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Documentation. NUR101 Lecture #5 Fall 2008 K. Burger, MSED, MSN, RN, CNE PPP by S. Niggemeier, MSN, BSN, RN. Supports Nsg actions indicates client’s condition Primary communication tool Legal protection Reimbursement. Education Quality Assurance

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Documentation

Documentation

NUR101

Lecture #5

Fall 2008

K. Burger, MSED, MSN, RN, CNE

PPP by S. Niggemeier, MSN, BSN, RN


Purpose of documentation

Supports Nsg actions indicates client’s condition

Primary communication tool

Legal protection

Reimbursement

Education

Quality Assurance

Research

Historic and legal document

Decision analysis

Purpose of Documentation


Types of documentation

Nurses Notes

Flow sheets

Graphics

Nursing Care Plans

Caremaps

Critical Pathways

Computer charting

Types of Documentation


Methods of documentation

Traditional (source oriented client record)

Problem Oriented Medical Record (POMR)-SOAP-PIE-Focus DAR

Charting by exception

Methods of Documentation


Documentation1

Documentation

  • NN (nurses notes) best assessment of pt. care. Most used section of the medical record in legal cases

  • Documentation or Charting is a skill

  • Record of pt.’s condition, activities and events that occurred to the PATIENT.

  • Not a diary of your activities.

  • Includes Subjective & Objective info


Documentation2

Documentation

  • Chart facts, not your opinion

  • Use quotations if pt. said it.

  • Be specific!! Using nonspecific terms implies doubt about your knowledge. i.e. appears/seems/tolerated well etc.

  • In most cases when care or observations are not charted it means it wasn’t done

  • ABC’s: Accuracy/Brevity/Completeness


Guidelines for documentation content

Guidelines for Documentation: Content

  • Focus on pt.

  • Not a novel or essay

  • Use short sentences

  • Abbreviations

  • Symbols

  • Don’t need to use word pt.


Guidelines for documentation timing

Guidelines for Documentation: Timing

  • Chart as soon as possible after care/observations

  • NEVER chart what you plan to do

  • Date & time each entry in the margin


Guidelines for documentation format

Guidelines for Documentation: Format

  • Use forms as per agency policy(i.e. flow sheets, graphic sheet, NCP, progress notes)

  • Follow agency guidelines regarding color ink, approved abbreviations, format of time (i.e. military/standard)

  • Write LEGIBLY-questionable info implies doubt suggests you lack reasonable knowledge

  • NEVER skip lines!!

  • Use correct grammar/spelling


Guidelines for documentation accountability

Guidelines for Documentation: Accountability

  • Record is permanent

  • Sign full name and title

  • No erasures

  • Do Not write ERROR for a mistake

  • Single line thru mistake, print “Mistaken Entry” or ME (if acceptable) above or next to mistake, enter correction, initial & date per policy


Guidelines for documentation confidentiality

Guidelines for Documentation: Confidentiality

  • Students only use patient initials on assignments

  • Only caregivers need to know info in chart

  • Follow facility policy for pt. review of chart.


Other guidelines for documentation

Hospitals- computers

Home care- laptops

Telephone orders

Other Guidelines for Documentation


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