Documentation

1. Documentation

2. What Is It? • Written record of everything done for a patient • Medications • Treatments • Activities • Education • supplies

3. Purpose • Accreditation • To prove meeting prescribed standards • Reimbursement • To show what was used • Legal • Shows condition of patient before, during and after treatment • Communication • Within the health team

4. Special Considerations • Confidentiality • Only for those with “need to know” • Must be accurate and thorough • Must be legible

5. Characteristics • Factual • Describe findings, not what “seems” or “appears” • Use exact patient statements, put in “ ---” • Accurate • Precise measurements • No unnecessary words • Only pertinent details • Correct spelling

6. More Characteristics • EACH ENTRY MUST BE: • Timed • At the time of activity ** • Dated • Signed • By the person recording • **exceptions: • after shift • Team effort

7. Signatures • First name or initial • Full last name • Title (ADNS) • At least once per page • Then may use initials

8. Still more characteristics • Completeness • Thoroughly describe events using details of • Quality • Quantity • Duration • Measurements • Rating scales

9. yet more characteristics • Current • Up to the minute • Don’t ‘wait til later’ • Organized • Use a logical method • Make & review notes before writing in record

10. Legalities • NEVER: • Erase • use white-out • scratch or scribble out • ALWAYS • Omit critical commentary • Completely record FACTS • Record clarification efforts • Write legibly, use black ink • Correct errors promptly

11. IMPORTANT • If it isn’t written, it wasn’t done

12. Malpractice Issues • Incorrect time of when events occurred • Not recording verbal orders • Not getting verbal orders signed • Charting actions in advance • Documenting incorrect data

13. Types of Records • Facility designates which format of documentation • SOAP • Subj, obj, assess, plan • PIE • Plan, implement, evaluate • DAR • Data, actions, responses

14. Discharge Planning • Begins at time of admission • Must educate the patient • Throughout hospital stay • Diet, meds, treatments, rehab, community resources • Continuity between health teams

15. End of Shift Reports • Report facts • Obj & subj data • Info about family, prn • Responses to care or treatments • Occurrences

16. Telephone or Verbal Orders • Listen carefully • Write down on notepad • Ask questions if necessary • Read back to physician • Document on order page • Sign after order: • T.O. Dr.Fry/N. Nurse, RN • V.O. Dr. Oar/N. Nurse, RN