DOCUMENTING-AND-REPORTING.2021-1.ppt
- 2. Objectives: At the end of the discussion, the learner will be able to: • List guidelines for effective documentation • Discuss reasons for keeping clients record • Explain how various forms in the client record are used to documents steps of nursing process • Identify guidelines for effective recording and reporting
- 3. Documenting Care • Documentation is the written, legal record of all pertinent interactions with the patient. • The Patient record is a compilation of a patient’s health information
- 4. Guidelines for Effective Documentation Content: – enter information in a complete, accurate, concise and factual manner – Avoid generalizations such as “seems comfortable today” – Document in a legally prudent manner. Know and adhere to professional standards – Avoid the use of stereotypes or derogatory terms when charting
- 5. Guidelines for Effective Documentation Timing: – chart in a timely manner – Indicate in each entry the date and both the time the entry was written and the time of pertinent observations and interventions – Document nursing interventions as closely as possible to the time of their execution – Never document interventions before carrying them out
- 6. Guidelines for Effective Documentation Format: – chart on the proper form as designated by agency – Print or write legibly in dark ink to ensure permanence. Use correct grammar and spelling. Use standard terminology. – Chart nursing interventions chronologically on consecutive lines. Never skip lines. Draw a single line through blank spaces
- 7. Guidelines for Effective Documentation Accountability: – sign your first initial, last name and title to each entry – Do not use dittos, erasures or correcting fluid. A single line should be drawn through an incorrect entry and words – “mistaken entry” or “error in charting” should be printed above or beside the entry and signed. The entry should then be rewritten correctly – Recognize that the patient’s record is permanent
- 8. Guidelines for Effective Documentation Confidentiality: – observe patient’s moral and legal rights – The student or graduate is bound by a strict ethical code and legal responsibility to hold all information in confidence. – Actual patient names and other identifiers should not be used in written or oral student reports
- 9. Ethical and Legal Consideration • ANA code of ethics states: – The nurse has a duty to maintain confidentiality of all patient information • The client’s record is protected legally as a private record of the client’s care.
- 10. Ensuring Confidentiality of computer records • A personal password is required to enter and sign off computer files. • After logging on, never leave a computer terminal unattended. • Do not leave client information displayed on the monitor where others may see it. • Shred all unneeded computer-generated worksheets.
- 11. • Follow the agency procedures for documenting sensitive material, such as diagnosis of AIDS. • IT personnel must install firewall to protect the server from authorized access.
- 12. Purpose of clients Records – Communication – Planning Client care – Auditing Health Agencies – Research – Education – Reimbursement Legal documentation – Health Care Analysis
- 13. Definition of Terms • Discussion – An informal consideration of a subject by two or more health care personnel to identify a problem or establish strategies to resolve a problem • Report – An oral, written or computer-based communication intended to convey information to others.
- 14. • Record – A written or computer based. – The process of making an entry on a client record is called recording, charting or documenting • Clinical record or chart or client record – A formal, legal document that provides evidence of a client’s care.
- 16. DOCUMENTATION SYSTEMS – Source- oriented Record – Problem – Oriented Medical Record – Problem Intervention Evaluation (PIE) Model – Focus Charting – Charting by exception – Computerized documentation – Case Management
- 17. SOURCE ORIENTED RECORD • One in which each healthcare group keeps data on its own separate form • Advantage: each discipline can easily find and chart pertinent data • Disadvantage: the data are fragmented making it difficult to tract problems chronologically with input from different group of professionals
- 18. SOURCE ORIENTED RECORD Progress notes written by nurses are Narrative notes – it consist of written notes that include the routine care, normal findings and client’s problem
- 19. Problem-Oriented Medical Record (POMR) • Also called as problem oriented record (POR) • Establish by Lawrence Weed in 1960’s • The data are arranged according to the problems the client has rather than the source of information
- 20. Advantages of POMR • It encourages collaboration • Problem list in the front of the chart alerts caregiver to the client’s needs and makes it easier to track each status of the problem • Progress notes clearly focus on patient’s problem
- 21. Disadvantages of POMR • Caregivers differ in their ability to use the required charting format • It takes constant vigilance to maintain an up- to-date problem list • It is somewhat inefficient because assessments and interventions that apply to more than one problem must be repeated
- 22. POMR 4 Basic Components • Database – consist all information known about the client when the client first enters the health care agency. • Includes nsg. Assessment , the physician’s history , social and family data and family data and result of the physical exam., and baseline diagnostic test
- 23. POMR 4 Basic Components • Problem List – is derived form the data base – It is usually kept in front of the chart and serves as an index to the numbered entries in the progress notes
- 24. • Plan of Care – the initial list of orders or plan of care is made with reference to the active problems – Care plans are generated by the person who list the problems ex. Physician writes order or medical care plans: nurses write nursing orders of nursing care plan, the written plan is listed under each problem in the progress notes
- 25. • Progress Notes – is a chart entry made by all health professional involves in a client’s care, they all use the same type of sheet for notes – Ex. SOAP format is frequently used, SOAPIE, SOAPIER
- 26. SOAPIE or SOAPIER • S- UBJECTIVE- What the clients says • O-BJECTIVE – observation of nurse with the use of senses ( physical assessment, v/slab results, X-rays • A- SSESSMENT– interpretation or conclusion drawn from S and O data on initial assessment. Problem list is created from data base. Statement of the problem • P-LAN- care designed to resolve the problem, desired outcomes criteria, Targets , SMART • I- NTERVENTION – specific intertvention that actually performed by the care giver. Includes treatment given • E-VALUATION – responses to nursing intervention and medical treatment • R-EVISION – Reflect care plan modification suggested by the evaluation. Changes may be made in desired outcomes.
- 27. PIE Model • The plan of care is incorporated into the progress notes in which problems are identified by number • 3 Categories: – Problems – Interventions – Evaluation
- 28. PIE Model • Advantage: it promotes continuity of care • Disadvantage: Nurses need to read all the nursing notes to determine problems and planned interventions before initiating care
- 29. Focus charting • Intended to make the client and the client concerns and strengths the focus of care • The focus maybe a condition, a nursing diagnosis, a behavior, sign and symptom, an acute change in client’s condition or a client’s strength • The progress notes are organized in: DAR – D data – A action – R response
- 30. DATA is used alone when the purpose of the note is to document assessment finding and there is no flow sheet/ checklist for that purpose. D: “Mainit ang pakiramdam ko” Skin warm to touch. Temperature is 39°C. D – “Miss, masakit ang pinaglagyan ng IV ko.” Check site of IV, found beginning signs of infiltration D: “Sumasakit and dibdib ko”Midclavicular line; pain of 4/5 Radiating to jaw. Relieved by Rest. VS stable.
- 31. Begin the note with ACTION when the patient's interaction beings with intervention or when including data would be unnecessary repetition A: Tepid sponge bath given. Encouraged toIncrease fluid intake. Referred to (Dr. Tan. Paracetamol 500mg 1 tab. po given. May Aquino, RN A: Patient instructed on the Actions and side effects of Digoxin. Given digoxin information Card. Discussion when He would call the physician About the medicine. May Aquino , RN
- 32. A– Remove IV, change the whole system, reinserted the new set aseptically into the distal portion of basilic vein, left arm anchored, splint applied, advised to call nurse for any presence of pain . May Aquino, RN A: Encourage to rest on bed. Medicated with Isordil 5mgSL. May Aquino, RN
- 33. DATA and ACTION are recorded at one hour, and RESPONSE is not added until later, when the patient outcome is evident.
- 34. RESPONSE is used alone to indicate a care plan goal has been accomplished. R: “Pinagpawisan na ako.” Temperature is 38°C. Tolerated 2 glasses of water . May Aquino, RN R: Return demonstration of Radial pulse. “I understand Purpose of medication.” May Aquino, RN R: Resting in bed “Navawasan ang sakit ng dibdib ko.” Rating of 2/5. May Aquino, RN
- 35. Sample of FDAR DATA/ TIME FOCUS DATA, ACTION, RESPONSE 3/2/17 Fever D: “Mainit ang pakiramdam ko” Skin warm to 7:00am touch. Temperature is 39°C. A: Tepid sponge bath given. Encouraged to Increase fluid intake. Referred to Dr. Tan. Paracetamol 500mg 1 tab. po given. M.. Aquino, RN 8:00nn Fever R: “Pinagpawisan na ako.” Temperature is 38°C. Tolerated 2 glasses of water A: Continue tepid sponge bath. Changed Cloting. Will monitor temperative. M. Aquino, RN
- 36. ACTION AND RESPONSE DATA/ TIME FOCUS DATA, ACTION, RESPONSE 3/2/17 Health A: Patient instructed on the 2:00 pm Teaching: Actions and side effects of Digoxin Digoxin. Given digoxin information Card. Discussion when He would call the physician About the medicine. R: Return demonstration of Radial pulse. “I understand Purpose of medication.” M. Aguino, RN.
- 37. DATA/ TIME FOCUS DATA, ACTION, RESPONSE 3/2/17 Chest pain D: “Sumasakit and dibdib ko” 10:00am Midclavicular line pain of 4/5 Radiating to jaw. Relieved by Rest. VS stable. A: Encourage to rest on bed. Medicated with Isordil 5mg SL. M. Aquino, RN 12nn Chest pain R: Resting in bed “Navawasan ang sakit ng dibdib ko.” Rating of 2/5. M. Aquino, RN
- 38. Charting by Exception (CBE) • Is a documentation system in which only abnormal or significant findings or exceptions to norms are recorded • Example: • Flow sheets- Vital signs graphic record, I & O, Medication Sheet
- 39. Computerized Documentation • Computerized clinical record system are being developed as a way to manage the huge volume of information required in contemporary health care • Nurse use computers to store the client’s database, add new data, create & revise care plans & document client progress
- 40. CASE MANAGEMENT • Emphasizes quality, cost-effective care delivered within the established length of stay. • Uses multidisciplinary approach to planning and documenting client care, using critical pathways • These form identify the outcomes that certain groups of clients are expected to achieve on each day of care, along with the interventions necessary for each day • Incorporates graphics and flow sheet
- 41. • Progress notes typically use some type of charting by exception • Ex. If goals are met, no further charting is required • A goal that is not met is called Variance
- 42. Documenting Nursing Activities • Admission Nursing Assessment • Nursing Care Plan • Kardexes • Flow Sheet • Progress Notes • Nursing Discharge/Referral Summaries
- 43. Admission Nursing Assessment • A comprehensive admission assessment also referred to as an initial database, nursing history or nursing assessment, is completed when the client is admitted to the nursing unit • The nurse generally records ongoing assessments or reassessments on flow sheets or on progress notes.
- 44. Nursing Care Plans 2 types of NCP 1. Traditional care plan is written for each client – Varies from agency to agency according to the needs of the client and the department – Most forms have 3 columns: nursing diagnosis, expected outcomes, nursing interventions
- 45. 2. Standardized Care Plan – were develop to save documentation time. – Based on an institution’s standard of practice, thereby helping to provide a high quality of nursing care – Individualized
- 46. Kardexes • Concise method of organizing and recording data about a client, making information quickly accessible to all health care professionals • System consist of series of cards kept in a portable index file or a computer generated forms
- 47. DO’S OF DOCUMENTATION 1.DO read what other providers have written before providing care and before charting your care. 2.DO time and date all entries 3.DO write the time you put your pen on the paper.
- 48. 4. Do record exactly what happens to patient and care given. 5. DO be factual and complete 6. DO draw a single line through an error. Mark this entry as “error” and sign your initials
- 49. 7.DO use next available line to chart. 8.DO document patient’s current status and response to medical care and treatments. 9.DO write legibly. DO use ink. Do use accepted chart forms. 10. Do use only approved abbreviations.
- 50. • Incident reports – Also termed a variance or occurrence report – Used to document the occurrence of anything out of the ordinary that results in or has the potential to result in harm to a patient, employee or visitor – These reports are for quality improvement and should not be used for disciplinary action against staff members
- 51. Thanks and God Bless You!