendation/ Request Often a framework for communication- calling MD, giving report, etc

Assessment  State what you think is the problem  Give review of symptoms Recommendation or Request  What needs to be done  What was done  Plan for discharge

 Information written in sentences or phrases usually time sequenced  Must write a narrative note q2 hrs  Many combined with flow sheets

 Document only findings that fall outside of “normal”  Flow sheet with check boxes  Assessment findings, routine care activities  Narrative notes only when there is an exception or abnormal finding  Eliminates redundancy