Documentation

 Nurses are legally and ethically bound to keep patient information confidential  Nurses must work to protect patient records from unauthorized readers  Documentation is required by the ANA standards for practice and nurse practice acts in all states

Nursing charting is used for:  Communication of patient needs/progress/therapy between healthcare providers  Financial billing  Chart reviews by researchers, accreditation agencies, and lawyers in event of malpractice suits

Charting guidelines  Be sure to review chart p. 486  Do not use White-Out on any patient charts or records Anyone reading the chart afterward may wonder what you are trying to cover up Altering patient charts is a criminal offense  Document times accurately Malpractice suits have been won due to inaccuracies in documentation about when care was delivered  Do not use abbreviations that are not accepted by the facility

Charting guidelines  Only enter factual information, not opinions like: “The patient was very cranky today” “The patient’s wound stunk really bad” “The patient had a good day today” “Patient appeared more whiny today”  If you make a mistake, draw a single line through it, write “error” and sign your name afterward  Always include the date and time with each entry with your signature and credentials (RN)

Methods of Recording  Narrative Documentation Traditional for recording nursing data Storylike format Disadvantages: tendency to have repetitious info; time consuming; require the reader to sort through much info

Methods of Recording  Problem-Oriented Medical Record (POMR) Method of documentation that places emphasis on the client’s problems Data are organized by problem or diagnosis Major sections:  Database  Problem list  Nursing care plan  Progress Notes: SOAP charting/ SOAPIE PIE format: has a nursing origin, simplifies documentation

Source Records  The client’s chart is organized so that each discipline (nursing, medicine, social work, respiratory therapy) has a separate section in which to record data

Charting  Focus of charting will reflect specialty areas of care. For instance: Rehab: patient mobility, continence, compliance with therapy Critical care: monitors, lines, ventilator settings Labor & delivery: dilation of cervix, fetal heart rate, pain management  Specialty areas will often have specific flow sheets for charting as well as blank areas for narrative charting as well

Watch your handwriting!  Even though doctors’ handwriting is a running joke, it is very important that your charting is legible!  Illegible entries can be misinterpreted- not good if the charting is used in a malpractice lawsuit  Only black ink is acceptable!  Do not leave any blank spaces in the chart- someone may come later and add information in your notes

Charting  Old saying: “If it wasn’t charted, it wasn’t done!”  Important for billing and if chart is ever called into evidence in a lawsuit  Hospitals are now facing huge fines for fraud- billing for procedures/treatments that were not done  If information is not recorded, it is not available for other members of the healthcare team caring for the patient

Charting  Must be current and up to date  Best to chart when assessment is done or care is delivered, not at the end of the shift  Frequency depends on unit and care: Code blue: may chart every minute Nursing home: may be daily or weekly  Do not repeat medical diagnoses from the patient’s chart or normal findings from the physical assessment flow sheet

Charting  If you chart about a problem, chart what you did about it “Patient complained of severe incisional pain- morphine 10 mg given with relief stated afterward”  Charting style varies by facility Narrative notes Flow charts Computer entry  Do not chart ahead of time- patients refuse treatments/medications all the time!

Charting  If you do a procedure on another nurse’s patient, chart on that patient’s chart- include the appropriate information and sign your name  DO NOT chart on procedures that you did not do  If another nurse does a procedure on your patient, chart as such: “18 French Foley catheter inserted by S. O’Meara RN, patent with clear yellow urine”

Charting by Exception (CBE)  An approach used to eliminate redundancy, ensure concise documentation of routine care emphasize abnormal findings Identify trends in clinical care.

Shift report  At the end of each shift, nurses give report about their patients to the on-coming nurse  May be given face-to-face, written down, or on audiotapes  Purpose is to provide continuity of care  Important information is relayed so that nurses can provide appropriate care

Shift report  Must be done quickly and efficiently  Should include: Background information (admitting diagnosis, physician, room number) Assessment findings and lab values Treatments and patient education Family information Priority needs Discharge planning

Telephone reports  Should be documented when significant events or changes in a patient’s condition have occurred  Documenting phone calls: When call was made Who made call and who was called Who the information was given to What information was given What information was received If no order was received from the physician, document as such

Telephone & verbal orders  Physicians may give orders over the phone to an RN  Order needs to be verified by repeating it clearly to the physician  RN is responsible for writing the order in the patient’s record  Telephone orders may only be given to RNs, not LPNs  Telephone orders may not be left with unit secretaries or on voice mail

Incidents  An incident is any event that is not consistent with the routine care for a patient or nursing unit  Examples of incidents: Malfunctioning patient equipment Patient falls or injuries Needlestick injuries Medication errors

Incident reports  Should be filled out for any kind of incident that occurs  If in doubt, ask nursing supervisor  Specific reports may be needed for some incidents such as: adverse medication effects medication injuries needlestick injuries patient falls  Are filled out in addition to any appropriate entries that are made in the patient’s chart regarding the incident

Incident reports  DO NOT chart in the narrative/ patient’s chart that an incident report was filled out: Incident reports are for internal investigations within the facility only, and are reviewed by facility supervisors and managers  If the presence of an incident report is included in the patient’s chart, it may be subpoenaed as evidence in a malpractice lawsuit