Draft of Documentation

8/6/2019 Draft of Documentation

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DOCUMENTATION


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Documentation

Written evidence of:

The interactions between and among health care

professionals, clients, their families, and healthcare organizations.

The administration of tests, procedures,

treatments, and client education.

The results of, or clients response to, diagnostic

tests and interventions


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Purposes of Documentation

Professionalresponsibility

Accountability

Communication

Education

Quality Assurance

Accreditation

Research

Satisfaction of Legaland Practice

standards

Reimbursement

Assures continuityof care


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PERMANENT RECORD

WRITTEN IN CHRONOLOGICAL

ORDER

FILED IN MEDICAL RECORDS DEPT

FOR FUTURE USE/REFERENCE


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Documentation as

Communication

Documentation is a communication methodthat confirms the care provided to theclient.

It clearly outlines all important informationregarding the client.


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SIX ITEMSTHAT NURSES MUSTDOCUMENT

ASSESSMENT NURSG DX AND PT NEEDS

INTERVENTIONS

CARE PROVIDED

PT RESPONSE TO CARE PTS ABILITYTO MANAGE CONTINUING

CARE AFTER DISCHARGE


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Documentation as Education

The medical record can be used by healthcare students as a teaching tool.

It is a main source of data for clinicalresearch.


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Documentation & Research

The medical record is a main source of datafor clinical research.


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RESEARCH

DATA ON TREATMENTS, MEDS, AND

THERAPY

INFO FORTUMOR BOARDS, DOCTORS

ROUNDS, NURSING ROUNDS, ETC.

BE AWARE OF PRIVACY ISSUES NURSES, STUDENT NURSES USE FOR

CARE PLANS.


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Legal & Practice Standards

Nurses are responsible for assessing anddocumenting that the client has an

understanding of treatment prior to

intervention.

Two indicators of the above are InformedConsent and Advance Directives.


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LEGAL EVIDENCE

RECORDS ARE CONSIDERED LEGAL ORP

OT

ENT

IAL LEGAL DOCUMENTS

MAY BE SUBPEONAED AS EVIDENCE BYATTORNEY OR NURSING BOARDS. CHECK FORDEVIATIONS FROM FACILITYPOLICY ORSTANDARDS.

EACH HEALTH CARE PROVIDER IS RESPONSIBLEFORTHE ABCS OF RECORDING. ACCURACY,BRIEF, COMPLETE.


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Informed Consent

A competent clients ability to make health care decisionsbased on full disclosure of the benefits, risks, and potential

consequences of a recommended treatment plan.

The clients agreement to the treatment as indicated by theclients signing a consent form.


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Advanced Directives

Written instructions about a clients health carepreferences regarding life-sustaining measures. (e.g. living

will and durable power of attorney forhealth care).

Allows clients, while competent, to participate in end-of-

life decisions.


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Documentation &

Reimbursement

Accreditation and reimbursement agenciesrequire accurate and thorough

documentation of the nursing care rendered

and the clients response to interventions.


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REIMBURSEMENT

LACK OF DOCUMENTATION MAYRESULT IN DENIAL FORPAYMENTSFROM MEDICARE AND PRIVATE

INSURANCE COMPANIES. THISPUTSTHE BURDEN OF PAYMENT ON THEPATIENT.


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Documentation & Quality

Assurance

QUALITY ASSURANCE

A PEER REVIEW PROCESS

CONDUCTED BY A STAFF NURSE

AND PHYSICIAN

ESTABLISHES AND REFLECTS

AGENCYSTANDARDS


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Documentation & Accreditation

ACCREDITATION JCAHO (JOINT COMMISSION ON

ACCREDIT

AT

ION OF HEALT

HORGANIZATION)/DSHSSTATE(EXTENDED CARE)

SETS MINIMUM STANDARDS FORSTAFFING

THE AMERICAN NURSES ASSOCIATIONSETSTHE STANDARDS FORPT CARE &DOCUMENTATION FOR NURSES


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ACCESS TO CHARTS

PATIENTS RIGHTS

WHO OWNS

CHART

AGENCYPOLICY


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PATIENT CONFIDENTIALITY

NEVER LEAVE CHART IN A PUBLIC PLACE.

DISCUSS CONTENTS ONLY WITH PERSONSDIRECTLY INVOLVED IN THE PATIENTS CAREORTHOSE THAT ARE AUTHORIZED BYTHEPATIENT. THESE PEOPLE SHOULD BE LISTED BY

NAME.

ASK FOR ID PRIOR. DO NOT DISCUSSPT ORPT INFO IN PUBLIC

PLACES, EG. ELEVATORS, CAFTERIA.


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ACCESS TO CHARTS

PATIENTS RIGHTS/AGENCYPOLICY

PATIENTS HAVE THE RIGHTTO THE INFOIN THEIR CHARTS.

THEY DO NOT HAVE THE RIGHTTO SEETHE CHART ON DEMAND OR REMOVE

ANYTHING FROM THE CHART, ORREMOVE THE CHART FROM THEFACILITY.


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ACCESS TO CHARTS

WHO OWNSTHE CHART

A PATIENTS CHART ISTHEPROPERTY OF THE FACILITY. IT ISTHE FACILITY WHICH SETSTHE

POLICY AND MAKESAPPOINTMENTS FOR VIEWING OFTHE CHART.


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PRINCIPLES OF EFFECTIVE

DOCUMENTATION

1. Document accurately, completely, and

objectively, including any errors.

2. Note date and time.

3. Use appropriate forms.

4. Identify the client.

5. Write in ink.

6. Use standard abbreviations.


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PRINCIPLES OF EFFECTIVE

DOCUMENTATION(continued)

7. Spell correctly.

8. Write legibly.

9. Correct errors properly.

10. Write on every line.

11. C

hart omissions.

12. Sign each entry.


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ABBREVIATIONS

YOU MUST USE YOUR FACILITYS

APPROVED ABBREVIATIONS.

BE AWARE THAT A LOT OF

COMMONLY USED ABBREVIATIONS:

EG. TID, BID, QOD, HS ARE NO

LONGER ALLOWED AND SHOULDBE CURRENTLY BEING PHASED OUT

OF YOUR FACILITY.


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TYPES OF PATIENT RECORDS

SOURCE-ORIENTED

PROBLEM-ORIENTED


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Source-Oriented Charting

A narrative recording by eac

hmember(source) of the health care team on separate

records.


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Problem-Oriented Charting

Focuses on t

he clients problem andemploys a structured, logical format called

SOAP charting:

S: Subjective data (what the client states)

O: Objective data (what is observed/inspected) A: Assessment

P: Plan


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Methods of Documentation

Narrative

PIE

FDAR

SOA

P

SOAPIER

Charting by

exception

Computerized

documentation

Critical pathways


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Narrative Charting

This traditional met

hod of nursingdocumentation takes the form of a story

written in paragraphs.

Before the advent of flow sheets, this wasthe only method for documenting care.


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NARRATIVE

CHRONOLOGICAL

BASELINE CHARTED QSHIFT

LENGTHY, TIME-CONSUMING

SEPARATE PAGES FOR EACH

SOURCE-ORIENTED


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SOAP

USED FOR PROBLEM-ORIENTED CHARTS

S SUBJECTIVE. WHAT PT TELLS YOU.

0 OBJECTIVE. WHAT YOU OBSERVE, SEE. A ASSESSMENT. WHAT YOU THINK IS GOING ON

BASED ON YOUR DATA.

P PLAN. WHAT YOU ARE GOING TO DO.

CAN ADD TO BETTER REFLECT NURSING PROCESS

I INTERVENTION (SPECIFIC INTERVENTIONSIMPLEMENTED)

E EVALUATION. PT RESPONSE TO INTERVENTIONS.

R REVISION. CHANGES IN TREATMENT.


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EXAMPLE OF SOAP CHARTING

#1 ALTERATION IN COMFORT. ABDOMINAL

PAIN.

S COMPLAINS OF PAIN IN RUQ

O IS PALE AND HOLDING RIGHT SIDE

A RECURRING ABDOMINAL PAIN

P PUT ON NPO AND NOTIFY PHYSICIAN


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Focus Charting

A documentation met

hod t

hat uses acolumn format to chart data, action, and

response (DAR).


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FDAR

USES NARRATIVE DOCUMENTATION

(DAR)

DATA SUBJECTIVE OR OBJECTIVE THATSUPPORTS THE FOCUS (CONCERN)

ACTION NURSING INTERVENTION

RESPONSE PT RESPONSE TO INTERVENTION


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EXAMPLE OF FOCUS CHARTING

D COMPLAINING OF PAIN AT INCISION SITE

ON LEVEL OF #7

A REPOSITIONED FOR COMFORT. DEMEROL

50MG IM GIVEN.

R (CHARTED AT A LATER DATE.) STATES ADECREASE IN PAIN, FEELS MUCH BETTER.


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PIE CHARTING

Similar to SOAP charting

Both are problem-oriented

PIE comes from theNursingProcess,

SOAP comes from aMedical Model.

P-Problem

I-Intervention

E-Evaluation


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PIE Charting

PROBLEMINTERVENTION

EVALUATION


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SAMPLE OF PIE CHARTING

P#1 Risk for trauma related to dizziness.

IP#1 Instructed to call for assistance when

getting OOB. Call light in reach.

EP#1 Consistently call for assistancebefore getting OOB. Continues to

experience dizziness.


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Charting by Exception

A documentation met

hod t

hat requires t

henurse to document only deviations from

pre-established norms.


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CHARTING BY EXCEPTION

USES FLOWSHEETS

EMPHASIS ON ABNORMAL (WHAT IS

ABNORMAL FORTHISPATIENT.

ALTHOUGH IT MAY BE ABNORMAL FORTHENORMAL PERSON, IF IT IS ABNORMAL FORYOURPATIENT ON A CONSISTENT BASIS, IT IS

NO LONGER CONSIDERED AN EXCEPTION.

ADVANTAGE


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COMPUTERIZED CHARTING

PASSWORD. NEVERSHARE. CHANGE FREQUENTLY.

LEGIBLE

CAN BE VOICE-ACTIVATED, TOUCH-ACTIVATED.

DATE AND TIME AUTOMATICALLY RECORDED.

ABBREVIATIONS AND TERMS ARE SELECTED BY A MENU

PROVIDED BYTHE FACILITY.

TERMINALS ARE USUALLY EASILY ACCESSIBLE, IN PT

ROOMS, CONVENIENT HALLWAY LOCATIONS.

MAKE SURE TERMINAL CANNOT BE VIEWED BY

UNAUTHORIZED PERSONS.


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Computerized Documentation:

Advantages

Decreased documentation

time.

Increased legibility and

accuracy.

Clear, decisive, and concise

words.

Statistical analysis of data.

Enhanced implementationof the nursing process.

Enhanced decision making.

Multidisciplinary

networking.


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Forms for Recording Data

Kardex Flow Sheets

Nurses Progress Notes

Discharge Summary


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Kardex

A summary worksheet reference of basicinformation that traditionally is not part ofthe record. Usually contains: Client data (name, age, marital status, religious

preference, physician, family contact).

Medical diagnoses: listed by priority.

Allergies.

Medical orders (diet, IV therapy, etc.).

Activities permitted.


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KARDEX

QUICK REFERENCE

CHANGED AS NEEDED

NOTPART OF PERMANENT RECORD


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Flow Sheets

Vertical orhorizontal columns forrecording dates and times and relatedassessment and intervention information.Also included are notes on:

Client teach

ing. Use of special equipment.

IV Therapy.


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Nurses Progress Notes

Used to document:

Clients condition, problems, and complaints.

Interventions.

Clients response to interventions.

Achievement of outcomes.


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Discharge Summary

Highlights clients illness and course of care.Includes: Clients status at admission and discharge.

Brief summary of clients care.

Intervention and education outcomes.

Resolved problems and continuing care needs.

Client instructions regarding medications, diet, food-drug interactions, activity, treatments, follow-up andother special needs.


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CRITICALPATHWAY

Also known as Care Maps.

Comprehensive pre-printed standard plan

reflecting ideal course of treatment for

diagnosis or procedure, especially with

relatively predictable outcomes.

Additional forms are needed to complementthe pathway.


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CriticalPathways

A compre

h

ensive, standard plan of care forspecific case situations.

The pathway is monitored to ensure thatinterventions are performed on time and

client outcomes are achieved on time.


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INFORMATION

FOR SHIFT REPORT

Name, room and bed,

age, gender

Physician, admissiondate, and diagnosis

Diagnostic tests or

treatments performed in

past 24 hours (results if

ready)

General status, any

significant change

New or changedphysicians orders

IV fluid amounts, last

PRN medication

Concerns about client


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CHANGE OF SHIFT REPORT

PERSON TO

PERSON BE PREPARED

AVOID

GOSSIP/SOCIALIZA

TION

TAPE RECORDER


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Summary Reports

The outlining of information pertinent to theclients needs as identified by the nursingprocess.

Commonly given at end-of-shift.


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WALKING ROUNDS

Members of the

care team walk

to each clientsroom and

discuss progress

and care witheach other and

with the client.


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Telephone Reports and Orders

Telephone communications are another way

nurses: Report transfers.

Communicate referrals.

Obtain client data.

Solve problems.

Inform a clients family members regarding a change inclients condition.


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TELEPHONE ORDERS

Date and time

Order as given by the physician

Signature beginning with t.o. (telephone

order)

Physicians name

Nurses signature

Physician must countersign


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INCIDENT REPORT

May also be called a variance.

Informs administration of incident, allows risk

management personnel to consider ways to

prevent future similar occurrences.

Alerts insurance company to potential claim

and possible need to investigate.


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INCIDENT REPORTS

OBJECTIVE

DO NOT BLAME OR

ADMIT LIABILITY

WHAT DID YOU DO? DO NOT INCLUDE

NAMES/ADDRESSESOF

WITNESSES

DOCUMENTTIME/NAME

OF DOCTOR DO NOT FILE IN CHART

DO NOT WRITE INCIDENT

REPORTMADE


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CORRECTING ERRORS

IF YOU SPILL SOMETHING ON THE CHART, DO NOTDISCARD NOTES. RECOPY, PUT ORIGINAL AND COPIEDSHEETS IN CHART. WRITE COPIED ON COPY.

DO NOTSCRIBBLE OUT CHARTING.

AVOID USING ERROR OR WRONG PATIENT WHENMAKING CORRECTION.

FOLLOW YOUR FACILITIESPOLICY.

DO NOT ALTER CHARTING, IT IS A LEGAL DOCUMENT.

Documents

Draft of Documentation