1. Documentation Guidelines
Greater Baltimore Medical Center

2. General Documentation Information
Most nursing documentation is completed on the computer using Meditech PCS
Agency nurses will be required to take an 8 hour Meditech course taught by GBMC before beginning to work at the hospital
This class will cover order entry, documentation, and barcoding medication delivery / using the electronic medication administration record

3. Patient Care System (PCS)
PCS is the system for documentation that reflects the nursing process, encourages clear and concise charting, is legally sound, and focuses on patient interventions to support patient outcomes
All information entered through PCS can be viewed in the EMR (Enterprise Medical Record)

4. With PCS, you are able to:
Fill out the Admission Database
Record vital signs and I&Os
Document the patient’s Past Medical History
Document your head-to-toe assessment (using System Flowsheets)
Enter nursing notes
Add Care Plans and record outcomes
View and print Kardexes and patient reports
Enter lab, radiology, respiratory, diet, and nursing orders through order entry
Document medication administration through the electronic MAR

5. Shift A shift is defined as 12 hours
Documentation that is required q shift is to be documented once every 12 hours, unless physician orders or unit specific policies dictate otherwise
Change in patient status or change of care provider necessitates a repeat of the q shift documentation (i.e. Patient System Flowsheets)

6. Real Time Documentation
Documentation completed at the time the intervention is performed
In the event that “real-time” documentation is not possible, documentation that occurs within one hour of the intervention is acceptable, except for those interventions with a time interval less than one hour (i.e. q15min)
Any documentation entered into Meditech after the one hour time interval must be retrospectively documented by defining the exact time the intervention was actually completed
Continuous reassessment of the patient is a nursing expectation, with documentation expected as changes occur

7. Standard of Care
Upon admission, each patient will have the appropriate “Standard of Care” (SOC) added to their intervention list in Meditech
The SOC is a predefined set of interventions that are designed for that patient’s population
Once the SOC and all physician orders are entered through Meditech order entry, the intervention list the nurse will document from will be complete and ready to be documented on

8. Plan of Care
The plan of care for the patient includes all computer documentation, entered orders, as well as a defined Care Plan
Every admitted patient must have a care plan added within 24 hours of admission
Care plans all have problems and expected outcomes that are documented against once every 12 hours
Care plans can be updated as needed to reflect new problems or change in patient status

9. Notes Nursing notes are entered on
a patient in the following situations:
Admission
Transfer
Discharge
When an unusual event occurs or with change of patient status
When an appropriate intervention cannot be found to document on

10. Documentation Details
A nurse can skip a question on an assessment if he/she is unable to assess the question due to patient condition or if the question is not applicable for the patient at that time
Any retrospective documentation can be entered up to 3 days following patient discharge

11. Documentation Details
Changes to documentation may only be made by the person who recorded the documentation
Partially documented entries, documentation editing, and undoing documentation can be completed by clicking in the History column for the appropriate intervention

12. Transfer of Patients
Transferring unit will change the status of any appropriate interventions from “Active” to “Complete” by clicking in the Status column
Completed Admissions Documentation
System Flowsheet
Receiving unit stops all nursing orders initiated in order entry, enters transfer orders according to policy and procedure, and the nurse will add on the correct system flowsheet for the patient on the intervention list using the “Add Intervention” Function

13. Order Entry All paper physician order sheets
must be faxed to pharmacy upon
admission
Pharmacy will enter any medications and IVs into Meditech – the list of current medications can be viewed in the EMR by clicking on the Medications tab
All non-medication orders will be entered by the nurse or secretary into the Meditech order entry system

14. Order Entry
It is the RN’s responsibility to verify ALL orders (lab, radiology, nursing, etc.) are entered into Meditech from the Physician Order Sheet (Use Order History in the EMR)
Initial each individual order with red ink after verification that the order is in Meditech
After all orders have been entered and verified, a Kardex will be printed from the Meditech desktop using the Reports button

15. Verification of Physician Orders
For ancillary department orders requiring pager notification (Respiratory Therapy) the time of the page is written on the order sheet next to the order
Co-sign each set of
physician orders with
initials, title, date, and time

16. 24-hour Chart Checks Performed on 11pm – 7am shift
Review ALL orders written during the previous 24 hours and verify they are in Meditech by accessing the EMR (order history section, sorted by date)
Sign entire physician’s order sheet with name/initials, title, date and time in red ink

17. Legal Medical Record
Combination of the Patient’s PCS archived discharge summary and the archived notes, as well as any documentation from the paper chart
The Medical Records Department archives these items 60 days after discharge
The discharge summary and notes are available upon request from the Medical Records Department

18. Admission Documentation
Document all interventions that have a frequency of “On Admission”
Also required to document the following, as appropriate:
System Flowsheet
Fall Risk / Safety Assessment Tool
IV Assessment / Invasive Line Status
Pain Assessment / Reassessment
Skin Risk Assessment
CAM
General Education Record
Nursing Note with Admission Details
Add a Care Plan to patient using
“Process Plan”
Print Out Home Medication Report from Meditech Desktop after entering in list of Patient’s Home Meds during admission

19. Discharge Documentation
The physician writes the discharge instructions
The nurse is responsible for reviewing all instructions with the patient and obtaining the patient signature
Carenotes can be printed out from the Infoweb (click on Micromedix link to access) for patient education
The nurse should make sure the patient understands the complete list of medications the patient is to take once being discharged (compared to any medications the patient was taking on admission), as part of the medication reconciliation process
Original form goes to medical records and a copy is given to the patient upon discharge

20. Blood Administration Documentation
Blood Transfusions are documented as an Intervention Set, which can be added using the “Add Intervention” link on the Intervention worklist (search for “set”)
The set is comprised of:
Blood Administration Verification (completed just prior to starting infusion)
Blood Product Infusion (start time and initial rate)
Infusion Changes (any rate changes during infusion)
Blood Product Completion (completed at end of infusion)
Blood Vital Signs (baseline vitals taken at start, then q15min x 2 after initiation, then hourly)

21. Documentation of Wounds
Wounds are documented as an Intervention Set, which can be added using the “Add Intervention” link on the Intervention worklist (search for “set”)
The set is comprised of:
Wound / Pressure Ulcer Status Assessment: for initial, weekly, and change of status wound documentation (more detailed)
Wound Care / Dressing Change Assessment: for daily documentation of dressing changes (focused assessment specifically for dressing changes)

22. Critical Lab Values Documentation
The lab will call the nurse (as well as the physician) responsible for taking care of the patient with the critical lab value
The telephonic critical result, upon receipt, will be read back to the technologist/technician and documented as having been read back. If that does not happen, the technologist/technician will request that the nurse receiving the critical result read it back.

23. Critical Lab Values Documentation
Procedure
Verify the result by verbally reading the result back to the technologist/technician
Notify the nurse assigned to the patient of the critical result if she/he was not the one to receive the telephonic notification.
Document receiving the phone call about the critical value, the critical result, and what you did about the result on the Critical Lab Values Intervention in Meditech PCS.

24. EMR
The Enterprise Medical Record (EMR) is where all the documentation for your patient is located
To open the EMR from PCS, click on “Open Chart”
Once in the EMR, you can click
on the options on the right side
of the screen to view documentation,
reports, labs, orders, etc.

25. Computer Downtime
In the event of a computer downtime, the documentation system reverts back to paper (all paper forms will be stocked on units)
For downtime less than 4 hours (med/surg) and 2 hours (critical care), information that is recorded on paper will need to be entered into PCS
For downtime exceeding 4 hours (med/surg) and 2 hours (critical care), the paper system will replace PCS until the end of the shift and until the system is back up – the only data that must be re-entered into PCS in this case are the Vital Signs and the I&O, so the EMR record will be accurate

26. Unscheduled Downtime
A 24-hour report, by unit, will be available upon request from the MIS Helpdesk, x The unit is responsible for picking up this report from the MIS department, building 9, 5th floor. The report includes the following documentation:
Vital Signs
Intake and Output
System Flowsheet
Pain Assessment
PCA: IV and Epidural

27. Scheduled Downtime
The unit is responsible for printing the following reports one hour prior to the downtime:
Nursing Downtime Flowsheet
Click on Reports button from desktop
Click on Patient Reports
Select Flowsheet Report
In Format box, Press F9 and select Nursing DT Flowsheet
Fill in Patient Last name and press F9 in Patient section
Select correct patient and click on green check mark to print
Patient Kardex
Select Profile Report
In Use Profile Format box, press F9 and select Pt Kardex – Treatment record and click on green check mark to print

28. Meditech Help Can be found on the nursing page of the Infoweb
Scroll down on the nursing page and click on Meditech Help Link

29. What stays on paper? Consent forms Admission / Transfer Summaries
OR/Recovery Documentation
Physician Order Sheets
Documentation During Patient Codes
Pre-op Checklist
Discharge Instructions
Labor Event – Triage up until Delivery
Monitoring Strips

30. Paper Documentation Guidelines
When your signature is required on any form, legibly sign your full name and status (i.e RN)
Before using your initials on any paper form, be sure to sign the Signature/Initial record in front of the medical record
Use black or blue ink pen for all entries, except when signing off medications – which should be done using red ink
If part of the paper medical record is damaged in any way (spills, tears), do not destroy the form – simply cross-reference to a newly initiated form

31. Documenting a Telephone Order from a Physician
Indicate date/time order was received
Document order as stated by physician
Read the written order back to the physician to verify accuracy
Document under the order RBO (read back order) and the recorder’s initials
Sign order: v.o. Dr. Jones / Kay Smith RN
Place a “sign here” sticker next to order
Flag the record green for a regular order and red for a STAT order for the secretary

32. Time-Out VISA
To be completed on ALL surgical and invasive procedures for which consents are required. This includes bedside procedures such as central lines, chest tubes, thoracentesis, etc.
3 Sections: Patient Verification, Site Marking, and Time Out for Procedure or Operating Room

34. Section 1: Patient Verification
Two identifiers: patient name and date of birth
Compare to ID band, consents, diagnostic images, and all other patient documentation related to the procedure
All areas on the VISA under section 1 are to be initialed

35. Section 2: Site Marking
Completed whenever laterality may become an issue
Performed by physician or person performing the invasive procedure
Exceptions
If not multiple digits/structures
Procedure occurs through an orifice (dental, colonoscopy, etc)
NICU babies
Green bracelet used on operative side
when patient refuses site marking
All areas to be initialed
if appropriate
Exceptions – if not multiple digits/structures, go through orifice (colonoscopy, dental), NICU babies
-This is only section potentially left undone – when patient refuses to site marking, put green band on operative side.

36. Section 3: Time-Out
Completed just prior to the beginning of the procedure
Includes the patient
All members present for the Time-Out must be identified
All areas to be initialed and form signed
References: Verification of Correct Site, Correct Procedure, Correct Patient and “Time-Out” for Invasive or Surgical Procedure; and Guidelines for Completing Procedure Visa