[1] documentation and reporting
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The document discusses various aspects of documentation and reporting in healthcare. It defines documentation as written records of interactions between providers and patients, as well as tests, treatments, and patient education. Documentation serves purposes like accountability, communication, education, reimbursement, and legal standards. There are different types of medical and nursing records that contain things like patient data, assessments, diagnoses, treatments, and progress. Effective documentation is factual, accurate, complete, current, and organized. Common documentation methods include narrative, problem-oriented, focus, and computerized charting. Forms for recording data include kardex, flow sheets, progress notes, and discharge summaries. Reporting involves verbal communication of patient status and can occur during shift reports or interdisciplinary rounds
[1] documentation and reporting
- 2. Documentation as Communication Reporting and recording are the major communication techniques used by health care providers.
- 3. Documentation as Communication Documentation is defined as written evidence of: • The interactions between and among health professionals, clients, their families, and health care organizations. • The administration of tests, procedures, treatments, and client education. • The results or client’s response to these diagnostic tests and interventions.
- 4. Purposes of Health Care Documentation Professional Responsibility and Accountability Communication Education Reimbursement Research Legal and Practice Standards Auditing and Monitoring
- 5. Types of Medical Records Components of medical record:- Patient identification & demographic data Present complains Informed consent for treatment & procedure Admission nursing history Family history Physical examination finding Medical history Tentative history Medical diagnosis Therapeutic order Treatment given Medical progress notes Supportive care given Reports of diagnosis studies Final diagnosis Patient education Summary of operative procedures Discharge plan and summary Any specific instructions
- 6. Types of Nursing Records Admission nursing assessment Nursing care plan Kardexes Pertinent information about patient Medication with date of order & time of administration Daily treatment & procedures Flow chart Graphic record (TPRBP) Fluid balance record Medication Skin assessment record Progress notes
- 7. Legal and Practice Standards Informed consent means that the client understands the reasons and risks of the proposed intervention. Witnessing confirms that the person who signs the consent is competent.
- 8. Elements of Effective Documentation Use of Common Vocabulary Legibility Abbreviations and Symbols Organization Accuracy Documenting a Medication Error Confidentiality
- 9. Elements of Effective Documentation Use of Common Vocabulary • Improves communication and lessens the chance of misunderstanding between members of the health team.
- 10. Elements of Effective Documentation Legibility • Print if necessary. • Do not erase or obliterate writing. • State the reason for the error. • Sign and date the correction.
- 11. Concepts of Nursing-NUR 123 Elements of Effective Documentation Correcting a documentation error
- 12. Elements of Effective Documentation Abbreviations and Symbols • Always refer to the facility’s approved listing. • Avoid abbreviations that can be misunderstood.
- 13. Elements of Effective Documentation Organization • Start every entry with the date and time. • Chart in chronological order. • Chart medications immediately after administration. • Sign your name after each entry.
- 14. Elements of Effective Documentation Accuracy • Use descriptive terms to chart exactly what was observed or done. • Use correct spelling and grammar. • Write complete sentences.
- 15. Elements of Effective Documentation Documenting a Medication Error • Document in the nurses’ progress notes: - Name and dosage of the medication - Name of the practitioner who was notified of the error - Time of the notification - Nursing interventions or medical treatment - Client’s response to treatment
- 16. Elements of Effective Documentation Confidentiality • The nurse is responsible for protecting the privacy and confidentiality of client interactions, assessments, and care.
- 17. Factual Accurate Complete Current Organized Elements of Effective Documentation
- 18. Types of records Patient clinical records Individual staff records Ward records Administrative records with educational value
- 19. Common ward records Patient clinical records Staff attendance record Staff leave record Staff patient assignment record Student attendance and patient assignment record Ward indent record Ward inventory record Equipment maintenance record Ward incidence record Infection surveillance record Ward quality indicator record Ward diet supply record Emergency drug and crash card record Patient admission/discharge/shift record
- 20. Methods of Documentation Narrative Charting Source-Oriented Charting Problem-Oriented Charting PIE Charting Focus Charting Charting by Exception (CBE) Computerized Documentation Case Management with Critical Paths
- 21. Methods of Documentation Narrative Charting • Describes the client’s status, interventions and treatments; response to treatments is in story format. • Narrative charting is now being replaced by other formats.
- 22. Methods of Documentation Source-Oriented Charting • Narrative recording by each member (source) of the health care team on separate records. • For example the admission department has an admission sheet, nurses use the nurses’ notes, physicians have a physician notes, etc….
- 23. Methods of Documentation Problem-Oriented Charting • Uses a structured, logical format called S.O.A.P. - S: subjective data - O: objective data - A: assessment (conclusion stated in a form of nursing diagnoses or client problems) - P: plan Uses flow sheets to record routine care. SOAP entries are usually made at least every 24 hours on any unresolved problem.
- 24. Methods of Documentation PIE Charting • P: Problem statement • I: Intervention • E: Evaluation Example: • P: Patient reports pain at surgical incision as 7/10 on 0 to 10 scale • I : Given morphine 1mg IV at 23:35. • E : Patient reports pain as 1/10 at 23:55.
- 25. Methods of Documentation Focus Charting • A method of identifying and organizing the narrative documentation of all client concerns. • Uses a columnar format within the progress notes to distinguish the entry from other recordings in the narrative notes (Date & Time, Focus, Progress note) • The progress notes are organized into: Data (D), Action (A), Response (R).
- 26. Example of focus charting Date & Time Focus: Progress notes: 09.Sep.2013 Acute pain related to surgical incision D: Patient reports pain as 7/10 on 0 to 10 scale. A: Given morphine 1mg IV at 2335. R: Patient reports pain as 1/10 at 2355.
- 27. Concepts of Nursing-NUR 123 Methods of Documentation Charting by Exception (CBE) • The nurse documents only deviations from pre-established norms (document only abnormal or significant findings). • Avoids lengthy, repetitive notes.
- 28. Methods of Documentation Computerized Documentation • Increases the quality of documentation and save time. • Increases legibility and accuracy. • Facilitates statistical analysis of data.
- 29. Methods of Documentation Case Management Process • A methodology for organizing client care through an illness, using a critical pathway. • A critical pathway is a multidisciplinary plan or tool that specifies assessments, interventions, treatments and outcomes of health related problems a cross a time line.
- 30. Forms for Recording Data Kardex Flow Sheets Nurses’ Progress Notes Discharge Summary
- 31. Forms for Recording Data The Kardex is used as a reference throughout the shift and during change-of-shift reports. • Client data (e.g name, age, admission date, allergy) • Medical diagnoses and nursing diagnoses • Medical orders, list of medications • Activities, diagnostic tests, or specific data on the pt.
- 32. Forms for Recording Data Flow Sheets The information on flow sheets can be formatted to meet the specific needs of the client. (e.g.: graphic sheets for vital signs, intake & output record, MAR, skin assessment record). Nurses’ Progress Notes Used to document the client’s condition, problems and complaints, interventions, responses, achievement of outcomes.
- 33. Forms for Recording Data Discharge Summary • Client’s status at admission and discharge. • Brief summary of client’s care. • Interventions and education outcomes. • Resolved problems and continuing need. • Referrals. • Client instructions.
- 34. Reporting Verbal communication of data regarding the client’s health status, needs, treatments, outcomes, and responses Reporting is based on the nursing process.
- 35. Reporting Summary / Hand-Off Reports Walking Rounds Incident or Occurrence Reports Telephone Reports and Orders
- 36. Reporting Summary / Hand-Off Reports Commonly occur at change of shift (or when client care is transfers to another health care provider). Walking Rounds Occur in the client’s room Include Nursing, physician, interdisciplinary team. Incident or Occurrence Reports Used to document any unusual occurrence or accident in the delivery of client care.
- 37. Reporting Telephone Reports and Orders Report transfers, communicate referrals, obtain client data, solve problems, inform a physician and/or client’s family members regarding a change in the client’s condition. Telephone orders are documented in the nurses’ progress notes and the physician order sheet.
- 38. 16-38 Documenting a Telephone Order
- 39. Minimizing legal liability through effective record keeping Date & time Timing Legibility Permanence Correct spelling Signature Accuracy Sequence Appropriateness Completeness Conciseness Accepted terminology
- 40. Thank you