1. Documentation
Documentation and communication are vital components of nursing. In order for other disciplines to know what is going on with the patient from all aspects, is thru documentation. The three components that are essential to nursing communication are documenting, reporting and conferring.

2. What Is It? Written record of everything done for a patient
Medications
Treatments
Activities
Education
supplies
It is the written, legal record of all pertinent interactions with the pt. The nursing process which involves assessing, diagnosing, planning, implementing, and evaluating are part of the documentation. The nurse pt interaction is recorded in the chart. If it is not charted, documented, written down, etc. It did not happen.
Where do we document? Patient record Patient chart Computer Paper chart (flow sheet)

3. Documentation Accreditation Reimbursement Legal Communication
To prove meeting prescribed standards
Reimbursement
To show what was used
Legal
Shows condition of patient before, during and after treatment
Communication
Within the health team
Documentation should be consistent with professional and agency standards; complete, accurate, concise, factual, organized, and timely; legally prudent; and confidential.

4. Documentation Guidelines
Content
Timing
Format
Accountability
Confidentiality
Content
Complete, accurate, concsie, and factual manner
record pt findings (observation) not your interpretation
avoid words such as good, average, normal or sufficient – they have different meaning
Pain scale instead of comfortable
note problems in an orderly sequential manner, etc. Pt problem, your interaction, pt response
also document your response to questionable medical order or tx or failure to tx.
Do not use stereotypes or derogatory terms when charting
Timing
in a timely manner
different agency policy regarding freq – follow specific area policy and if pt status warrants chart more freq
Each entry must have date and time of observation and or intervention
document at time of care
NEVER DOCUMENT AN INTERVENTION PRIOR TO DOING IT!
Format
each agency has specific form or format to document
black ink, correct grammar and spelling, standard terminology and only accepted terms and abbreviations
never skip lines. Draw a single line through blank spaces.
Accountability
sign your first initial, last name, and title to each entry
do not use dittos, erasures or correcting fluids (white out)
A single line should be drawn thru an incorrect entry and words “mistaken entry” or “error in charting” should be printed above or beside the entry and signed. Then rewrite the entry correctly.
each page of record with pt name and number
Confidentiality
You are bound professionally and ethically to keep in strict confidence all the info you learn by reading pt chart or taking care of a pt.
do not use actual pt names or other identifiers when using them in your work.

5. Privacy and Confidentiality
All information regarding patient.
HIPAA
Health Insurance Portability and Accountability Act
Permitted disclosure of PHI
Incidental Disclosure of PHI
Students and nurses often make the mistake of discussing pt’s on the elevator, at lunch, etc. Even if you do not mention the name, certain characteristics can ID the pt.
Professional codes of ethics, agency policies, and state and federal privacy legislation dictate how pt information can be communicated (verbally and in writing), where and how it can be stored, the appropriate persons and entities to whom it may be divulged, and the purposes for which it may be divulged.
HIPAA How many of you have signed a HIPAA form at your dr ofc?
Congress passes HIPAA in 1996, final regulations in 2000, bush administration modified and released in 2002.
Patients have a right to:
See and copy their helath record
Update their health record
Get a list of the disclosures a healthcare institution has made independent of disclosures made for the purposes of tx, payment, and healthcare operations
Request a restriction on certain uses or disclosures
Choose how to receive health information.
Vilation of HIPAA for financial gain can be fined as much as 250 thousand dollars or jail for 10 yrs. Even if it is an accident.
Permitted Disclosure of PHI
Three exceptions where authorization is not required prior to releasing pt information:
Public health activities – disease outbreak, infection control, problems with drugs or med equip
Law enforcement and judicial proceeding – investigation and prosecution of a crime, id victims of crime or disaster, reporting child abuse, neglect, or domestic violence, valid subpoena
Deceased individuals – coroners, medical examiners, funeral directors, facilitate organ donations, law enforcement (death from a potential crime)
Incidental Disclosure of PHI
secondary disclosure that cannot reasonably be prevented, is limited in nature, and occurs as a byproduct of an otherwise permitted use or disclosure of PHI
Sign in sheets
Confidential conversation being overheard
Pt charts outside exam room – as long as public traffic is not in are and face sheets are turned towards the wall
Use of white boards
X-ray light boards
Calling out names in waiting room
Leaving appointment – reminder voic messages – minimum amount of information is disclosed.

6. Purpose Communication Diagnostic and Therapeutic Orders Care planning
Quality-of-care reviewing
Research
Decision analysis
Education
Legal documentation
Reimbursement
Historical documentation
Communication – primary purpose – helps other diciplines who interact with pt at different times to communicate with one another.
Diagnostic and Therapeutic Orders – nurses are responsible for insuring that orders are entered and implemented. Orders should be written and signed except in emergencies – verbal orders, telephone, or fax
Care planning – pts baseline and ongoing data to determine if pt responding to tx plan from day to day. Modification of the plan of care are based on this data.
Quality-of-care reviewing – Nursing audit – randomly selected to evaluate the quality of care being rendered. If deficiences are found, in service training . JCAHO – accrediting agencies reviews in order to determine if facility is meeting its standards.
Research -
Decision analysis – identify needs and the means and strategies to meet the needs (Under used or overused service, etc.
Education – You as students can learn a lot from the patients chart.
Legal documentation – Can and will be used as evidence in court proceedings, play a crucial role in implicating or absolving health practitioners charged with improper care. The record can also be used in accident or injury claims made by the patient.
Reimbursement – use to demonstrate that pt received the care for which reimbursement is being sought.
Historical documentation – Each time a patient is hospitalized, old charts may be obtained to give information regarding the patient’s past healthcare.

7. Verbal Orders Usually in a medical emergency situation
RN responsibility:
Record in medical record
Read back to verify
Date and time
Record V. O., name of physician, nurse name and time
Physician or nurse practitioner responsibility:
Review order for correctness
Sign with their name, title, and pager number
Unit secretary responsibility:
Ensure orders are transcribed

8. Telephone and Fax Orders
Repeat back
Transcribe to an order sheet
Date and time
Sign order with name and title
(01/10/ Lasix 40 mg po now T. O. John Smith, MD/Nancy Nurse, RN)
Cosigned by physician within a set time
If order is questionable – have another nurse listen to order
Fax orders must be legible and issued from a credentialed and privileged individual

9. Signatures First initial Full last name Title (CCNS) N. Nurse, CCNS
Initials
N. Nurse, CCNS NN

10. Legalities NEVER: ALWAYS Erase use white-out scratch or scribble out
Omit critical commentary
Completely record FACTS
Record clarification efforts
Write legibly, use black ink
Correct errors promptly

11. IMPORTANT
If it isn’t written, it wasn’t done

12. Malpractice Issues Incorrect time of when events occurred
Not recording verbal orders
Not getting verbal orders signed
Charting actions in advance
Documenting incorrect data

13. Methods of Documentation
Source-Oriented
Problem-Oriented
SOAP
Subjective, objective, assess, plan
PIE
Problem, intervention, evaluation
Focus Charting
DAR
Data, actions, responses
Facility designates which format of documentation
Source Oriented – each discipline keeps data on its own separate form. Sections of chart are separated and designated for each discipline. Notations are entered chronologically with most recent on top. Table 17-3 on page 345 have examples of forms and information on these types.
Admission sheet – what’s included
Admission nursing assessment
Problem-Oriented
All healthcare professionals record info on the same forms
PIE – unique in that it does not develop a separate plan of care. Plan of care are in progress notes and are identified by number
Focus charting – focusing on care of pt and pt concerns. May be pt strength, problem, or need

14. Methods of Documentation
Case Management Model
Collaborative Pathways
Variance Charting
Computerized Records
Case management model – focus on quality, cost effective care within a certain time frame. Promotes collaboration, communication, and teamwork, makes efficient use of time and increases quality by focusing care on carefully developed outcomes. Limitation – “typical” pt
Collaborative pathways – critical pathway or care map. In this pathway the pt has certain things that must be done and should be achieve by certain days. Example page 352 Fiqure 17-6 Pre op day, day of operation, PACU, POD, etc
Variance Charting = unexpected event, the cause of the event, actions taken in response to the event, and discharge planning
Computerized Records Safe Computer Charting = Box Never give password, don’t leave computer without logging off. Follow protocol for correcting errors, make sure others can’t see, never use to send protected health info

15. Format for Nursing Documentation
Initial Nursing Assessment
Kardex and Patient care Summary
Plan of Nursing Care
Critical/Collaborative Pathways
Progress Notes
Flow Sheet
Discharge and Transfer Summary
Home Healthcare Documentation
Long-Term Care Documentation
Initial Nursing Assessment provides baseline
Kardex plan of nursing care for pt, kept at nursing station, contains info such as admitting dx, orders concerning activity levels, diet, v/s, dx tests, medications, and other tx and procedures
Plan of Nursing Care – Care Plan – Nsg dx, goal and expected outcome, nursing intervention, data. Most facilities have standardized care plans.
Progress Notes = purpose is to inform caregivers of the progress a pt is making toward achieving expected outcomes.
Flow sheets –
eg. v/s or graphic sheet – records bp, p, rr, temp, wt, fluid intake and output, bowel movements, etc
24 hours fluid balance – records 24 I&O for pt
Medication record – all meds ordered and administered to patient. Drug, dose, route, time, the nurse adm drug, reason and effectiveness for some such as analgeics.
24 hour pt care records and acuity charting forms – designed for quick documentation and are also used to help rank pt acuity.
Discharge and Transfer Summary – when pt is dc to another facility, a clinical report should be written and/or verbally given that summarizes the reason for admission, tx, significant findings, procedures performed, pt condition on dc, and other pertinent instructions. Make sure when receiving or sending info, you get the name and title of the individual that you give or have taken report from.
Home Health – each visit documented and physicians and third party payers obtain copies to ensure continuity of care and determine whether pt meets requirements.
Medicare requirements:
1)pt homebound and still needs skilled nursing care
2)rehab potential is good (or pt is dying)
3)pt status is not stabilized
4)The pt making progress in expected outcomes of care
OASIS – Outcome and Assessment Information Set is a group of data elements that:
represent core items of a comprehensive assessment for an adult home care pt
form the basis for measuring pt outcomes for outcome based quality improvement (OBQI)
Key component for Medicare
Long term care documentation
RAI – resident assessment instrument – helps id resident’s strengths and needs – goal is for resident to achieve highest level of functioning

16. Potential Legal Problems in Documentation
Documentation Content:
not in accordance with standards
Does not reflect patient needs
Does not include description(s) of situations that are out of the ordinary
Incomplete or incosistent
Does not include appropriate medical orders
Implies a potential or actual risk situation
Implies attitudinal bias

17. Potential Legal Problems in Documentation
Documentation Mechanics:
Lines between entries
Countersigning documentation
Tampering
Different handwriting or obliterations
Illegibility
Sloppiness (sloppy care from sloppy charting)
Dates and times of entries omitted or inconsistent
Improper nurse signature or unidentifiable initials
Transcription errors

18. Reporting Care Change-of-Shift Reports Telephone/Telemedicine Reports
Transfer and Discharge Reports
Reports to Family Members and Significant Others
Incident Reports
To report is to give an account of something that has been seen, heard, done, or considered. Reporting is the oral, written, or computer-based communication of patient data to others. Example Lab report, shift report, etc. There are different type and methods for reporting: See table 17-6 page 363 all have advantages and disadvantages. Usually practice dictates which type that facility believes is most efficient.
Face to face
Telephone
Writtten
Audiotaped
Computer
Incident report – variance or occurrence report – used to document anything out of the ordinary that results in or has the potential to result in harm to a pt, employee, or visitor. Used for quality improvement and not disciplinary action. Use to id risk

19. Conferring About Care Consultations and referrals
Nursing and Interdisciplinary Team Care Conferences
Nursing Care Rounds
Confer – to consult with someone to exchange ideas or to seek info, advice, or instructions. During nursing school you will confer with fellow students and instructors.
Consultation and Referrals – inviting another professional to eval the pt and make recommendations to you about his or tx consultation Referral is the process of sending or guiding the pt to another source for assistance.
Nsg and Interdisciplinary Team Care Conferences – Group to plan and coordinate pt care. We will use pre and post conferences to discuss pt care pt condition, etc
Nsg Care Rounds group of nurses visit selected pt individually at each pt bedside. This helps gather info the help plan nsg care, to eval nsg care and to provide pt with an opporutnity to discuss care. Be mindful of terminology being used in front of pt.

20. Discharge Planning Begins at time of admission
Must educate the patient
Throughout hospital stay
Diet, meds, treatments, rehab, community resources
Continuity between health teams