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Documentation

Documentation

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Documentation

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  1. Documentation By: Cindy Quisenberry

  2. Documentation • Care Plan – a written, interdisciplinary document developed for each patient, listing the patient’s needs and goals as well as the actions and approaches that staff will take to help the patient meet their goals

  3. Documentation • Documentation – written reports that the facility maintains • Objective – information that can be observed; factual; not subjective • Subjective – guess or hunch about what you observe, or something a patient feels inside and tells you about (not objective)

  4. Documentation • Assessment – an evaluation of a patient or condition • Minimum Data Set (MDS) resident information on the RAI, including levels of physical functioning and bowel and bladder continence • Resident Assessment Instrument (RAI) – an assessment tool used in long term care facilities to document key information about residents including their care plans and outcomes

  5. Documentation • Resident Assessment Protocols (RAPs) – section of the RAI that includes a more detailed assessment of problem areas • Quality Indicators – outcomes or a summary of the entire facility’s MDS information, which indicates the quality of care provided by a facility • Summary report can tell an agency (for example) how many residents have pressure ulcers, etc.

  6. Documentation • Think back to a special event you experienced months ago, like a birthday or holiday. Try to remember the event in detail. • What were people wearing? • What did they talk about? • What did they eat and how much? • What was their mood? • What time did each person come and go?

  7. Documentation • You have probably forgotten many facts. It’s only human to forget details like these. • Because of memory limits, we often have to write things down. • If we do not write down details, the only known “facts” might be what we happen to remember. • We do not know at the time how important some details could be later on. • Therefore, the documentation you do on the job is essential so that we do not loose information.

  8. Documentation • Some written notes may be used months or years later. • You and others in a facility can later state facts with certainty because you wrote them down.

  9. Documentation • Sources of Information • The patient is usually the main source of information • Their needs • Their preferences • Verify with the charge nurse, etc.; some patient’s might be confused. • The Family • Other Staff

  10. Documentation • Sources of Information • The Chart (Medical Record) • Main communication tool used by the interdisciplinary team • Legal Record • Basic Tool for Planning, Recording, and Evaluating Plan of Care • Confidential and Belongs to the Facility • Must be Complete and Accurate • If it isn’t charted, it wasn’t done • Contains the Patient’s Medical Hx, Current Records, Care Plans, Medication Records, etc.

  11. Documentation • The Chart Contains • Patient’s identifying Information (Face Sheet or Demographic Sheet) • Name • Medical Record Number • DOB, etc. • Admission Papers (reason for admission) • Permission Forms • Consent to Treat • Instructions • DNR

  12. Documentation • The Chart Contains • Sections of Documentation (from individual disciplines) • Physician’s Orders • Nurse’s Notes • Graphics or Flow Sheets (VS’s, I & O, ADL’s, BM’s, etc.) • Progress Notes • Physician • Physical Therapy • Respiratory Therapy • Dietary • Lab, X-rays, etc.

  13. Documentation • Other Communication Devices and Systems • Patient Wristbands • Colored Wristbands • Words or Symbols on the Patient’s Door, Bed or Chart

  14. Documentation • Facility Policies and Procedures • Rules for how to do things in the facility • Tell you how and why things are done • Completing the Personal Possession Record • Residents Leaving the Facility • HIPAA If you are unsure of anything when talking with members of the team, the resident or family members, just ask. Don’t assume anything you are not sure of.

  15. Documentation • Resident Assessment – CNA’s area key part of gathering data, because they spend so much time with the residents • RAI-is first completed on a resident on admission, and a new assessment is done at least yearly or whenever the resident’s condition changes (improvement or decline) • Five Parts • The Minimum Data Set (MDS) – Done on Computer • Resident Assessment Protocols (RAPs) • Care Plan Development • Care Plan Implementation • Evaluation and Outcome

  16. Documentation • RAI - different sections are completed by different staff members • Nursing Section – Nurses complete this section, however the nurse will ask the CNA for information • Examples • Objective Data – “Mr. Brown puts on his own shirt, but he doesn’t button the buttons himself.” • Subjective Data – “I think he could button his shirt if he had bigger buttons.”

  17. Documentation • RAPs – done after the MDS is completed; a detailed assessment of possible problem areas • Example • Mobility Problem • Gives the staff additional information or “protocols” to determine if there is a problem

  18. Documentation • Care Plan – an interdisciplinary document that lists a resident’s needs and goals as well as the actions and approaches the team will use to help the resident to meet their goals. • Use of the care plan ensures consistent care • List each patient’s medical, nursing and psychological needs. • Good communication skills are needed in care-plan meetings because many people are sharing a lot of information

  19. Documentation • Care Plan • Problem - Poor appetite and weight loss since beginning chemotherapy • Nursing Diagnosis – Imbalanced nutrition; less than body requirements related to decreased appetite secondary to chemotherapy • Goal – Patient will gain 2 pounds within three weeks • Plan • Dietary and physician consult • Weigh every Friday morning

  20. Documentation • Care Plan • Plan • High Calorie Diet • Monitor Intake and Output • High protein drink at 1000 and qhs • Offer ice cream if refuse to drink high protein drink (resident likes ice cream) • Offer snack at bingo • Son will eat with resident at noon • Serve try in A wing lounge

  21. Documentation • How to Report Information • Use a private place to give an oral report • Be careful when talking with family members and visitors • Routine Reporting – reported at the end of a shift • What did you see, hear, smell, or touch when caring for each patient? • Was anything new or changed? • Did I meet each resident’s needs?

  22. Documentation • How to Report Information • Immediate Reporting • Frayed electrical cord • Any unusual incident, such as a resident’s fall • Any suspicion of resident abuse • Any resident’s complaint of ill health, such as a complaint of pain or dizziness • Any unusual observations, such as a resident’s temperature of 103 F or confusion and agitation in a normally alert resident

  23. Documentation • How to Report Information • “By a Certain Time” Reporting • Example – the nurse may need a resident’s temperature before the physician calls

  24. Documentation • Incident Reports • Document an accident or an injury • Provide information about what happened • Protect residents, you, the facility, and others • Documents the incident and all related facts • May give information about what you: • Heard • Saw • Smelled • Touched • Do not document in the patient’s chart that you filled out an incident report

  25. Documentation • Documentation: • Helps you to notice changes in the patient’s condition (ie: comparing blood pressures) and the need for reporting • Helps you watch trends as well as changes • Be sure you understand your facility’s policies and procedures for your documentation • Some facilities use checklists or a combination of different charting methods.

  26. Documentation • Documentation may include: • General statements of care given • The resident’s appointments and activities • Any complaints from the resident • General statements about the resident’s psychological well-being • Visitors, including physician’s visits

  27. Documentation • Guidelines for Documentation (to prevent misunderstandings) • The patient’s name should be on every page. • Write all entries in permanent black ink, not pencil or felt tip markers that may smear when wet. • Write each entry so that it is easy to read. • Charting is continuous. Do not leave spaces or skip lines between entries. • Document only your own actions and observations. • Do not tamper with or change entries made into the chart unless you make an error. If you make an error, correct it immediately and properly.

  28. Documentation • Guidelines for Documentation (to prevent misunderstandings) • Use standard medical terminology and standard abbreviations. • Write down the date and the time of each entry as required. • Sign each entry and include your title after your name. In some cases you may initial the entry when your signature is somewhere else on the form.

  29. Documentation • Correcting a Mistake • Draw a single line through the word. • ? Print the word “error” above or beside the word (depends on the facilities policy). • Add your initials and date above it. • Then write the correct word before continuing • Do not try to cover an error with “x’s” or scribble all over it, use white out, etc. • If you are correcting a large amount of writing, be sure to write the reason you are making the correction. (discovered that you wrote information on the wrong patient’s chart)

  30. Documentation • Correcting a Mistake • Do not try to erase a mistake. (NEVER erase a mistake) • Ask someone for help if you cannot figure out how to clearly correct a documentation mistake.

  31. Documentation • The interdisciplinary care team uses the minimum data set (MDS) to: • Make roommate assignments • Develop a resident’s care plan • Keep a record or monthly expenses • Teach nurse assistants correct medical terminology

  32. Documentation • The interdisciplinary care team uses the minimum data set (MDS) to: • Make roommate assignments • Develop a resident’s care plan • Keep a record or monthly expenses • Teach nurse assistants correct medical terminology

  33. Documentation • Who is the primary source of information about a resident? • The resident • The charge nurse • The social worker • The resident’s physician

  34. Documentation • Who is the primary source of information about a resident? • The resident • The charge nurse • The social worker • The resident’s physician

  35. Documentation • A medical record is used to maintain: • The facility’s financial information • The facility’s equipment maintenance record • Lab results and reports by all care staff • Correspondence between the resident and their family

  36. Documentation • A medical record is used to maintain: • The facility’s financial information • The facility’s equipment maintenance record • Lab results and reports by all care staff • Correspondence between the resident and their family

  37. Documentation • Mr. Houston’s weight is checked each day. Before the end of your shift, you would record this information on: • A wall calendar • A flow sheet • The Quarterly Review form • The Resident Assessment Protocols

  38. Documentation • Mr. Houston’s weight is checked each day. Before the end of your shift, you would record this information on: • A wall calendar • A flow sheet • The Quarterly Review form • The Resident Assessment Protocols

  39. Documentation • You have just taken Mrs. Cotton’s temperature. It is 98.4˚. This is a type of: • A wall calendar • A flow sheet • The Quarterly Review form • The Resident Assessment Protocols

  40. Documentation • You have just taken Mrs. Cotton’s temperature. It is 98.4˚. This is a type of: • A wall calendar • A flow sheet • The Quarterly Review form • The Resident Assessment Protocols

  41. Documentation • The minimum data set (MDS) is one part of the: • Quality indicators • Resident’s care plan • Resident Assessment Instrument (RAI) • Resident Assessment Protocols (RAPs)

  42. Documentation • The minimum data set (MDS) is one part of the: • Quality indicators • Resident’s care plan • Resident Assessment Instrument (RAI) • Resident Assessment Protocols (RAPs)

  43. Documentation • A resident’s care plan is used as a tool to: • Determine whether the resident qualifies for Medicaid payments • Invite family members to facilities parties • Plan for new building improvement • Coordinate all treatments and services for the resident

  44. Documentation • A resident’s care plan is used as a tool to: • Determine whether the resident qualifies for Medicaid payments • Invite family members to facilities parties • Plan for new building improvement • Coordinate all treatments and services for the resident

  45. Documentation • Your role in the care plan meeting includes: • Sharing information about the resident • Serving coffee and doughnuts to the interdisciplinary team • Deciding which doctors and nurses should attend • Diagnosing the resident’s medical condition

  46. Documentation • Your role in the care plan meeting includes: • Sharing information about the resident • Serving coffee and doughnuts to the interdisciplinary team • Deciding which doctors and nurses should attend • Diagnosing the resident’s medical condition

  47. Documentation • Routine information about residents is usually shared with the charge nurse: • On your lunch break • At the end of your shift • During weekly personnel meetings • Immediately

  48. Documentation • Routine information about residents is usually shared with the charge nurse: • On your lunch break • At the end of your shift • During weekly personnel meetings • Immediately

  49. Documentation • When you write in a resident’s chart, you should: • Erase any mistakes and then write in the correct information • Get the doctor’s permission before you write anything • Write neatly and legibly • Correctly any mistakes you see that were made by others

  50. Documentation • When you write in a resident’s chart, you should: • Erase any mistakes and then write in the correct information • Get the doctor’s permission before you write anything • Write neatly and legibly • Correctly any mistakes you see that were made by others