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Documentation. N-205 Fundamentals Lecture. Objectives. Demonstrate the role of caregiver and communicator by documenting nursing care, following legal guidelines. Understand the purpose of patient records, ethical accountability and confidentiality.

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  1. Documentation N-205 Fundamentals Lecture

  2. Objectives • Demonstrate the role of caregiver and communicator by documenting nursing care, following legal guidelines. • Understand the purpose of patient records, ethical accountability and confidentiality. • Review legal abbreviations used by all health care providers.

  3. Objectives (cont’d.) • As caregiver, understand the different methods of documenting care (narrative, pie charting, focus charting, charting by exception and computerized records). • Describe the difference between a Kardex graphic and flow sheet and progress notes. • As the communicator, describe what a change of shift report should include and its purpose.

  4. Objectives (cont’d.) • Discuss documentation mechanics that increase risk for legal problems. • Discuss difference between telephone reports and telephone orders • Identify ways to maintain confidentiality of records and reports

  5. Important concepts: • Effective communication is essential to the coordination and continuity of care. • Avoid duplications and omission of care • Supports & complements one another’s care • 3 methods: • Documenting • Reporting • Conferring

  6. Documenting Care • Documentation – a written, legal record of all pertinent interactions with patient: assessing, diagnosing, planning, implementing and evaluating. • Contains data to facilitate patient care, serve as financial & legal records, help in clinical research, & decision analysis • Patient record – a compilation of a patient’s health information. • legal document

  7. What makes up the medical record? • Face sheet • Medical history & Physical exam • Initial nursing assessment form • Doctor’s order sheet • Problem or nursing diagnosis list • Nursing plan of care • Graphic sheet

  8. What makes up the medical record? • Medication administration record • Nurse’s progress notes • Doctor’s progress notes • Diagnostic findings • Health care team records • Consultation sheets • Discharge plan and summary

  9. Why is it important to document everything? • Patient record - a legal document that details all nurse’s interaction with the patient • It is the nurse’s best defense. • It should be: complete, accurate, concise, factual, organized and timely; legally prudent and confidential.

  10. Guidelines for Effective Documentation • Content • Enter information in a complete, accurate, concise and factual manner • Record patient findings (not your interpretation but observation) • Reflects the nursing process & professional responsibilities • Avoid words like “good”, “average”, or “sufficient”; avoid generalizations “seems comfortable”

  11. Guidelines for Effective Documentation • Content • Note problems in an orderly, sequential manner. • Document in a legally prudent manner. (adhere to agency policy & professional standards) • Document the nursing response to questionable medical orders or treatment (or failure to treat).

  12. Guidelines … (cont’d.) • Timing • Chart in a timely manner. Follow agency policy and modify if patient’s status warrants it. • Indicate the date and the time. • Most agencies used military time to avoid confusion. • Document as closely as possible to the time of their execution. • NEVER document interventions before carrying them out.

  13. Military Clock Time

  14. Guidelines.. (cont’d.) • Format • Make sure you have the correct chart before writing. • Chart on the proper form as designated by agency policy. • Print or write legibly in dark ink. • Use correct grammar & spelling. • Use only standard terminology. • Follow computer documentation guidelines. • Date and time each entry • NEVER skip lines. Draw a single line through blank spaces. • Chart chronologically.

  15. Guidelines (cont’d.) • Accountability • Sign your first initial, last name and title to each entry. • Do not use dittos, erasures or correcting fluids. • Draw a single line • Use words like “mistaken entry” or “error in charting” • Re-write the entry correctly • Identify each page of record • Ensure patient record is complete before sending to medical records.

  16. Guidelines … (cont’d.) • Confidentiality • Patient have a moral and legal right to privacy. • Students should be familiar with agency policy • Most agencies allow students to access. • Students are bound professionally and ethically to keep in strict confidence all the info they read. • Actual patient names and other identifiers should not be used in reports.

  17. What information is confidential? • All information about patients whether written on paper, saved on a computer or spoken aloud. • Names, addresses, telephone and fax numbers • Reason the patient is sick, treatments and info about past health condition.

  18. Breaches of confidentiality: • Discussing patient info in any public area. • Leaving patient medical info in a public area. • Leaving a computer unattended in an accessible area with record info unsecured • Failing to log off • Sharing or exposing passwords • Improperly accessing, reviewing and/or releasing info to media or other individuals

  19. HIPAA of 1996 • Health Insurance Portability and Accountability Act • Final regulations published in December 2000 • Modified and released in August 2002. • Every nurse undergo training about the HIPAA to maintain confidentiality. • Includes punishment for anyone violating privacy • Fines: $250,000.

  20. Permitted Disclosure • Authorization Rule • Release of patient’s health information (PHI) for purposes other than treatment, payment and routine health care operations  authorization form must be signed. • 3 exceptions: • Public health activities • Law enforcement and judicial proceedings • Deceased individuals – for coroners, MEs and funeral directors, organ donations

  21. Incidental Disclosure • Secondary disclosure that can not reasonably be prevented. • Limited in nature and occurs as a by-product of an otherwise permitted use or disclosure • Examples: • Use of sign-in sheets • Possibility of confidential conversation being overheard • Placing patient charts outside exam rooms • Use of white boards; calling out names in the waiting room; leaving appointment reminder voicemail msgs

  22. QUESTION Choose all that apply: Which of the following documentation guidelines are correct? • Enter information in a complete, accurate, concise, factual, and organized manner. • Use word such as “good”, “average”, “normal” or “sufficient” to communicate judgment about data. • Wait until the end of shift to document nursing interventions to ensure comprehensive charting • Date and time every entry.

  23. ANSWER 1 & 4 • Enter information in a complete, accurate, concise, factual and organized manner. • Date and time every entry.

  24. Important concepts: • Agency policies indicate which personnel are responsible for recording on each form in the record. • Additional policies regarding: • Frequency of entry • Recording of routine care • Identification manner of personnel after an entry • Manner in which recording errors are handled • Keeping of records – microfilmed or entered in to a computer • Types of abbreviations are acceptable

  25. Common Abbreviations

  26. Common Abbreviations

  27. Common Abbreviations

  28. Common Abbreviations

  29. Common Abbreviations

  30. JCAHO “Do not use” abbreviations, acronyms or symbols

  31. Other “do not use” abbreviations: • > or < - maybe misinterpreted as 7 or the letter L • Abbreviations for drug names • @ - mistaken for 2. • c.c. – mistaken for U; write “mL” • μg – mistaken for mg; write “mcg.”

  32. Purposes of Patient Records • Communication • Diagnostic & therapeutic orders • Care Planning • Quality Review • Research • Decision Analysis • Education • Legal Documentation • Reimbursement • Historical Documentation

  33. Communication • To help healthcare professionals from different disciplines communicate with one another. • Foster continuity of care • Keep in mind that other healthcare professionals make judgments about nurses and nursing’s contributions to the healthcare team on what is documented.

  34. Diagnostic & therapeutic orders • The chart contains all the diagnostic studies ordered for the patient since admission. • Nurses should ensure that these orders are entered and implemented. • Orders should be written and signed except: • Emergencies (verbal orders) • Practitioner is unable to be present on the unit (telephone or faxed orders)

  35. Diagnostic orders… (cont’d.) • Take order only from: (licensed and have credentials) • Physicians • Dentists • Psychologists • Podiatrists • Advanced practice nurses • Medical students: only when countersigned by the attending physician, nurse practitioner or a house officer

  36. Verbal orders • Issued only during medical emergency when the physician/nurse practitioner is present but finds it impossible to write the order. • Order must be directly from the physician/nurse practitioner • Nurse receives, document and executes order • Mostly depends on agency policies.

  37. Sample policy on verbal order documentation: • Record orders then read back the order to verify • Date and note the time orders were issued • Record V.O., name of physician, followed by nurse’s own name & title • After the conclusion of emergency, physician should review orders and sign orders. Date and note the time he/she signs the orders.

  38. Telephone and Fax orders • Depends on agency policy. • Orders should be repeated back to the physician. • Must be transcribed on an order sheet. • Fax orders are acceptable as long as they are legible

  39. Sample policy for telephone/fax orders • Physician or nurse practitioner should be referred to a house officer/ RN or registered pharmacist • Record the orders (T.O.) on patient’s record. Read the order back. • Date and note the time the orders were issued • Sign the orders with name & title • “Demerol 100mg IM now and q 4 hr p.r.n for pain. T.O. James E. Walker, MD/Mary Pint, RN”

  40. Care Planning • Records help professionals how the patient is responding to the treatment plan from day to day. • Example: • If the patient is gradually becoming weaker and is not unable to tolerate ambulation, orders for physical therapy and other nurse-initiated ambulation will need to be modified.

  41. Quality Review • Charts are usually evaluated for the quality of care patient’s received and the competence of the nurses • Nursing audits – random charts are selected and reviewed • Accreditations by agencies.

  42. Research • Researchers use charts and study patient records. • Charts used in studies hoping to learn how best to recognize or treat identified health problems from the study of similar cases.

  43. Decision Analysis • Charts/ records provide data needed by administrative strategies planners • Helps to identify needs and the means and strategies most likely to address needs • Record review might reveal: • Underused or overused services • Prolonged hospital stays • Financial information

  44. Education • Healthcare students/professionals can learn a great deal about clinical manifestations of particular health problems. • Effective treatment modalities and factors that affect patient goal achievement can be highlighted.

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