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8/17/2019 Documentation SLP
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Documentation Guidelines
Greater Baltimore Medical Center
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General Documentation
Information• Most nursing documentation is completed on thecomputer using Meditech PCS
• Agency nurses will be reuired to ta!e an " hour
Meditech course taught by GBMC before
beginning to wor! at the hospital
• #his class will co$er order entry% documentation%
and barcoding medication deli$ery & using theelectronic medication administration record
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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 inter$entions to support
patient outcomes
) All information entered through PCS can be
$iewed in the *M+ '*nterprise Medical+ecord(
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,ith PCS% you are able to-
• .ill out the Admission Database
• +ecord $ital signs and I/0s
• Document the patient1s Past Medical 2istory
• Document your head3to3toe assessment 'using System.lowsheets(
• *nter nursing notes
• Add Care Plans and record outcomes
• 4iew and print 5arde6es and patient reports
• *nter lab% radiology% respiratory% diet% and nursing orders throughorder entry
• Document medication administration through the electronic MA+
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Shift
) A shift is defined as 78 hours
) Documentation that is reuired shift is to bedocumented once e$ery 78 hours% unless physician orders or unit specific policies dictateotherwise
) Change in patient status or change of care pro$ider necessitates a repeat of the shiftdocumentation 'i9e9 Patient System .lowsheets(
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+eal #ime Documentation
• Documentation completed at the time the inter$ention is performed
• In the e$ent that :real3time; documentation is not possible%documentation that occurs within one hour of the
inter$ention is acceptable% e6cept for those inter$entionswith a time inter$al less than one hour 'i9e9 7
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Standard of Care
• =pon admission% each patient will ha$e the
appropriate :Standard of Care; 'S0C( added to
their inter$ention list in Meditech
• #he S0C is a predefined set of inter$entions that
are designed for that patient1s population
• 0nce the S0C and all physician orders are
entered through Meditech order entry% theinter$ention list the nurse will document from
will be complete and ready to be documented on
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Plan of Care
• #he plan of care for the patient includes allcomputer documentation% entered orders% as wellas a defined Care Plan
• *$ery admitted patient must ha$e a care plan addedwithin 8> hours of admission
• Care plans all ha$e problems and e6pectedoutcomes that are documented against once e$ery
78 hours• Care plans can be updated as needed to reflect new
problems or change in patient status
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?otes
• ?ursing notes are entered on
a patient in the following situations-
) Admission
) #ransfer
) Discharge
) ,hen an unusual e$ent occurs or with change of
patient status
) ,hen an appropriate inter$ention cannot be found to
document on
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Documentation Details
• A nurse can s!ip a uestion on an
assessment if he&she is unable to assess the
uestion due to patient condition or if theuestion is not applicable for the patient at
that time
• Any retrospecti$e documentation can be
entered up to @ days following patient
discharge
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Documentation Details
• Changes to documentation may only be
made by the person who recorded the
documentation• Partially documented entries%
documentation editing% and undoing
documentation can be completed by
clic!ing in the 2istory column for the
appropriate inter$ention
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#ransfer of Patients
• #ransferring unit will change the status of anyappropriate inter$entions from :Acti$e; to:Complete; by clic!ing in the Status column
) Completed Admissions Documentation ) System .lowsheet
• +ecei$ing unit stops all nursing orders initiated inorder entry% enters transfer orders according to policyand procedure% and the nurse will add on the correctsystem flowsheet for the patient on the inter$entionlist using the :Add Inter$ention; .unction
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0rder *ntry
• All paper physician order sheets
must be fa6ed to pharmacy upon
admission
• Pharmacy will enter any medications and I4s intoMeditech ) the list of current medications can be$iewed in the *M+ by clic!ing on the Medicationstab
• All non3medication orders will be entered by thenurse or secretary into the Meditech order entrysystem
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0rder *ntry
• It is the +?1s responsibility to $erify A orders
'lab% radiology% nursing% etc9( are entered into
Meditech from the Physician 0rder Sheet '=se
0rder 2istory in the *M+(
• Initial each individual order with red in! after
$erification that the order is in Meditech
• After all orders ha$e been entered and $erified% a5arde6 will be printed from the Meditech des!top
using the +eports button
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4erification of Physician 0rders
• .or ancillary department orders reuiring
pager notification '+espiratory #herapy(
the time of the page is written on the ordersheet ne6t to the order
• Co3sign each set of
physician orders withinitials% title% date% and time
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8>3hour Chart Chec!s
• Performed on 77pm ) am shift
• +e$iew A orders written during the
pre$ious 8> hours and $erify they are inMeditech by accessing the *M+ 'orderhistory section% sorted by date(
• Sign entire physician1s order sheet with
name&initials% title% date and time in red in!
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egal Medical +ecord
) Combination of the Patient1s PCS archi$eddischarge summary and the archi$ed notes% as
well as any documentation from the paper chart ) #he Medical +ecords Department archi$es
these items days after discharge
) #he discharge summary and notes are a$ailable
upon reuest from the Medical +ecordsDepartment
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Admission Documentation
• Document all inter$entions that ha$e a freuency of :0n Admission;
• Also reuired to document the following% as appropriate-
) System .lowsheet
) .all +is! & Safety Assessment #ool
) I4 Assessment & In$asi$e ine Status
) Pain Assessment & +eassessment
) S!in +is! Assessment
) CAM
) General *ducation +ecord
• ?ursing ?ote with Admission Details
• Add a Care Plan to patient using :Process Plan;
• Print 0ut 2ome Medication +eport from Meditech Des!top after entering in listof Patient1s 2ome Meds during admission
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Discharge Documentation
• #he physician writes the discharge instructions
• #he nurse is responsible for re$iewing all instructionswith the patient and obtaining the patient signature
• Carenotes can be printed out from the Infoweb 'clic! onMicromedi6 lin! to access( for patient education
• #he nurse should ma!e sure the patient understands thecomplete list of medications the patient is to ta!e once
being discharged 'compared to any medications the
patient was ta!ing on admission(% as part of themedication reconciliation process
• 0riginal form goes to medical records and a copy is gi$ento the patient upon discharge
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Blood Administration
Documentation• Blood #ransfusions are documented as an Inter$ention
Set% which can be added using the :Add Inter$ention;
lin! on the Inter$ention wor!list 'search for :set;(
• #he set is comprised of- ) Blood Administration 4erification 'completed Eust 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 4ital Signs 'baseline $itals ta!en at start% then 7
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Documentation of ,ounds
• ,ounds are documented as an Inter$ention Set%which can be added using the :Add Inter$ention;
lin! on the Inter$ention wor!list 'search for :set;(• #he set is comprised of-
) ,ound & Pressure =lcer Status Assessment- for initial%wee!ly% and change of status wound documentation
'more detailed( ) ,ound Care & Dressing Change Assessment- for daily
documentation of dressing changes 'focusedassessment specifically for dressing changes(
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Critical ab 4alues
Documentation• #he lab will call the nurse 'as well as the physician( responsible for ta!ing care of the
patient with the critical lab $alue
• #he telephonic critical result% upon receipt% will
be read bac! to the technologist&technician and
documented as ha$ing been read bac!9 If that
does not happen% the technologist&technician willreuest that the nurse recei$ing the critical result
read it bac!9
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Critical ab 4alues
DocumentationProcedure
79 4erify the result by $erbally reading the result bac! to the technologist&technician
89 ?otify the nurse assigned to the patient of thecritical result if she&he was not the one to recei$ethe telephonic notification9
@9 Document recei$ing the phone call about the
critical $alue% the critical result% and what you didabout the result on the Critical ab 4aluesInter$ention in Meditech PCS9
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*M+
• #he *nterprise Medical +ecord '*M+( is where
all the documentation for your patient is located
• #o open the *M+ from PCS% clic! on :0pen
Chart;
• 0nce in the *M+% you can clic!
on the options on the right side
of the screen to $iew documentation%
reports% labs% orders% etc9
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Computer Downtime
• In the e$ent of a computer downtime% the documentationsystem re$erts bac! to paper 'all paper forms will bestoc!ed on units(
• .or downtime less than > hours 'med&surg( and 8 hours
'critical care(% information that is recorded on paper willneed to be entered into PCS
• .or downtime e6ceeding > hours 'med&surg( and 8 hours'critical care(% the paper system will replace PCS until theend of the shift and until the system is bac! up ) the onlydata that must be re3entered into PCS in this case are the4ital Signs and the I/0% so the *M+ record will beaccurate
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=nscheduled Downtime
• A 24-hour report, by unit, will be availableupon request from the MIS Helpdes,!"#2$% &he unit is responsible for pi'in(up this report from the MIS department,buildin( ), $th *oor% &he report in'ludes thefollowin( do'umentation+ ) 4ital Signs
) Inta!e and 0utput
) System .lowsheet ) Pain Assessment
) PCA- I4 and *pidural
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Scheduled Downtime
• &he unit is responsible for printin( the followin( reports onehour prior to the downtime+
ursin( .owntime /lowsheet • 0li' on 1eports button from destop
• 0li' on atient 1eports
• Sele't /lowsheet 1eport• In /ormat bo!, ress /) and sele't ursin( .& /lowsheet
• /ill in atient 3ast name and press /) in atient se'tion
• Sele't 'orre't patient and 'li' on (reen 'he' mar to print
atient arde!• 0li' on 1eports button from destop
•0li' on atient 1eports• Sele't ro5le 1eport
• /ill in atient 3ast name and press /) in atient se'tion
• In 6se ro5le /ormat bo!, press /) and sele't t arde! &reatmentre'ord and 'li' on (reen 'he' mar to print
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Meditech 2elp
• Can be found on the nursing page of the
Infoweb
Scroll down on the
nursing page and clic!
on Meditech 2elp
in!
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,hat stays on paperF
• Consent forms
• Admission & #ransfer Summaries
• 0+&+eco$ery Documentation
• Physician 0rder Sheets• Documentation During Patient Codes
• Pre3op Chec!list
• Discharge Instructions
• abor *$ent ) #riage up until Deli$ery• Monitoring Strips
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Paper Documentation Guidelines
• ,hen your signature is reuired on any form% legiblysign your full name and status 'i9e +?(
• Before using your initials on any paper form% be sure to
sign the Signature&Initial record in front of the medicalrecord
• =se blac! or blue in! pen for all entries% e6cept whensigning off medications ) which should be done usingred in!
• If part of the paper medical record is damaged in anyway 'spills% tears(% do not destroy the form ) simplycross3reference to a newly initiated form
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Documenting a #elephone 0rder
from a Physician• Indicate date&time order was recei$ed
• Document order as stated by physician
• +ead the written order bac! to the physician to $erify
accuracy• Document under the order +B0 'read bac! order( and
the recorder1s initials
• Sign order- $9o9 Dr9 ones & 5ay Smith +?
• Place a :sign here; stic!er ne6t to order • .lag the record green for a regular order and red for a
S#A# order for the secretary
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#ime30ut 4ISA
• #o be completed on A surgical and
in$asi$e procedures for which consents are
reuired9 #his includes bedside procedures
such as central lines% chest tubes%
thoracentesis% etc9
• @ Sections- Patient 4erification% Site
Mar!ing% and #ime 0ut for Procedure or
0perating +oom
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Section 7- Patient 4erification
• #wo identifiers- patient name and date of
birth
• Compare to ID band% consents% diagnosticimages% and all other patient
documentation related to the procedure
• All areas on the 4ISA under section 7 areto be initialed
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Section 8- Site Mar!ing
• Completed whene$er laterality may become an issue
• Performed by physician or person performing the in$asi$e procedure
• *6ceptions
) If not multiple digits&structures
) Procedure occurs through an orifice 'dental% colonoscopy% etc(
) ?IC= babies
• Green bracelet used on operati$e side
when patient refuses site mar!ing
• All areas to be initialed
if appropriate
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Section @- #ime30ut
• Completed Eust prior to the beginning of the procedure
• Includes the patient
• All members present for the #ime30ut must beidentified
• All areas to be initialed and form signed
• +eferences- 4erification of Correct Site% Correct
Procedure% Correct Patient and :#ime30ut; forIn$asi$e or Surgical ProcedureH and Guidelines forCompleting Procedure 4isa