DocumentationDocumentation

Improving Your ChartingImproving Your Charting

The chart remains as the The chart remains as the only evidence of the only evidence of the

nursing care you have nursing care you have given!!!given!!!

If it was not charted it If it was not charted it was not done!!!was not done!!!

But I swear it But I swear it

did it!!did it!!

There are many factors required to There are many factors required to be assessed for each and every be assessed for each and every patient:patient:

• Patient needsPatient needs

• Care necessary to meet those needsCare necessary to meet those needs

• What needs to be done in respect to What needs to be done in respect to continuing care after patient is continuing care after patient is discharged.discharged.

Nursing charting must Nursing charting must contain:contain:• Physical/psychosocial assessment to Physical/psychosocial assessment to

determine the need of care and the determine the need of care and the frequency for additional assessmentsfrequency for additional assessments

• Assessment of patient nutritional Assessment of patient nutritional assessmentassessment

• Assessment of functional abilities/status Assessment of functional abilities/status to determine the need for post-to determine the need for post-discharge planning and rehabilitationdischarge planning and rehabilitation

The charting must reflect:The charting must reflect:

• Age specific and appropriate assessment Age specific and appropriate assessment and interventionsand interventions

• On-going assessment of educational needsOn-going assessment of educational needs

• Involvement of family and/or significant Involvement of family and/or significant others when appropriateothers when appropriate

• Adjustments in the plan of care with Adjustments in the plan of care with changes in condition or diagnosischanges in condition or diagnosis

• Continual assessment of discharge planning Continual assessment of discharge planning needsneeds

All entries should All entries should reflect:reflect:

• The care you have givenThe care you have given

• Adherence to MD orders or plan of careAdherence to MD orders or plan of care

• Care should be consistent with standards Care should be consistent with standards of care (“Best Practice”) of care (“Best Practice”)

i.e. Your charting will be measured i.e. Your charting will be measured against what any other educated and against what any other educated and prudent nurse would have delivered to the prudent nurse would have delivered to the same patient in the same care situationsame patient in the same care situation

Finding Time to ChartFinding Time to Chart

• Flow sheets help minimize the time Flow sheets help minimize the time required to document “routine” carerequired to document “routine” care

however,however,

Charting must also be individualizedCharting must also be individualized

So, how do you find the time to do this??So, how do you find the time to do this??

Multi-task !Multi-task !• While assisting a patient to the BR who needs While assisting a patient to the BR who needs

help getting back to bed….help getting back to bed….

• Combine care delivery with history taking, Combine care delivery with history taking, teaching, assessment. (Bed Bath)teaching, assessment. (Bed Bath)

• While giving medications you can teach your While giving medications you can teach your patient about what they are receiving.patient about what they are receiving.

• What other ideas do you have??What other ideas do you have??

Your Initial AssessmentYour Initial Assessment

Examples:Examples:

Identify pressure ulcers in detail when Identify pressure ulcers in detail when

admitting a patient:admitting a patient:• location, size, depth, drainage location, size, depth, drainage

characteristics, characteristics, integrity of tissue margins. integrity of tissue margins.

• If this is not done, it must be assumed that If this is not done, it must be assumed that the the ulcer developed during the course of ulcer developed during the course of this hospital this hospital visit!!visit!!

Patient at fall risk:Patient at fall risk:

• If a patient was to fall and fracture a hip, If a patient was to fall and fracture a hip, you have no evidence that steps were you have no evidence that steps were taken for the patient’s safety to prevent taken for the patient’s safety to prevent falls falls if you don’t document that youif you don’t document that you::

– Instructed the patient NOT to get up to the Instructed the patient NOT to get up to the bathroom without using the call light (and the bathroom without using the call light (and the call light was at the bedside)call light was at the bedside)

– Ensured that the bed was left in the lowest Ensured that the bed was left in the lowest positionposition

Patient refusing Patient refusing medications:medications:• Document the exact reason why the patient refused Document the exact reason why the patient refused

medication or treatment:medication or treatment:

Example: Mr. Dysphasia states, “I cannot swallow pills” Mr. Dysphasia states, “I cannot swallow pills”

You chart:: “Instructed patient regarding importance “Instructed patient regarding importance of of taking taking potassium replacement, with understanding potassium replacement, with understanding verbalized. verbalized. Call to Dr. Jones to notify of patients Call to Dr. Jones to notify of patients refusal and refusal and request liquid alternative” request liquid alternative”

NOT “Patient refused.”NOT “Patient refused.”

A complete chart contains:A complete chart contains:

• Identification of patient (stamp / sticker)Identification of patient (stamp / sticker)

• Date and time of assessment or Date and time of assessment or interventionintervention

• Assessment of problem, knowledge Assessment of problem, knowledge deficit requiring teaching, patient deficit requiring teaching, patient concern etc.concern etc.– Assessment contains subjective and Assessment contains subjective and

objective informationobjective information

A complete chart contains:A complete chart contains:

• Statement of problem or knowledge deficit Statement of problem or knowledge deficit

• Measurable goals: outcomesMeasurable goals: outcomes

• Implementation measures: interventions Implementation measures: interventions taken to correct the problem or knowledge taken to correct the problem or knowledge deficitdeficit

• Evaluation of patients response to Evaluation of patients response to interventionsinterventions

• Your signature!Your signature!

What about flow sheets??What about flow sheets??

* Excellent for recording repetitive * Excellent for recording repetitive data:data:

Vital signs, I/Os, routine careVital signs, I/Os, routine care

Don’t forget to chart Don’t forget to chart patient’s response to patient’s response to interventions:interventions:

If pain is rated as 8/10, and you If pain is rated as 8/10, and you

give a pain medication, be sure to: give a pain medication, be sure to:

•Document their pain level or Document their pain level or response (i.e. asleep) 30min-1 hour response (i.e. asleep) 30min-1 hour afterwardafterward..

Common reasons for lawsuits Common reasons for lawsuits involving nursing care :involving nursing care :

• Failure to question inappropriate physician’s Failure to question inappropriate physician’s ordersorders

• Failure to adequately monitor a patientFailure to adequately monitor a patient• Failure to protect the patient from an Failure to protect the patient from an

avoidable injuryavoidable injury• Failure to document care that was given in Failure to document care that was given in

an adequate manneran adequate manner• Failure to properly administer medicationsFailure to properly administer medications• Failure to take a complete and appropriate Failure to take a complete and appropriate

nursing historynursing history

Common reasons for lawsuits Common reasons for lawsuits involving nursing care :involving nursing care :

• Failure to follow orders correctly and timelyFailure to follow orders correctly and timely• Failure to perform procedures properlyFailure to perform procedures properly• Failure to protect patient confidentialityFailure to protect patient confidentiality• Failure to assess an emergency situation Failure to assess an emergency situation

properly and initiate appropriate resuscitative properly and initiate appropriate resuscitative measuresmeasures

• Functioning outside the scope of nursing Functioning outside the scope of nursing practicepractice

• Failure to request help when the nurse is Failure to request help when the nurse is unable to meet the needs of a patientunable to meet the needs of a patient

Common reasons for lawsuits Common reasons for lawsuits involving nursing care :involving nursing care :

• Failure to notify the physician of test Failure to notify the physician of test resultsresults

• Failure to follow hospital policy and Failure to follow hospital policy and procedure when restraining patientsprocedure when restraining patients

Why make such a big deal??Why make such a big deal??• Charting is a professional responsibilityCharting is a professional responsibility

• Medical record may be scrutinized by insurance Medical record may be scrutinized by insurance companies or Medicare or Medical and evaluated for companies or Medicare or Medical and evaluated for errorserrors

• Length of stay justificationLength of stay justification

• Quality of care assessment through chart review by Quality of care assessment through chart review by accreditation organizationsaccreditation organizations

• Risk management reviews chart to evaluate safety Risk management reviews chart to evaluate safety concernsconcerns

• To protect hospitals/nurses in the event of a lawsuit.To protect hospitals/nurses in the event of a lawsuit.

What about handwriting??What about handwriting??

•How you write is as important How you write is as important as what you write!as what you write!

Up to 25% of medication errors are Up to 25% of medication errors are related to illegible handwriting!related to illegible handwriting!

•PRINT PRINT PRINTPRINT PRINT PRINT

•SLOW DOWNSLOW DOWN

•NUMBERS NUMBERS MUSTMUST BE BE WRITTEN CLEARLYWRITTEN CLEARLY

2 not 2.02 not 2.0 0.2 not .20.2 not .2

You Should Never…You Should Never…

• Never leave blank spaces for others to “catch Never leave blank spaces for others to “catch up”up”

• Never destroy or change any part of the Never destroy or change any part of the medical record after it has been created.medical record after it has been created.

• Never chart in advance—watch out for flowNever chart in advance—watch out for flow

sheets!sheets!

You Should Never..You Should Never..

• Chart for othersChart for others

• Chart the observations that others have Chart the observations that others have made. made.

Ex. “patient fell on the floor” (Ex. “patient fell on the floor” (NONO))

““patient found on the floor next patient found on the floor next to to bed” (bed” (YESYES))

• Never chart in a way that could be Never chart in a way that could be determined as a negative assault on determined as a negative assault on the patient’s character.the patient’s character.

i.e. “patient was a drunk and i.e. “patient was a drunk and obnoxious jerk”obnoxious jerk”

• Instead chart specific behaviors:Instead chart specific behaviors: i.e. “The patient refuses to have i.e. “The patient refuses to have

x-rays performed, refused x-rays performed, refused assessment, was observed to have assessment, was observed to have

a very a very unsteady gait while unsteady gait while ambulating in the ambulating in the waiting room and waiting room and urinated in the trash urinated in the trash can in the waiting can in the waiting room.”room.”

Dangerous AbbreviationsDangerous Abbreviations

* Know where the list is located* Know where the list is located on your unit and in the on your unit and in the

Org. Wide manual.Org. Wide manual.

DO NOT USE THEM!DO NOT USE THEM!

* There is also a list of Acceptable * There is also a list of Acceptable Abbreviations in the OWM.Abbreviations in the OWM.

Performance ImprovementPerformance Improvement

Regulatory Agencies, Occurrence Regulatory Agencies, Occurrence Reports, Risk ManagementReports, Risk Management

Performance ImprovementPerformance Improvement

• All nursing departments have a planned, All nursing departments have a planned, systematic and ongoing monitoring and systematic and ongoing monitoring and evaluation program to assess the quality of care evaluation program to assess the quality of care delivered to patientsdelivered to patients

• The Performance Improvement Coordinator as The Performance Improvement Coordinator as well as the unit managers, are responsible and well as the unit managers, are responsible and accountable for assuring this process is in place accountable for assuring this process is in place and that consistent standards are used to monitor and that consistent standards are used to monitor and evaluate patient careand evaluate patient care

Performance ImprovementPerformance Improvement

• Performance Improvement data is presented Performance Improvement data is presented to the staff during their staff meetings. to the staff during their staff meetings. – This is an opportunity for all to review the data, This is an opportunity for all to review the data,

analyze the scores, and provide ideas for how analyze the scores, and provide ideas for how improvements can be achieved.improvements can be achieved.

• The findings from the Performance The findings from the Performance Improvement activities are used to formulate Improvement activities are used to formulate continuing education programs for the staff.continuing education programs for the staff.

Regulatory Agency UmbrellaRegulatory Agency Umbrella

CMS

AOA JCAHO

CDPH

CMS CMS • Centers for Medicare & Medicaid SystemsCenters for Medicare & Medicaid Systems

• Reimbursement for Medi-Cal and Reimbursement for Medi-Cal and Medicare patientsMedicare patients

• Reimbursements effected by performanceReimbursements effected by performance

• Improved Performance = Increased Improved Performance = Increased ReimbursementReimbursement

What does CMS do with info What does CMS do with info about our performance?about our performance?

• We are mandated to submit our We are mandated to submit our performanceperformance

• CMS publicly reports our performance CMS publicly reports our performance compared with other hospitalscompared with other hospitals

• CMS pro-rates our reimbursement CMS pro-rates our reimbursement based on our performance and based on our performance and “grades” us on a scale with other “grades” us on a scale with other hospitalshospitals

• Rewards for being in top 10%Rewards for being in top 10%

CDPH EvaluationCDPH Evaluation

• California Department of California Department of Public HealthPublic Health

• For State of California For State of California licensurelicensure

• Investigates complaints and Investigates complaints and deficienciesdeficiencies

• Deficiencies can incur finesDeficiencies can incur fines

OSHA: Occupational Safety & OSHA: Occupational Safety & Health AdministrationHealth Administration

• Federal and StateFederal and State

• Primary concern: YOUPrimary concern: YOU

• Safe work placeSafe work place

How do Regulatory Agencies How do Regulatory Agencies decide on what to focus on?decide on what to focus on?

• Focus on Focus on QUALITYQUALITY

• Focus on Focus on PATIENT SAFETYPATIENT SAFETY

• Focus on Focus on BEST PRACTICEBEST PRACTICE

• Focus on Focus on PATIENT SATISFACTIONPATIENT SATISFACTION

• Input from:Input from:– Institute for Healthcare ImprovementInstitute for Healthcare Improvement– National Quality ForumNational Quality Forum

Why Participate? Why Participate?

• Because QUALITY, BEST PRACTICES & Because QUALITY, BEST PRACTICES & Patient Safety are IMPORTANT!Patient Safety are IMPORTANT!

• And because we are rewarded for good And because we are rewarded for good practicepractice

What do we focus on here?What do we focus on here?

• Best Practices around patients with:Best Practices around patients with:– PneumoniaPneumonia– Heart FailureHeart Failure– AMIAMI– Surgical patientsSurgical patients

• Quality in all the services we provide: Quality in all the services we provide: – from food to diagnostic testsfrom food to diagnostic tests

• Patient SatisfactionPatient Satisfaction• All inpatients and outpatients are surveyedAll inpatients and outpatients are surveyed

What do we focus on What do we focus on here?here?

• Patient SafetyPatient Safety– Culture of SafetyCulture of Safety

•Recognition of unsafe conditions and Recognition of unsafe conditions and environmentsenvironments

•Recognition of situations that could result in Recognition of situations that could result in a problem or undesired outcomea problem or undesired outcome

•Talking about what we can do to make our Talking about what we can do to make our workplace saferworkplace safer

– Communication!Communication!

Core MeasuresCore Measures• What is it?What is it?

– Best Practices identified by CMS as contributors Best Practices identified by CMS as contributors to better outcomes, decreased length of stay to better outcomes, decreased length of stay and decreased occurrence of readmissionand decreased occurrence of readmission

• The diagnoses include:The diagnoses include:– Heart FailureHeart Failure– PneumoniaPneumonia– Acute Myocardial InfarctionAcute Myocardial Infarction– Surgical Care Improvement ProjectSurgical Care Improvement Project

Occurrence ReportOccurrence Report• Used for reporting Used for reporting

unanticipated events unanticipated events such as:such as:– Equipment failuresEquipment failures– Patients leaving AMAPatients leaving AMA– FallsFalls

• If you notice a potential If you notice a potential problem:problem:– Isolate the problem Isolate the problem

(the piece of (the piece of equipment, etc)equipment, etc)

• Report the problem Report the problem to your supervisor or to your supervisor or the department that the department that can fix the problemcan fix the problem

Risk ManagementRisk Management• Uses Occurrence Report informationUses Occurrence Report information

• Patient/Family complaintsPatient/Family complaints– If you hear a family or patient complaining, If you hear a family or patient complaining,

address the complaint if you canaddress the complaint if you can– If you can not address the complaint, report it If you can not address the complaint, report it

to someone who canto someone who can

• ““ABUSE”ABUSE”

• ““HARRASSMENT”HARRASSMENT”– RED FLAGS!RED FLAGS!

Cultural Cultural

AwarenessAwareness

Cultural AwarenessCultural Awareness

• Why learn about cultural awareness?Why learn about cultural awareness?

Cultural AwarenessCultural Awareness

• Help patients receive more effective Help patients receive more effective care.care.

• Improve your job performance and Improve your job performance and your job satisfaction.your job satisfaction.

• Meet expectations of regulatory Meet expectations of regulatory agencies.agencies.

Cultural AwarenessCultural Awareness

• What is Cultural What is Cultural

Awareness?Awareness?

Cultural AwarenessCultural Awareness

• Considering every patient’s culture Considering every patient’s culture when giving care.when giving care.

• Treating every patient, family Treating every patient, family member, visitor and co-worker as an member, visitor and co-worker as an individual.individual.

BACK CAREBACK CARE

BODY MECHANICS and BODY MECHANICS and

LIFTING TECHNIQUESLIFTING TECHNIQUES

A Healthy BackA Healthy Back

• Composed of 24 movable bones Composed of 24 movable bones called vertebraecalled vertebrae

• Disks act like cushionsDisks act like cushions

• Muscles and ligaments Muscles and ligaments

support the backsupport the back

• Injury or disease = PAINInjury or disease = PAIN

A Balanced Back A Balanced Back

• Cervical, Thoracic, and Lumbar Cervical, Thoracic, and Lumbar curves must be alignedcurves must be aligned

• Ears shoulders and hips stackedEars shoulders and hips stacked

• A healthy back is also protected and A healthy back is also protected and supported by well conditioned supported by well conditioned musclesmuscles

Preventive Back CarePreventive Back Care• Always warm upAlways warm up

• Exercise the muscles that support Exercise the muscles that support your backyour back

• Stretch to improve flexibilityStretch to improve flexibility

• Posture is importantPosture is important

TASK ANALYSISTASK ANALYSIS

• Fancy name for “PLANNING AHEAD”Fancy name for “PLANNING AHEAD”

• Break task into stepsBreak task into steps

• Think it throughThink it through

PLANNING AHEAD.....PLANNING AHEAD.....

• Can I do the task by myself in a safe Can I do the task by myself in a safe manner? manner?

• If not, determine the number of If not, determine the number of people it will take.people it will take.

• What equipment or materials are What equipment or materials are needed to do the job?needed to do the job?

Use Your Use Your POWER ZONE!POWER ZONE! • Floor to shoulders, Floor to shoulders,

directly in front of the bodydirectly in front of the body

• The maximum Power Zone is from the The maximum Power Zone is from the knees to the waistknees to the waist

• You have 5-7 times the load capacity when You have 5-7 times the load capacity when using the Power Zoneusing the Power Zone

Keep it “Locked In”Keep it “Locked In”

• Keep your back muscles “Locked In” Keep your back muscles “Locked In” while liftingwhile lifting

• 10x disk pressure when 10x disk pressure when

“ “Bowed Out”Bowed Out”

• Head and shoulders upHead and shoulders up

BACK SAVING TIPSBACK SAVING TIPS

• Always lift with your legsAlways lift with your legs

• Support lower back Support lower back

• ““Nose between the toes!”Nose between the toes!”

• Be aware of trip or slip hazardsBe aware of trip or slip hazards

• Push, don’t pullPush, don’t pull

• ExerciseExercise

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