Documentation

DocumentationPatient Medical RecordPurposesLegal Document

Communication and Care Planning

Quality AssuranceFinancial reimbursement

Education

ResearchComponents of the Medical RecordNursing admission assessmentH & P by the primary and consulting MDsMD ordersPlan of careFlow sheetsvital signs, I & Os, routine assessmentsFocused assessmentsMedication administration record/eMARLaboratory and diagnostic recordProgress notesConsultationsDischarge and transfer summariesPrinciples of DocumentationConfidential

Accurate and complete

organizedTimely

Concise

Clinical SignificanceClear documentation that reflects time sequencing is especially important for patients with unstable conditions. If litigation occurs, lawyers use documentation to reconstruct the sequence of events, the time of interventions, and the time that providers were notified. In a code or emergency, the team should designate a single member to document so that entries are accurate and timelyBecause assessment requires much critical thinking and clinical judgment and is a professional responsibility, nurses cannot delegate it to an unlicensed personnel.Documentation FormatsNarrative

SOAP (IE)

PIE

Focus

Charting by exceptionNarrativeFormat: information written in phases, usually time sequencedAdvantages: easy to learn, easy to adjust length, can explain in detailDisadvantages: time consuming, difficult to retrieve information, may include irrelevant information, possibly unfocused and disorganizedNarrative11/10/10, 1500; Pt c/o of 8/10 in rt hand; states he is using his PCA, but it doesnt help. Notified MD of pain level at 1430. Pain is throbbing from fingers to elbow. Pain increases with movement. Fingers to left hand pink and warm with brisk cap. refill. Left radial pulse +2. Rt hand cool to touch with delayed cap. refill of >6 seconds. Waiting for MD to arrive and assess. J.Steele, RNSOAP (IE)Ssubjective dataOobjective dataAanalysisPplanIinterventionE--evaluationSOAP (IE)Advantages: all charting focuses on identified or new problems, interdisciplinary, easy to track progress or identify problems, similar to steps in nursing processDisadvantages: lengthy and time consuming, repeats assessment data on flow sheetsSOAP (IE)Sstates pain 8/10 from elbow to fingertipsOCap refill > 6 secs, cool to touchAreduced tissue perfusion to rt hand r/t injury and inadequate pain controlPcontact Dr. Smith to eval patient. Waiting for MD arrivalIMorphine 4 mg IVPEevaluate pain med effectiveness in 30 minutesPIEP: problem

I: intervention

E: evaluationPIEAdvantages: incorporates POC, includes outcomes which increase quality assurance, less redundancy, easily adapted to computer chartingDisadvantages: may need to read progress note to determine POC if not on separate document, not multidisciplinaryPIEPinadequate tissue perfusion IDr. Smith contacted at 1430 to report pain and assessment findings. MD evaluated patient. Pain orders receivedEDr. Smith reports no change in circulation since admission. Continue hourly neurovascular checks, evaluate pain q30mins. J. Steele, RNCharting by ExceptionFormat: standards metsign or check off, standards not metwrite narrative or SOAP noteAdvantages: efficient, no duplicate charting b/c assessments are on flow sheets, clearly outlines abnormal findings.Disadvantages: expensive to develop and educate staff, not prevention focused, may pose legal problems b/c details are often missing HandoffOccurs when care for a patient is transferred from one health provider to another. Receiving staff must have up-to-date assessment data Common situations:Shift changeMeal breaksTransfer to a different unit or level of careStrategies for Effective handoffUse a standardize formatSBARCommunicate face to face with current and historical dataEnsure limited interruptionsUse read-back policiesUse written documentation to supplement handoffSBARSsituation, state concisely why you are communicatingBbackground, describe circumstances that lead up to the situationAassessment, give objective/subjective data pertinent to situationRrecommendation, make suggestions for what needs to be done to manage the patient