Documentation PN 103

Purposes of Patient Records Five Basic Purposes for Written Records Written communication Permanent record for accountability Legal record of care Teaching Research and data collection

Purposes of Patient Records Purposes of Patient Records Auditors assess quality of care Peer Review appraisal by co-workers of equal status Quality Assurance/Assessment/Improvement audit in health care evaluates services provided and the results achieved compared with accepted standards

Purposes of Patient Records Purposes of Patient Records Diagnosis Related Groups (DRGs) classifies patient by: -age -diagnosis -surgical procedure predicts the use of hospital resources -length of stay cost reimbursement rates for Medicare and Medicaid and private insurance companies

Purposes of Patient Records Nurse’s Notes form on the patient’s chart nurses record their observations, care given, and the patient’s responses Institutions reimbursed by insurance companies or government programs only for the patient care documented

Purposes of Patient Records Quality and accuracy Spelling Grammar Punctuation Good penmanship Clear Concise Complete Accurate.

Purposes of Patient Records The nurse has primary responsibility for the initial admission nursing history, physical assessment, and development of the care plan based on the nursing diagnoses identified.

Charting Rules Basic Rules for Charting All sheets should have the correct patient name, date, and time. Approved abbreviations and medical terms. Timely, specific, accurate, and complete. Write legibly. Follow rules of grammar and punctuation. Fill all spaces; leave no empty lines Chart consecutively, line by line Do not indent left margin. Chart after care is given, not before.

Charting Rules as soon and as often as possible. your own care, observations, and teaching - never chart for anyone else. direct quotes when appropriate. describe each item as you see it. write only what you hear, see, feel, and smell. Chart facts -avoid judgmental terms and placing blame.

Charting Rules Sign each block of charting or entry -full legal name and title. What you observe, not opinions. When the patient leaves a unit -chart the time -method of transportation on departure and return. All ordered care as given -or explain deviation. Patient response to treatments Response to analgesics/other medications.

Charting Rules Hard-pointed, permanent black ink pens -no erasures or correcting fluids If charting error is made -draw one line through the faulty information -mark error -initial -make the correct entry. Note a late entry and then proceed with your notation. Follow each institution’s policy and procedures

Charting Rules Avoid using generalized empty phrases -“status unchanged” -“ had a good day.” If order is questioned, record that clarification was sought.

Common Medical Abbreviations and Terminology A nurse needs some understanding and knowledge of common abbreviations and medical terms Most facilities have a published list of generally accepted medical abbreviations and terms approved for use in charting.

Commonly Used Abbreviations Abd Abdomen ABO The main blood group system ac Before meals ad lib As desired ADL Activities of daily living Adm Admitted or admission AM Morning amb Ambulatory amt Amount approx Approximately bid Twice daily BM (bm) Bowel movement BP Blood pressure BRP Bathroom privileges c– With C Celsius (centigrade CBC Complete blood count c/o Complains of DAT Diet as tolerated Dc Discontinue drsg Dressing Dx Diagnosis ECG (EKG) Electrocardiogram F Fahrenheit fld Fluid GI Gastrointestinal gtt Drop h (hr) Hour H2O Water I&O Intake and output IV Intravenous (L) Left LMP Last menstrual period

Commonly Used Abbreviations MEDS Medications mL Milliliter mod Moderate neg Negative Ø None # Number or pounds NPO (NBM) Nothing by mouth NS (N/S) Normal saline O2 Oxygen OD Right eye or overdose OOB Out of bed OS Left eye p~ After pc After meals PE (PX) Physical examination per By or through PM Afternoon po By mouth postop Postoperatively preop Preoperatively prep Preparation prn When necessary qid Four times a day (R) Right s¯ Without stat At once, immediately tid Three times a day TO Telephone order TPR Temperature, pulse, respirations VO Verbal order VS Vital signs WNL Within normal limits WT Weight

Methods of Recording Traditional Chart Divided into specific sections or blocks. Specific sheets of information: -admission sheet -physician’s orders -progress notes -history and physical examination data -nurse’s admission information -care plan and nurse’s notes -graphics -laboratory and x-ray reports.

Methods of Recording Narrative charting Descriptive form -basic patient need or problem data -whether someone was contacted -care and treatments provided -patient’s response to treatment Written in an abbreviated story form

Methods of Recording Problem-Oriented Medical Record Scientific problem-solving system or method. -database -problem list -care plan -progress notes.

Methods of Recording Database Accumulated data -history and physical examination -diagnostic tests Used to identify and prioritize the health problems on the master medical and other problem lists.

Methods of Recording Problem list Active, inactive, potential, and resolved problems -serve as the index for chart documentation. A care plan with nursing diagnosis is developed for each problem by disciplines involved with the patient’s care.

Methods of Recording SOAPIER is an acronym for seven different aspects of charting. S – Subjective information O – Objective information A – Assessment P – Plan I – Intervention E – Evaluation R – Revision

Methods of Recording Focus Charting Format Modified list of nursing diagnoses -used as an index for nursing documentation. Uses the nursing process -positive concept of the patient’s needs rather than the medical diagnoses and problems

Date/Hour Focus Progress Notes 5/20/201 08:00pm Pain D: Reports of sharp pain on the abdominal incision area with a pain scale of 8 out of 10 Facial grimacing Guarding behavior Restless and irritable   A: Administered Celecoxib 200mg IV Encouraged deep breathing exercises and relaxation techniques Kept patient comfortable and safe R: Patient reports pain was relieved The focus of this problem is pain. Notice the way how the D, A, and R are written.

Methods of Recording Data, Action and Response Example: D – Facial grimacing, graded the pain as 7 in the scale of 1 to 10 with 10 as severe pain A – Given Oxycodone 5 mg po at 10:00. R – Rated pain as 2 and able to walk on her own

Basic Guidelines for Documentation Charting by Exception At the beginning of each shift pertinent data is charted -physical assessments -observations -vital signs -IV site and rate During the shift -additional treatments given or withheld -changes in patient condition -new concerns Detailed flow sheets

Alternative Record-Keeping Forms Variety of forms are used -make medical record documentation -easy -quick -comprehensive. -eliminate the need to duplicate repeated data in the nurse’s notes. -unnecessary to chart a narrative -medication -bath -vital signs

Methods of Recording Kardex/Rand Card system -consolidates patient orders and care needs in a centralized, concise way Kept at the nursing station for quick reference

Methods of Recording Nursing Care Plan Preprinted guidelines -patients with similar health problems -meet the nursing needs of a patient -based on nursing assessment and nursing diagnosis

Methods of Recording Incident Report Any event not consistent with the routine care of a patient -patient care was not consistent with facility or national standards of expected care Write: -objective, observed information -do not: -admit liability -give unnecessary details -mention the incident report in the nurse’s notes

Methods of Recording 24-Hour Patient Care Records and Acuity Charting Forms A system that accommodates a 24-hour period -Consolidation of the nursing records -Aids in the elimination of unnecessary record-keeping forms -More easily obtained with 24-hour notations: -assessment information -documentation of activities of daily living are

Methods of Recording Discharge Summary Forms Patient's continued health after discharge. -MD appointments -equipment (oxygen, bath bench, etc.) -Home Health follow-up The summary should be concise and instructive.

Methods of Recording Clinical (Critical) Pathways Managed care is a systematic approach -a framework to target the coordination of medical and nursing interventions -staff from all disciplines -develop integrated care plans -projected length of stay for a specific case type -pathways to monitor a patient’s progress and as a documentation tool

PATHWAY: TOTAL HIP REPLACEMENT DOS/Day 1 Respiratory Pain Management Outcome: • Verbalizes comfort or tolerance of pain Circle: V NV Variance: Key: V = Variance NV = No Variance Signature: Initials: • Verbalizes comfort with pain control measures Outcomes: • Breath sounds clear to auscultation • Achieves 50% of volume goal on incentive spirometer • Achieves 100% of volume Days 2–3 Figure 15–8 ■ Excerpt from a critical pathway documentation form.

Home Health Care Documentation Home health care reimbursement -Medicare has specific guidelines for establishing eligibility 50% of the nursing time is spent in documentation. Documentation: -quality control -justification for reimbursement from Medicare, Medicaid, or private insurance companies. -unique problems -need for different health providers to access the medical record

Long-term Health Care Documentation Omnibus Budget Reconciliation Act (OBRA) of 1987 regulated standards for: -resident assessment -individualized care plans -qualifications for health care providers. Each state’s Department of health for governs: -frequency of written nursing records of residents in long-term care facilities. Long-term care documentation -multidisciplinary approach (Nursing, Rehabilitation, Social Work, Dietary, Activities) -assessment -planning process

Special Issues in Documentation Record Ownership and Access Original health care record/chart -property of the institution or physician. -patient usually does not have immediate access to his/her full record. Patients have gained access rights to their records in most states -only if they follow the established policy of each facility. A lawyer can gain access to a chart with the patient’s written permission.

Special Issues in Documentation Confidentiality Health care personnel -respect the confidentiality of the patient’s record. The Patient’s Bill of Rights and the law -patient’s medical information will be kept private -unless the information is needed in providing care -patient gives permission for others to see it The nurse: -should not read a record unless there is a clinical reason -hold the information regarding the patient in confidence.