NUR3026 Fall08 Chapter 16

8/4/2019 NUR3026 Fall08 Chapter 16

1/36

F. A. Daviss Fundamentals of NursingF. A. Daviss Fundamentals of Nursing

Chapter 16: Documenting and

Reporting

Documentation: The act of recording client care

in written form

Creating a written record of client care

Client record: A collection of material that serves

as a legal record of the client's healthcare

experience


2/36


Purpose of the Written Record

Communication between providers

Educational tool: Snapshot of what is going on

with the patient so that you can prepare to give

safe care

Legal documentation of care Quality assurance: Chart audits

Research

Reimbursement


3/36


Main Documentation Systems

Source-oriented:

Disciplines charted separately; Variety of sections

Data scattered; may lead to fragmentation

May include: Admission data; Advanced directives

(End-of-life care wishes); H&P; Dr.'s orders;Progress notes; Diagnostic studies (Lab results; X-

Rays, etc.); Nurses' notes; Graphic sheet (V/S, I/O,

BMs, weight, etc), Rehab & therapy notes (PT, OT,

Resp Therapy), Discharge planning


4/36


Main Documentation Systems

Problem-oriented:

Organized around client problems

Four components: Database, problem list, plan of

care, and progress notes Allows greater collaboration


5/36


Common Types of Charting

Narrative

SOAP

PIE

Focus Charting By Exception (CBE)


6/36


arrative Charting

Can use with source- or problem-oriented system

Story of care in chronological format

Tracks the clients changing status

Can be lengthy and disorganized


7/36


SOAP Charting

S for Subjective data

O for Objective data

A for Assessment

P for Plan

Some Add IER Ifor Intervention

E for Evaluation

R for Revision


8/36


PIE Charting

P for Problem I for Interventions

E for Evaluation

Used only in problem-oriented charting

Establishes an ongoing plan of care


9/36


Focus Charting

Highlights the client

s concerns, problems, orstrengths

Occurs in 3 columns:

Column 1: Time and date

Column 2: Focus or problem beingaddressed

Column 3: Charting in a DAR format: Data,Action, Response


10/36


ursing Documentation Forms:

Admission Database

Record of baseline data from which to monitor

change

Helps forecast future needs


11/36


Admission Database

Chief complaint or reason for admission

Physical assessment data

Vital signs

Allergy information

Current medications ADL status and discharge planning information/

needs

Data about client support system and contactinformation


12/36


Flow Sheets

Record routine aspects of care (hygiene, turning) Document assessments; usually organized

according to body systems

Track client response to care (wound care, pain,

intravenous fluids) Graphic records - used to record vital signs

Intake and output record


13/36


Medication Administration Records

Comprehensive list of all ordered medications Provides information on clients medication

allergies

Documents scheduled/routine, PRN, STAT, or

omitted doses Additional explanation may be required for

nonroutine or omitted medications


14/36


KARDEX or Client Care Summary

Demographic data Medical diagnoses

Allergies

Diet/activity orders Safety precautions

continued


15/36


KARDEX or Client Care Summary

Intravenous therapy orders

Ordered treatments (wound care, physical

therapy), surgery, laboratory, and tests

A summary of medications ordered Special instructions such as preferred intensity of

care or isolation orders


16/36


Integrated Plans of Care (IPOC)

A combined charting and care plan form

Maps out on a daily basis, from admission todischarge:

Client outcomes, interventions and treatments for

a specific diagnosis or condition Laboratory work, diagnostic testing, medications,

and therapies included in the pathway


17/36


Discharge Summary

Time of departure and method of transportation

Name and relationship of person(s) accompanyingclient at discharge

Condition of client at discharge

Teaching conducted and handouts/informationalmatter provided to client

Discharge instructions (including medications,treatments, or activity)

Follow-up appointments or referrals given


18/36


Occurrence Events

Also known as Incident reports Closely follow each institution's procedure for

how to report and document an Incident Report


19/36


Computerized Charting

Confidentiality is

important

Protect client

confidentiality when

doing/using the computer


20/36


Home Health-Care Documentation

Home-bound status

Assessment highlighting changes in the clientscondition

Interventions performed (wound care, teaching, etc.)

Clients response to interventions

Any interaction or teaching that you conducted withcaregivers

Any interaction with the clients physician


21/36


Long-Term Care Documentation

Minimum data set (MDS) for resident

assessment and care screening must be

completed within 4 days of admission and

updated every 3 months


22/36


Long Term Care: Weekly Summary

A summary of the clients condition

An evaluation of the clients ability to performADLs

The clients level of orientation and mood

Hydration and nutrition status Response to medications

Any treatments provided

Safety measures used (e.g., bed rails)


23/36


Reporting

Informing other caregivers about the clientcondition

Nurse to nurse; nurse to physician

Passage of vital information related to theclients status/plan of care


24/36


Change-of-Shift Report

May be: Verbal

Through walking rounds

Taped report


25/36



Client demographics and diagnoses

Relevant medical history Significant assessment findings

Treatments (e.g., wound care, breathing treatments)

Upcoming diagnostics or procedures

Restrictions (e.g., diet, activity, isolation)

Plan of care for the client

Concerns


26/36



Keep It CUBAN: Confidential

Uninterrupted

Brief

Accurate

Named Nurse


27/36


Transfer Reports Your contact information

Client demographics, diagnoses, reason for transfer

Family contact information

Summary of care

Current status, including medications, treatments,and tubes in the client

Presence of wounds or open areas of the skin Special directives, code status, preferred intensity of

care, or isolation required

Always ask if the receiver has any questions


28/36


Verbal/Telephone Physician Orders

Verbal orders:

Spoken to you; often during a client emergency

Should not be used as a routine means ofcommunicating

Telephone orders: Received by phone and transcribed onto chart order

sheet

Have an increased risk for errors


29/36


Telephone Orders

Write the order only if you heard it yourself

Make sure the verbal orders make sense with theclients status

Repeat the order

Spell unfamiliar names; pronounce digits ofnumbers separately

continued


30/36


Telephone Orders

Directly transcribe the order on the chart Date/time

Text

TO followed by providers name

Your signature

Physicians must countersign within 24 hours


31/36


Documenting Client Care

Be familiar with facility

forms Chart in the required

format; use military time if

required

Include all aspects of care Be accurate, complete, and

consistent


32/36


Documentation Dos and Donts

Be accurate and nonjudgmental

Adhere to the requirements for reimbursement

Provide details about the clients condition,

nursing interventions provided, and client

response Document legibly and as soon as possible


33/36



Record significant events or changes in condition

Any attempts you have made to contact the

primary care provider

Chart teaching performed

Chart use of restraints, including reason for use,type of restraints, and frequent checks of the

client


34/36



Do not chart that you have filled out anoccurrence report

Chart any client refusal of treatment or

medication

Document any spiritual concerns expressed bythe client and your interventions


35/36



Always use black or blue ink for handwritten

notes

Date and time all notes

Avoid subjective terms

Use proper spelling and grammar

Use only authorized abbreviations

Document complete data about medications


36/36



If a client refuses a medicine:

Record on the medication administration record in

narrative form; chart the reason given

Do not leave blank lines

If you make a mistake, draw a single line through the

entry, and place your initials next to the change

Sign all your charting entries