Chart This, Not That!Mary-Beth Newell, RN

Vice President of Clinical ReimbursementPost Acute Consulting

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Understand the importance of documentation from a clinical & legal perspective

Gain knowledge on how documentation can serve as a great communication tool

Learn how to change current charting into a focused, picture of the resident

Describe at least two helpful tips or best practices to improve the documentation process

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Complete Accurate Accessible Organized

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Paints a clear picture Shows a level of care that only a licensed professional can deliver

See change/progress towards goals Includes patient response to treatment & changes in their condition

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Neat, legible Complete signature, date & time Uses only approved abbreviations Uses only acceptable standards for correction of errors

Identifies late entries appropriately

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PIE (Problem, Intervention, Evaluation) DAR (Data, Action, Response) SOAP/SOAPIE (Subjective, Objective, Assessment, Plan of Action, Intervention & Evaluation)

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Used as evidence◦ Survey process◦ Quality Measures/Indicators◦ Litigation◦ In court

Used for reimbursement◦ Case Mix◦ Medicare Part A◦ RAC & MAC Audits

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Focused Documentation Written evidence of care provided, resident’s response & effect of care

Shows continuity of care Provides a communication tool Supports the MDS

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Not accurate or complete Does not indicate the “why” of a problem Lacks action taken Omits teaching & response Not objective Cut & paste IPN notes

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Avoid assumptions Be specific & descriptive Never chart prior to care being provided Document phone calls to the family & physicians (include results)

Don’t just rely on your memory

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Ortho Skin integrity/Surgical

site Pain management Functional abilities Weight bearing Activity tolerance Assistive devices Capillary refill &

pulses

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Neuro• Muscle weakness• Ataxia• Syncope• Communication/Aphasia• Dysphagia• Memory impairment• Incontinence• Loss of Consciousness

Cardiac Respiratory status◦ Breath sounds, cough,

O2 sats & use VS/BP, I&O & labs◦ Pulses (radial, pedal &

apical)◦ Anticoagulant therapy

Edema Chest pain & response to

meds Hyper/hypo-tension or

syncope Nausea & Vomiting

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Respiratory• Breath sounds, cough, resp.

rate & ancillary muscle use• Activity tolerance• Respiratory Therapy

– Nebulizers, aerosal tx, suctioning, meds

• Oxygen therapy & O2 sats

Infection VS & BP Antibiotic &

response I & O Appetite Level of

Consciousness Lab work Pain Impact on affected

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Renal• Hematuria• Blood sugar• I & O• Pain• Abdominal distention• Continence/Constipat

ion• Diet restrictions &

compliance

Specific behavior or dysfunction ◦ Presence or absence◦ Precipitating factors◦ Frequency◦ Safety awareness◦ Response to

medication & non-drug interventions

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•Alterations in sleep &/or nutrition

•Ability to perform complex tasks (Ex; ADLs)

•Affect & ability to communicate or participate in milieu

•Alteration in psychomotor function

Resident’s baseline & any deviations Interventions utilized & effectiveness

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Nursing needs to know what deficits rehab is treating

Notes should reflect function & progresswhile on the nursing unit◦ Distance traveled, cueing provided, tolerance,

assistive devices, etc Medical/clinical issues that impact rehab,

nursing interventions & pt response

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Check these areas closely for accuracy & supporting documentation: ◦ Dressing◦ Bed Mobility◦ Transfers◦ Eating◦ Toileting◦ Ambulation

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Use of “catch all” or vague phrases◦ Cookie cutter charting◦ No ”picture” of resident

Documenting interventions without a rationale &/or how patient responded◦ Do not “repeat” the care plan

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Chart This!

Transferred to w/c by 1 staff. Able to bear weight & pivot. Rt hip pain “not as bad” per pt with routine Tylenol ES, but easily fatigued.

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Not That!

Up in w/c

Chart This!

Supervised w/walker to BR. Needed fewer safety cues than yesterday. Unsteady & had difficulty managing pants. Able to dress & undress UB at bedtime w/cueing.

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Not That!

PT 5x/week, working w/OT

Chart This!

Oriented to self only. Mistaking staff for family members. Is able to follow simple commands.

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Not That!

Confused

Chart This!

Reminders given to pt to use BR, underwear remained dry. Able to manage own clothes & peri care. Needed limited assist to get up & off toilet.

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Not That!

On bladder program

Chart This!

Help of 2 staff to get into w/c. Propels w/left hand. Forgot to lock brakes in DR.

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Not That!

Propels self

Chart This!

Ambulated 15 ft w/walker. Needed supervision, gait unsteady & walker positioned too far in front of him.

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Not That!

Up ad lib

What condition requires a licensed nurse to intervene?

What is the nurse observing? What does the nurse hope to accomplish?

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Chart This!

Selects own clothing, fills out menu choices independently and organizes her time to attend her favorite activities; Bingo & Current Events.

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Not That!

Makes needs known

Chart This!

Stage 2 pressure ulcer on sacrum (2x2x1cm) had dressing changed after incontinent episode. Scant sero-sanguinous drainage, granulation tissue present. Tolerated well, no pain.

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Not That!

Treatment done as ordered

Chart This!Only eating dessert, despite encouragement to eat other foods. c/o “not being hungry”. Down 2# since last week. MD notified & seen by RD. Multivitamin, CBC & pre-albumin ordered. Switched to small meals at lunch. Ate mashed potatoes & gravy in addition to chocolate milkshake & pudding.

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Not That!

Ate 25% of meals, new orders received

Chart This!Isolating self in room & stating that other residents are “laughing at me”. Other residents were laughing during a tvprogram, but resident continued with the belief they were laughing at him.

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Not That!

Delusional

Chart This!Yelling out “No, no stop saying that” when no one was present. Resident reports “The voices are telling me I am evil & won’t stop”. Resident is breathing rapidly, has a wide eyed look, pacing in his room & grabbing his head. Given prnHaldol with some relief after 1 hour. Resident reports “I can hardly hear them anymore”

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Not That!

Experiencing auditory hallucinations

Mrs. Car is a new patient that was admitted to the Dementia Care Unit from the hospital & has Alzheimer’s disease.  

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Chart This!Anxious at times stating “Where do I go?” repeatedly. Redirected to activities & attends for 10 minutes then begins pacing. Eating 50% of meals w/cues, snacks between meals started. Needs cueing & oversight to dress self.

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Not That!

Confused, no complaints

Ms. Fidel is actively dying. She’s having diarrhea, vomiting, losing weight & has had multiple medication changes.

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Chart This!Moaning & crying, states pain is steady & throbbing at a 5 with limited relief w/OxyContin. MD ordered Roxanol & provided relief. Took 200 cc ginger ale, had one emesis of 50 cc green bile. Abdominal cramping w/one loose stool.

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Not That!

Loose stools, emesis, pain med given

Miss Park has been having severe blood pressure swings, had a seizure & has been lethargic.

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Chart This!Remains sleepy, but responds to verbal commands. No seizure activity. BP ranged from 80/42 to 136/88. Lower BPs with sit to stand position change. Takes fluids with encouragement. Fluid intake 600cc this shift.

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Not That!

No seizure activity VS stable

Mr. Bay has COPD & has been SOB on exertion recently.  

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Chart This!Using O2 at 2L/min continuously, O2 sat levels at 94%, becomes SOB when dressing or ambulating. Wheezing noted on auscultation. Ate 30% of dinner, refused snacks & states “I’m just not hungry”

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Not That!

SOB on exertion, using O2

Mr. Moon is underweight, a picky eater, showing subtle weight loss & has stopped going to the Men’s Group.  He has limited mobility & is incontinent.

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Chart This!Ate toast for breakfast & dessert for lunch. Refused alternate entrée. Likes grilled cheese sandwiches, but refused that too. RD & SSD to meet w/resident. Received order for fortified meals, CBC and pre-albumin. Started on scheduled toileting & I&O. Fluid intake 150cc, took another 100 cc w/encouragement. Wt134#. Did attend exercise & ambulation restorative program

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Not That!Incontinent of urine,

ate 50% of meal

Mrs. Singh has new fecal incontinence with loose stools & is receiving Kaopectate & Imodium. She has lost 17# in a month, has a rash being treated with Nystatin.

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Chart This! Upset about bowel

incontinence x 2; loose, watery w/foul smell. Drank 800 cc fluid, ate 25% of dinner .Stool to lab for testing. Imodium given w/relief after 2 hours. Dermatitis on Lt buttock “burning”, Nystatin applied w/some relief

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Not That!

Loose stools x 2, rash on buttocks.

Chart This!Showed nurse her “medication organizer” she’ll use at home to keep from taking all her pills at once. Understands hypotensive side effects. Able to demonstrate “dangling” & changed positions slowly when getting OOB without cueing. Used home BP monitor to check BP & was able to state her “safe” BP range.

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Not That!

Discharge plans in place

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mnewell@postacuteconsulting.com508-414-1180

postacuteconsulting.com

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