Documentation!

Documentation and Reports Communicate information about clients healthcare needs Ensures that all goals and interventions are directed towards same goal

Report vs. Record Report –Oral or written –Between staff, other health professionals, lab reports Record –Permanent written communication –Legal part of chart

Guidelines for Good Charting Fact –Stick to them –Descriptive/objective –Vague –Response to medications –Clients own words

Accuracy –I & O –Wound size –Wound length –Abbreviations –Correct spelling!!! –Don’t chart for others –Sign name, no nicknames

Concise –Playing vs. running, laughing Current –Delays in reporting can result in delay of treatment –Delay can be interpreted as negligence –Report ASAP –Bed baths, I & O don’t have to be immediate but in timely manner –Keep notepad in pocket –Know military time!

Organization –Chart in order things occurred Confidentiality –All patient info is CONDIFENTIAL!!

Common Types of Reporting Change of shift –Oral, recorded, during rounds –Report quickly and efficiantly Health status Kind of care required Changes in therapy Behavior changes Allergies Nursing intervention results IV and meds Don’t label grumpy, mean

Common Types of Reporting Telephone Transfer reports Incident reports –Not part of the chart –Used when something abnormal happens

Documentation Purposes –Communicate info to health care team –Keep track of interventions and goals Legal guidelines–Table 25-1 pg. 480 –Always use ink –Always sign your name –Never destroy charting or mark through it –Time and date notes –If you did not chart it, it never happened!!!

Methods of Documentation Problem oriented medical record –Places emphasis on problems –Organized by problems –Compiled of Data base Problem list Care plan Progress notes

Modified problem oriented Source records Charting by exception –Eliminates redundancy –Makes it concise –Easy to document normal findings –Critical for nurses to chart abnormal!

Focus charting Case management plan and critical pathways –Incorporates multidisciplinary approach –Broken down into critical pathways

Other Record Keeping Forms Nursing History –Completed when a client is admitted –Complete assessment –Provides baseline data Graphic sheets –Allows doctors and nurses to easily and quickly enter data –Vital signs –Routine care –Have codes to enter data

Standardized care plans –Pre-printed guidelines for patients with similar problems Discharge summary forms –Discharge planning begins on admission –Education on medications –Summarized patient instructions for home

Nursing kardex Computerized documentation –Advantages –Disadvantages