Documentation john
- 2. 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
- 3. Written evidence of the interaction between and among students, families, school staff, health care professionals, regarding care, training, consultation, student education, and the results or response to the intervention. Written record of nursing process to deliver care.
- 4. Professional Responsibility and Accountability Communication Education Research Legal and Practice Standards Quality assurance Statistics reimbursement 16-4
- 5. Professional Responsibility and Accountability Recording documents compliance with professional practice standards and accreditation criteria. Written records are a resource for review, audit, reimbursement, and research. Documentation provides a written legal record to protect the client, institution and practitioner. documentation is considered as an important criteria of an profession. 16-5
- 6. Documentation as Communication Communication is a dynamic, continuous, and multidimensional process for sharing information. Reporting and recording are the major communication techniques used by health care providers. The medical record serves as a legal document for recording all client activities by health care practitioners. 16-6
- 7. Nurses rely on charting, records, and systems that support the implementation of the nursing process. Systematic documentation is critical to presenting the care administered by nurses in a logical fashion. Critical thinking skills, judgments, and evaluation must be clearly communicated through proper documentation. 16-7
- 8. Education Health care students use the medical record as a tool to learn about disease processes, diagnoses, complications, and interventions. Clinical rounds and case conferences rely heavily on information contained in the medical record. Research Researchers rely heavily on medical records as a source of clinical data. Documentation can validate the need for research.
- 9. Legal and Practice Standards In 80% to 85% of malpractice lawsuits involving client care, the medical record is the determining factor in providing proof of significant events. 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. Recording provide evidence of the care provided by the nurses.
- 10. Quality assurance Documentation provide information about the care provided during the time of audit. Statistics Documentation provides information for formulation of statistical report of the hospital. Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 16-10
- 11. Reimbursement(compensation) Peer review organizations (PROs) are required by the federal government to monitor and evaluate care. Medical record documentation is the mechanism for the PRO review. Diagnosis-Related Groups (DRG) The medical record must provide documentation that supports the DRG and appropriateness of care. If nurses fail to document the equipment or procedures used daily, reimbursement to the facility can be denied.
- 12. Nursing notes must be logical, focused, and relevant to care, and must represent each phase of the nursing process. Nursing documentation based on the nursing process facilitates effective care. 16-12
- 13. Use of Common Vocabulary Legibility Abbreviations and Symbols Organization Accuracy Documenting a Medication Error Confidentiality Timing Sequence completeness 16-13
- 14. Use of Common Vocabulary Enhances the quality of documentation. Supports the efforts of research. Improves communication and lessens the chance of misunderstanding between members of the health team. Legibility Print if necessary. Do not erase or obliterate writing. Draw one line through an erroneous entry. State the reason for the error. Sign and date the correction. 16-14
- 15. 16-15 Correcting a documentation error
- 16. Abbreviations and Symbols Always refer to the facility’s approved listing. Avoid abbreviations that can be misunderstood. Organization Start every entry with the date and time. Chart in chronological order. Chart in a timely fashion to avoid omissions. Chart medications immediately after administration. Sign your name after each entry. 16-16
- 17. 16-17 Charting a late entry
- 18. Accuracy Use factual, descriptive terms to chart exactly what was observed or done. Use correct spelling and grammar. Write complete sentences. Maintain continuity of care by recording with respect to notes made on previous shifts. 16-18
- 19. Documenting a Medication Error Chart the medication on the MAR. 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 16-19
- 20. Confidentiality The nurse is responsible for protecting the privacy and confidentiality of client interactions, assessments, and care. The client’s significant others, insurance companies, or other parties not directly involved in care provided by the health team may not have access to clients’ records. 16-20
- 21. Timing The recording must be done on the particular time to prevent error. Sequences The recording must be done in a continuous manner . Completeness The recording must be fully completed including the sign. 16-21
- 22. Narrative Charting Source-Oriented Charting Problem-Oriented Charting PIE Charting Focus Charting Charting by Exception (CBE) Computerized Documentation Case Management with Critical Paths 16-22
- 23. 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. Source-Oriented Charting Narrative recording by each member (source) of the health care team on separate records. 16-23
- 24. Problem-Oriented Charting (POMR) Uses a structured, logical format called S.O.A.P. S: subjective data O: objective data A: assessment (conclusion stated in form of nursing diagnoses or client problems) P: plan Uses flow sheets to record routine care. A discharge summary addresses each problem. SOAP entries are usually made at least every 24 hours on any unresolved problem. SOAP was developed on a medical model. 16-24
- 25. SOAPIE and SOAPIER refer to formats that add: I: Intervention E: Evaluation R: Revision 16-25
- 26. PIE Charting P: Problem I: Intervention E: Evaluation Key components are assessment flow sheets and the nurses’ progress notes with an integrated plan of care. PIE charting is a nursing model. 16-26
- 27. Focus Charting A method of identifying and organizing the narrative documentation of all client concerns. Includes data, action, response. Uses a columnar format within the progress notes to distinguish the entry from other recordings in the narrative notes. Charting by Exception (CBE) The nurse documents only deviations from preestablished norms. Avoids lengthy, repetitive notes. Enables the identification of trends in client status. 16-27
- 28. Computerized Documentation Increases the quality of documentation and save time. Increases legibility and accuracy. Enhances implementation of the nursing process. Enhances the systematic approach to client care. Provides clear, decisive, and concise key words (standardized nursing terminology). Provides access to other data, enhancing critical thinking. Information is quickly coordinated and integrated by other departments. Facilitates statistical analysis of data. 16-28
- 29. Point-of-Care System A handheld portable computer is used for inputting and retrieving client data at the bedside. Provides each health care practitioner with all pertinent client data to ensure continuity of care without duplication. Provides crucial client information in a timely fashion. 16-29
- 30. Case Management Process A methodology for organizing client care through an illness, using a critical pathway. A critical pathway is a monitoring and documentation tool used to ensure that interventions are performed on time and that client outcomes are achieved on time. 16-30
- 31. Kardex Flow Sheets Nurses’ Progress Notes Discharge Summary 16-31
- 32. The Kardex The Kardex is used as a reference throughout the shift and during change-of-shift reports. Client data Medical diagnoses and nursing diagnoses Medical orders Activities 16-32
- 33. Forms for Recording Data Flow sheets reduce the redundancy of charting in the nurses’ progress notes. The information on flow sheets can be formatted to meet the specific needs of the client. Nurses’ progress notes are used to document the client’s condition, problems and complaints, interventions, responses, achievement of outcomes. Progress notes can be completely narrative or incorporated into a standardized flow sheet. 16-33
- 34. 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 Trends in Documentation Standardized data bases are required to ensure accuracy and precision in nursing information systems. 16-34
- 35. Verbal communication of data regarding the client’s health status, needs, treatments, outcomes, and responses Summary of current critical information to facilitate clinical decision making and continuity of client care Reporting is based on the nursing process, standards of care, and legal and ethical principles. Reports require participation from everyone present. 16-35
- 36. Summary Reports Walking Rounds Telephone Reports and Orders Incident Reports 16-36
- 37. Commonly occur at change of shift (or when client is transferred). Assessment data Primary medical and nursing diagnoses Recent changes in condition, adjustments in plan of care, and progress toward expected outcomes Client or family complaints 16-37
- 38. Walking Rounds Nursing, physician, interdisciplinary Occur in the client’s room and include the client 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. 16-38
- 39. Used to document any unusual occurrence or accident in the delivery of client care. The incident report is not part of the medical record, but it may be used later in litigation. 16-39
- 40. Trends in Charting Reduction in duplicate charting Bedside charting Multidisciplinary charting Clinical paths More uniformity in documentation Computerized documentation Fax machines 16-40
- 41. proper documentation will protect the nurse in critical situation 16-41