documentationstudentoutline-100429135309-phpapp01.pptx

8/21/2019 documentationstudentoutline-100429135309-phpapp01.pptx

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Subtitle

Documentation and

RecordingCommunication with the HealthcareTeam


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Document and Reporting

Ensures quality of care

Regulatory agencies require it

Medicare reimbursement dependsupon it

Shows nursing action

Serves as a legal document


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Reporting

Summary of activities, observations,and actions performed

Objective and non-judgmental


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Reports

Oral or written

Shift report

Verbal reports to physicians Miscellaneous

Written lab reports

Dietary reports Social workers notes

PT, OT, Speech therapies


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Types of Reports

Change of shift Oral, audiotape, rounds

Telephone

Transfer Incident

Any event not consistent with routine careof client

Concise, objective Not a part of the chart Oral, audiotape, rounds


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Confidentiality

Law protects any information gainedby exam, observation, conversation,or treatment

Information not discussed or sharedwith anyone not directly involved inpatients care

Nurses are legally and ethicallyobligated to keep patient informationconfidential


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Medical Records

Permanent written communications

Continuing account of care status

Discussion, discharge planning,conferences, consultations

All caregivers can benefit from

information and plan accordingly


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Purpose of Records

Communication

Financial billing

Education Assessment

Research

Auditing and monitoring Legal documentation


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Documentation

Anything written or printed that isrelied upon as a record of proof forauthorized persons


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Standards for Documentation

Federal regulations-Medicare andMedicaid

State and Federal regulations JCAHO

Professional standards ANA

Facility policies- charting techniquesand responsibilities


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Legibility

All charting should be easy to read

Reduces errors

May be used in court years after caregiven


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Factual

Descriptive, objective information

Decreases misinterpretation

Do not use seems, appears,apparently, good well

Subjective information is

documented with clients own wordsin quotations

No opinions


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Complete and Concise

Thorough, exact, brief, and NO blah,blah, blah blah

Clear and succinct

Eliminate irrelevance

Short and to the point (long notes

difficult to read) Too abbreviated gives impression of

being hurried and incomplete


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Timeliness

Delay in reporting can result in seriousomissions and delays in care

Late entries may be interpreted as negligence

Certain things must be reported at time ofoccurrence

Routine activities need not be chartedimmediately

Military time used

No leaving until important informationrecorded

Avoids errors and duplication of care


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Accurate

Reliable and precise

Exact measurements when possible

Use only accepted abbreviations Spell correctly


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More accuracy

No charting for someone else

Students notes are countersigned byperson who assured care was given

Descriptive entries signed with fullname and status (first initial, lastname, and title)


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Guidelines for Documentationand Reporting

Certain abbreviations not acceptable

Abbreviations used


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Organization

Logical format and order

Chronological flow of events


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Chart Components

Data base

Assessment data

Problems list

Care plan

Progress notes

Narrative Flow sheets

Discharge planning summaries


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Documentation Methods

Problem oriented medical record

S.O.A.P. or S.O.A.P.I.R

P.I.E.

Source records

Charting by exception

Flow sheets

Focused charting

D.A.R.


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Problem Oriented MedicalRecord

Focus on patients problems

Follows the nursing process

Organized by problems or diagnoses Coordinated care


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Advantages of POMR

Easy to retrieve information andfollow progress

Easy to monitor for QA purposes

SOAP notes establish structure thatreflects what nurses do


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PIE Charting

PIE

Daily assessment data appears onflow sheets

Continuing problems documenteddaily

Focuses exclusively on single clientproblem


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Source Records

Each discipline has a separatesection of the chart for recording

Can easily locate proper section

Examples: admission sheet,physician's order sheet, history andphysical, flow sheets, nurses notes,medication record


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Charting by exception

Reduces repetition

Clearly defined standards of practiceand predetermined criteria

Nurses documents only significantfindings or exceptions

Preventive and wellness-focusedfunctions not documented


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Focus Charting - DAR

Easily understood and adaptable tomost settings

Reflects analysis and conclusions

Does not indicate problemassessment


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Standardized Care Plans

Pre-printed and establishedguidelines for clients with similarproblems

Improved continuity

Less time to document

Inhibits unique or individualizedtherapies


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Writing the Nursing Care Plan

Prioritize problems

ABCs

Maslow

Problems perceived by patient


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Formats

5 columns

Assessment data or defining characteristics

Diagnosis

Goals/outcomes

Interventions

Evaluation

Concept Map Same five components linked by rationales

Better indicates process of critical thinking


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Critical Pathways

Documentation tool to integratestandards of care for multipledisciplines

List problems, key interventions,expected outcomes, expectedtimelines

Attempt to control and decreaselength of stay


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Discharge Summaries

Multidisciplinary involvement isrequired by HCFA

Client leaves hospital in timelymanner with the necessary resources

Client signs original for chart andtakes copy home


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Kardex

Information

Medication

IVs

Treatments

Diagnostic procedures

Allergies

Data

Problem list


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Computer Documentation

Saves time in storage and retrieval

Information is permanent

Various departments can coordinateinformation

Can be used at the bedside


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Protocol Charting

Newest method

Primary use in outpatient care

Written for use as a references orguide for care

Individualized, current, according tointended purpose

Documents

documentationstudentoutline-100429135309-phpapp01.pptx