1. Documentation and Informatics in Nursing
Entry Into Professional Nursing
NRS 101

2. Why Document? Accreditation (TJC) Reimbursement (DRG’s, Medicare)
Communication (Continuity, education)
Legal (Not documented, not done)

3. Multi-Disciplinary Communication
Reports-Oral: End of shift
Written
Record-Chart: Permanent, legal, healthcare management on-going account
Healthteam: All disciplines, nursing, social workers, discharge planning PT, OT, RT

4. Documentation
Anything written or printed that is relied on as a record of proof for authorized persons
Reflects quality of care
Provides evidence of healthcare team members care rendered

5. Purposes of Records Communication Legal Documentation
Financial Billing
Education
Research
Audits-Monitoring

6. Guidelines for Quality Documentation & Reporting
Factual
Accurate
Complete
Current
Organized

7. Follow TJC Standards Physical Psychosocial Environmental Self-care
Client education
Discharge Planning
Evaluation of outcomes
Nursing Process oriented

8. Types of Documentation
Narrative
POMR
Source records
Charting by Exception
Critical Pathways
Record Keeping Forms
Acuity Recording Systems
Standardized Care Plans
Discharge Summary Forms

9. Types of Documentation
Discharge Summary Forms
Home Health
Long Term care
Computerized

10. Narrative Traditional type of nursing charting Story-like, repetitive
Time consuming

11. Problem-Oriented Medical Records
Data organized by problem or diagnosis
Ideally all healthcare team members can contribute to list
Coordinated plan of care
POMR Components: Database, problem list, NCP, progress notes

12. POMR Database History and physical Nursing admission assessment
On-going assessment
Labs
Radiology reports
Record of each hospital visit

13. POMR Problem List Holistic needs based on data
Chronological list on front of chart
Dates when problem resolved or new problem occurs

14. POMR Progress Notes
SOAP/SOAPIE Notes: Subjective data, objective data, assessment, plan, intervention, evaluation
PIE Charting: Problem-Intervention-Evaluation
Focus Charting/DAR-Data (subjective and objective) Action (intervention) Response of Client (evaluation)

15. Source Records
Chart is so organized that each discipline has own section to record data
Sections can be easily located
Disadvantage: Not organized by client problems
Narrative style notes

16. Charting by Exception Streamlines documentation
Reduces repetition, saves time
Short version to document normals, routine care items
Based on established standards
Progress note when standard not met
Assumes all standards are met unless otherwise charted
Exceptions must be noted

17. Critical Pathways
Multi-disciplinary care plans used in case management
Key interventions, expected outcomes, time frame
Variances charted and analyzed

18. Record Keeping Forms Admission Assessment/Nursing history
Graphic Sheets (Vitals, weights, I&O)
Nursing Kardex
Medication Administration Records

19. Acuity Reporting Systems
Staffing patterns based on acuity of patients
Numeric rating for interventions
Varies per unit and standard
Update every 24 hours and justify

20. Standardized Care Plans
Pre-printed established guidelines
Based on health problems
Need to modify based on individual assessment, update and use judgement
Standards of care are known, promotes continuity, staff knowledge

21. Discharge Summary Forms
DRG’s encourage early discharge, but must ensure good patient outcomes
Necessary resources, Client and family involved in process
Begins at admission
Client education integral to process (food-drug interactions, rehab referrals, medications, disease process)

22. Home Health Medicare/Medicaid Guidelines
50% of nursing time is documentation
Care witnessed by client and family
Good assessment skills
Health care team focused
Direct care in home
Use of laptops for documentation

23. Long Term Care Residents not clients
Governmental agencies: Many standards and policies regarding assessments, individualized plan of care
Dept. of Health in each state determines frequency of charting
Skilled Nursing Units

24. Nursing Informatics Computer based patient care record
Assessments, care plans, MAR’s physician orders
Maintain confidentiality with pass codes, looking at other records
Nursing Information Systems
Clinical Information Systems
Electronic Medical Record

27. Reporting Oral or written Change of shift Nurse to nurse
Promotes continuity
Report on client health status, care required for next shift, significant facts, head to toe assessment, pertinent labs, priority needs, treatments, family issues

28. SBAR Technique for Communication
S- Situation
B- Background
A- Assessment
R- Recommendation

29. End of Shift Report Keep professional Avoid judgemental language
Include assistive personnel

30. Telephone Reports Inform physician of changes
Client transfers to different units
Result reports from lab or radiology
Client transfers to different institutions
Info needed: When call made, to whom, info given
Keep clear, accurate, repeat info if necessary

31. Telephone Orders Physician to RN
Physician must co-sign within 24 hours
Nightime, emergency orders
Guidelines and procedure per institution
Be careful, precise and accurate with order
Write order as said by physician, repeat it back

32. Transfer Reports Unit to unit report Phone or in person
All pertinent data about patient
Send all belongings with client
Review clothing/belonging list prior to transfer
Transfer Sheet Documentation

33. Incident Reports
Any event not considered routine (falls, needlesticks, med errors, accidental omissions, visitor injury)
Risk Management will analyze trends
Changes in policy/procedure, educational programs may be related to findings
Notify supervisor, physician of incident
Nurse who witnesses makes out report
Do not assign blame, be objective, facts only

34. Tips for Documentation
Accurate, timely, thorough, factual, neat
Use only approved abbreviations & terms
Blue or black ink
Always get and give report
Focus on a team approach
Date, time each entry, do not block chart
Document in a timely fashion
Follow the nursing process
Use appropriate forms

35. Documentation Tips Correct errors promptly, using proper technique
Write on every line, leave no spaces
Sign each entry with full signature and correct title
Follow institution policy and procedure for charting
Military vs standard time