Documentation

1. Documentation PN 103

2. Purposes of Patient Records • Five Basic Purposes for Written Records • Written communication • Permanent record for accountability • Legal record of care • Teaching • Research and data collection

3. Purposes of Patient RecordsPurposes of Patient Records • Auditors • assess quality of care • Peer Review • appraisal by co-workers of equal status • Quality Assurance/Assessment/Improvement • audit in health care • evaluates services provided and the results achieved compared with accepted standards

4. Purposes of Patient RecordsPurposes of Patient Records • Diagnosis Related Groups (DRGs) • classifies patient by: -age -diagnosis -surgical procedure • predicts the use of hospital resources -length of stay • cost reimbursement rates for Medicare and Medicaid and private insurance companies

6. Purposes of Patient Records • Nurse’s Notes • form on the patient’s chart • nurses record their observations, care given, and the patient’s responses • Institutions reimbursed by insurance companies or government programs only for the patient caredocumented

7. Purposes of Patient Records • Quality and accuracy • Spelling • Grammar • Punctuation • Good penmanship • Clear • Concise • Complete • Accurate.

8. Purposes of Patient Records • The nurse has primary responsibility for the initial admission nursing history, physical assessment, and development of the care plan based on the nursing diagnoses identified.

9. Charting Rules • Basic Rules for Charting • All sheets should have the correct patient name, date, and time. • Approved abbreviations and medical terms. • Timely, specific, accurate, and complete. • Write legibly. • Follow rules of grammar and punctuation. • Fill all spaces; leave no empty lines • Chart consecutively, line by line • Do not indent left margin. • Chart after care is given, not before.

10. Charting Rules • as soon and as often as possible. • your own care, observations, and teaching - never chart for anyone else. • direct quotes when appropriate. • describe each item as you see it. • write only what you hear, see, feel, and smell. • Chart facts -avoid judgmental terms and placing blame.

11. Charting Rules • Sign each block of charting or entry -full legal name and title. • What you observe, not opinions. • When the patient leaves a unit -chart the time -method of transportation on departure and return. • All ordered care as given -or explain deviation. • Patient response to treatments • Response to analgesics/other medications.

12. Charting Rules • Hard-pointed, permanent black ink pens -no erasures or correcting fluids • If charting error is made -draw one line through the faulty information -mark error -initial -make the correct entry. • Note a late entry and then proceed with your notation. • Follow each institution’s policy and procedures

13. Charting Rules • Avoid using generalized empty phrases -“status unchanged” -“ had a good day.” • If order is questioned, record that clarification was sought.

14. Common Medical Abbreviations and Terminology • A nurse needs some understanding and knowledge of common abbreviations and medical terms • Most facilities have a published list of generally accepted medical abbreviations and terms approved for use in charting.

15. Commonly Used Abbreviations • AbdAbdomen • ABOThe main blood group system • acBefore meals • ad lib As desired • ADLActivities of daily living • AdmAdmitted or admission • AMMorning • ambAmbulatory • amt Amount • approxApproximately • bidTwice daily • BM(bm) Bowel movement • BPBlood pressure • BRPBathroom privileges • c– With • C Celsius (centigrade • CBCComplete blood count • c/oComplains of • DATDiet as tolerated • DcDiscontinue • drsg Dressing • DxDiagnosis • ECG (EKG) Electrocardiogram • FFahrenheit • fldFluid • GIGastrointestinal • gtt Drop • h (hr) Hour • H2OWater • I&OIntake and output • IVIntravenous • (L) Left • LMPLast menstrual period

16. Commonly Used Abbreviations • MEDSMedications • mLMilliliter • modModerate • negNegative • ØNone • # Number or pounds • NPO (NBM) Nothing by mouth • NS (N/S) Normal saline • O2Oxygen • OD Right eye or overdose • OOB Out of bed • OS Left eye • p~ After • pc After meals • PE (PX) Physical examination • per By or through • PM Afternoon • po By mouth • postopPostoperatively • preopPreoperatively • prepPreparation • prn When necessary • qid Four times a day • (R) Right • s¯ Without • stat At once, immediately • tid Three times a day • TO Telephone order • TPR Temperature, pulse, respirations • VO Verbal order • VS Vital signs • WNL Within normal limits • WT Weight

17. Methods of Recording • Traditional Chart • Divided into specific sections or blocks. • Specific sheets of information: -admission sheet -physician’s orders -progress notes -history and physical examination data -nurse’s admission information -care plan and nurse’s notes -graphics -laboratory and x-ray reports.

18. Methods of Recording • Narrative charting • Descriptive form -basic patient need or problem data -whether someone was contacted -care and treatments provided -patient’s response to treatment • Written in an abbreviated story form

20. Methods of Recording • Problem-Oriented Medical Record • Scientific problem-solving system or method. -database -problem list -care plan -progress notes.

21. Methods of Recording • Database • Accumulated data -history and physical examination -diagnostic tests • Used to identify and prioritize the health problems on the master medical and other problem lists.

22. Methods of Recording • Problem list • Active, inactive, potential, and resolved problems -serve as the index for chart documentation. • A care plan with nursing diagnosis is developed for each problem by disciplines involved with the patient’s care.

23. Methods of Recording • SOAPIER is an acronym for seven different aspects of charting. • S – Subjective information • O – Objective information • A – Assessment • P – Plan • I – Intervention • E – Evaluation • R – Revision

25. Methods of Recording • Focus Charting Format • Modified list of nursing diagnoses -used as an index for nursing documentation. • Uses the nursing process -positive concept of the patient’s needs rather than the medical diagnoses and problems

26. The focus of this problem is pain. Notice the way how the D, A, and R are written.

27. Methods of Recording • Data, Action and Response • Example:D – Facial grimacing, graded the pain as 7 in the scale of 1 to 10 with 10 as severe painA – Given Oxycodone 5 mg po at 10:00.R – Rated pain as 2 and able to walk on her own

28. Basic Guidelines for Documentation • Charting by Exception • At the beginning of each shift pertinent data is charted -physical assessments -observations -vital signs -IV site and rate • During the shift -additional treatments given or withheld -changes in patient condition -new concerns • Detailed flow sheets

30. Alternative Record-Keeping Forms • Variety of forms are used -make medical record documentation -easy -quick -comprehensive. -eliminate the need to duplicate repeated data in the nurse’s notes. -unnecessary to chart a narrative -medication -bath -vital signs

31. Methods of Recording • Kardex/Rand • Card system -consolidates patient orders and care needs in a centralized, concise way • Kept at the nursing station for quick reference

32. Methods of Recording • Nursing Care Plan • Preprinted guidelines -patients with similar health problems -meet the nursing needs of a patient -based on nursing assessment and nursing diagnosis

34. Methods of Recording • Incident Report • Any event not consistent with the routine care of a patient -patient care was not consistent with facility or national standards of expected care • Write: -objective, observed information -do not: -admit liability -give unnecessary details -mention the incident report in the nurse’s notes

36. Methods of Recording • 24-Hour Patient Care Records and Acuity Charting Forms • Asystem that accommodates a 24-hour period -Consolidation of the nursing records -Aids in the elimination of unnecessary record-keeping forms -More easily obtained with 24-hour notations: -assessment information -documentation of activities of daily living are

38. Methods of Recording • Discharge Summary Forms • Patient's continued health after discharge. -MD appointments -equipment (oxygen, bath bench, etc.) -Home Health follow-up • The summary should be concise and instructive.

40. Methods of Recording • Clinical (Critical) Pathways • Managed care is a systematic approach • -a framework to target the coordination of medical and nursing interventions • -staff from all disciplines -develop integrated care plans -projected length of stay for a specific case type • -pathways to monitor a patient’s progress and as a documentation tool

41. PATHWAY: TOTAL HIP REPLACEMENT DOS/Day 1 Respiratory Pain Management Outcome: • Verbalizes comfort or tolerance of pain Circle: V NV Variance: Key: V = Variance NV = No Variance Signature: Initials: Signature: Initials: Outcome: • Verbalizes comfort with pain control measures Circle: V NV Variance: Outcomes: • Breath sounds clear to auscultation • Achieves 50% of volume goal on incentive spirometer Circle: V NV Variance: Outcomes: • Breath sounds clear to auscultation • Achieves 100% of volume goal on incentive spirometer Circle: V NV Variance: Days 2–3 Figure 15–8 ■ Excerpt from a critical pathway documentation form.

42. Home Health Care Documentation • Home health care reimbursement -Medicare has specific guidelines for establishing eligibility • 50% of the nursing time is spent in documentation. • Documentation: -quality control -justification for reimbursement from Medicare, Medicaid, or private insurance companies. -unique problems -need for different health providers to access the medical record

43. Long-term Health Care Documentation • Omnibus Budget Reconciliation Act (OBRA) of 1987 regulated standards for: -resident assessment -individualized care plans -qualifications for health care providers. • Each state’s Department of health for governs: -frequency of written nursing records of residents in long-term care facilities. • Long-term care documentation -multidisciplinary approach (Nursing, Rehabilitation, Social Work, Dietary, Activities) -assessment -planning process

44. Special Issues in Documentation • Record Ownership and Access • Original health care record/chart -property of the institution or physician. -patient usually does not have immediate access to his/her full record. • Patients have gained access rights to their records in most states -only if they follow the established policy of each facility. • A lawyer can gain access to a chart with the patient’s written permission.

45. Special Issues in Documentation • Confidentiality • Health care personnel -respect the confidentiality of the patient’s record. • The Patient’s Bill of Rights and the law -patient’s medical information will be kept private -unless the information is needed in providing care -patient gives permission for others to see it • The nurse: -should not read a record unless there is a clinical reason -hold the information regarding the patient in confidence.