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Documentation. Kelli Shugart RN,MS. Documenting Care. Documentation- written or typed, legal record of all pertinent interactions with the patient Contains data used to: Facilitate patient care Serve as financial and legal record Help in clinical research Support decision analysis.

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  1. Documentation Kelli Shugart RN,MS

  2. Documenting Care • Documentation- written or typed, legal record of all pertinent interactions with the patient • Contains data used to: • Facilitate patient care • Serve as financial and legal record • Help in clinical research • Support decision analysis

  3. Documenting Care • Patient Record- is a compilation of a patient’s health information • Joint Commission on Accreditation of Healthcare Organizations (JCAHO)- specifies that nursing care data be implemented into the patient record. • Patient assessment • Nursing diagnosis • Patient needs • Nursing interventions • Patient outcomes

  4. Documentation Guidelines- BOX 17-1 • Aim: complete, accurate, concise, current, factual, and organized data communicated in a timely and confidential manner to facilitate care coordination and serve as a legal document. • Content • Timing • Format • Accountability • confidentiality

  5. Using the 24-hr Cycle Military Clock for Documenting Times

  6. Documentation • Should be: • Consistent with professional and agency standards • Complete • Accurate • Concise • Factual • Organized • Timely • Legally prudent • confidential

  7. Problems • Crucial Omissions • Meaningless repetitious entries • Inaccurate entries • Length of time • Problems • Undermine nurse’s credibility as a professional discipline • Cause legal problems for the nurse responsible

  8. Privacy and Confidentiality • All info about patients is considered private or confidential. • Written on paper • Saved on computer • Spoken out aloud • Names • Address • Telephone number • Fax number • Social security • Reason person is sick or in the hospital, office, or clinic • Treatment • Information about PMH

  9. Protected health information • Might be found in: • Patient medical record • Computer systems • Telephone calls • Voice mails • Fax transmissions • E-mails that contain patient info • Conversations about patients between clinical staff

  10. Examples of privacy violation • Giving info over phone • Discussing a patient in areas where you can be over heard (elevators/cafeteria) • Discussing a patient you are not directly involved with • Leaving patient medical info in a public area • Failing to log off computer • Sharing or exposing passwords • Improperly accessing, reviewing, and/or releasing confidential info ………

  11. Health Insurance portability and Accountability Act (HIPPA) • Workers must undergo HIPPA training and sign confidentiality agreements • Patients have a right to: • See and copy their health record • Update their health record • Get a list of the disclosures a healthcare institution has made independent of disclosures made for the purposes of treatment, payment, and healthcare options • Request a restriction on certain uses or disclosures • Choose how to receive health info

  12. Agency Policy • Everyone who has access to the record (direct caregivers) is expected to maintain its confidentiality • Most agency grant nursing students access for education purposes….must hold info in confidence…Never use patient’s name when preparing written or oral reports • Agency policy indicates which personnel are responsible for recording on each form in the record… • Policy also indicates order of chart

  13. Agency Policy • Policy may indicate frequency to record entries • What to record • Manner to identify self • Kelli Shugart, RN, GBCN • Sally Cabbage Patch, SN, GBCN • Which abbreviations are acceptable– see table 17-2

  14. Agency Policy • Manner to record errors error KPS • Abdominal dressing dry and intact, 6 inches • Usually draw one line through and write “error” with your initials….Do not erase, use white out or scratch out • Documentation by unlicensed personnel • Storage of patient records • www.dukehealth.org/Privacy/PatientConfidentiality.

  15. Purposes of patient record • Communication • Diagnostic and therapeutic orders • Verbal orders-order must be given directly by the physician, or nurse practitioner to a registered nurse or registered pharmacist • The only circumstance in which an attending physician, nurse practitioner, or house officer may issue orders verbally is in a medical emergency, when they are present but unable to write the actual order.

  16. Verbal Order sequence • The RN who receives the order will: • Record the orders in the medical record • Read the order back to verify accuracy • Date and note the time • Record V.O. (verbal orders), name of the MD who issued the orders, followed by the nurse’s name and title • Example: • Give 0.25mg po lanoxin Daily, starting in Am 9/18/09 V.O. Micheal Smith, MD/Kelli Shugart, RN

  17. Verbal Orders • It is the responsibility of the physician or nurse practitioner who issued the verbal order to: • Review the order for correctness • Sign the orders with his or her name, title, and pager number • Date and note the time he or she signs the orders • It is the responsibility of the unit secretary and/or the registered professional nurse to see that the orders are transcribed according to procedure

  18. Telephone & Fax orders • Agency policy must be followed • Every T.O. must be repeated back to ensure that the nurse correctly understands what was ordered. • Must be on an order sheet • Co-Signed by physicians within a specific time • Fax orders must be legible and issued from a credentialed and privileged individual

  19. Telephone & Fax Orders • Follow similar protocol as V.O. (1-3) • Record T.O. (telephone order) and the full name and title of the physician or nurse practitioner (NP) who issues the orders. • Sign the orders with name and title • It is the responsibility of the physician or NP dictating the orders to sign them as soon as practical. With exception of orders for narcotics, anticoagulants, and antibiotics, which must be signed within 24 hours.

  20. Purposes of patient record • Care Planning • Quality review • Research • Decision analysis • Education • Legal documentation • Reimbursement • Historical documentation

  21. Methods for documenting • Source oriented Records • Advantage • Each discipline can easily find and chart data • Disadvantage • Data fragmented • Problem-Oriented Medical Record- (POMR) • Example Box 17-3 • Advantage • Entire health team works together to determine list of problems • Collaborative plan of care • Progress notes clearly focus on patient problems

  22. Methods for documenting • Major parts of POMR: • Defined database • Problem list • Care plan • Progress notes • SOAP- originated from medical record • SOAPE • SOAPIE • SOAPIER (Intervention, Evaluation, Response)

  23. Methods for documenting • PIE- Problem, Intervention, Evaluation- originated from nursing • Example figure 17-2 • Does not develop separate plan of care • At beginning of each shift patient problems are identified, numbered and documented in progress notes, and worked up using PIE format • Resolved problems are dropped • Advantage • Continuity and saves time (no separate Plan of Care) • Disadvantage • Nurses have to read all nursing notes to determine problems and planned interventions

  24. PIE Example

  25. Methods for documenting • Focus charting • Focus may be on a patients • Strength • Problem • Need • Topics may include • Patient concerns and behaviors • Therapies and responses • Changes in condition • Significant events

  26. Methods for documenting • Focus • Narrative section uses the Data, Action, Response (DAR) format- example figure 17-3 • Advantage • Holistic emphasis on patient • Ease of charting • Disadvantage • Some nurses argue that the DAR categories are artificial and not helpful when documenting care

  27. Focus Example

  28. Methods for documenting • Charting by exception (CBE)- figure 17-4 • Advantages • Decreased charting time • Greater emphasis on significant data • Easy retrieval of significant data • Timely bedside charting • Standardize assessment • Greater interdisciplinary communication • Better tracking of important patient responses • Lower cost • Disadvantage – limited usefulness in response to negligence claims against nurses

  29. Methods for documenting • Case Management Model • Advantages • Collaboration • Communication • Teamwork among disciplines • Efficient use of time increases quality • Disadvantage • Works for “typical” patient

  30. Methods for documenting • Case Management Model • Collaborative Pathways/critical pathways/care mapping –figure 17-5 • Variance Charting • Personal Health Records (PHRs)

  31. Methods for documenting • Computerized Records • Guidelines/strategies for safe computer charting • Never share passwords • Don’t leave computer unattended • Follow protocol when correcting errors, “mistaken entry” add correct info, date and initial entry. If wrong chart, write “mistaken entry – wrong chart”. • Never create, delete or change entries • Back up files • Don’t leave info about patient for others to see • Never use email to send protect health info • Follow policy for documenting sensitive material

  32. Nursing Documentation • Initial nursing assessment- Database • Kardex and Patient Care Summary • Plan of Care- student example chapter 14 • Diagnosis • Goals • Expected outcomes • Interventions • Critical/collaborative pathways-chapter 14, figure 17-5 • Abbreviated case management plan

  33. Nursing Documentation • Progress notes • See Table 17-5 for advantages and disadvantages • Flow Sheets • Graphic (clinical) Record • 24 Hour Fluid Balance Record • Medication Record • 24 Hour Patient Care Record and Acuity Charting Forms

  34. Nursing Documentation • Discharge and Transfer Summary • Home Healthcare Documentation • Long-Term Care Documentation • Potential legal problems—see BOX 17-4, page 381

  35. Reporting care • Reporting – • Face to face • Telephone • Messengers • Written • Audiotaped • Computer messages • Table 17-6 see advantages and disadvantages

  36. Reporting care • Change of Shift Reports • Telephone/telemedicine Reports • Transfer and Discharge Reports • Report to Family and Significant Others • Incident Reports

  37. Change of Shift Report • Basic identifying information about each patient • Current appraisal of each patient’s health status • Changes in medical conditions and patient response to therapy • Where patient stands in relation to identified diagnoses and goals • Current orders (nurse and physician) • Summary of each newly admitted patient • Report on patient transferred or discharged

  38. Conferring about care • Consultations and Referrals • Nursing and Interdisciplinary team Care Conferences • Nursing Care Rounds

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