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Documentation. Improving Your Charting. The chart remains as the only evidence of the nursing care you have given!!!. If it was not charted it was not done!!! But I swear it did it!!. There are many factors required to be assessed for each and every patient:. Patient needs

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  1. Documentation Improving Your Charting

  2. The chart remains as the only evidence of the nursing care you have given!!!

  3. If it was not charted it was not done!!! But I swear it did it!!

  4. There are many factors required to be assessed for each and every patient: • Patient needs • Care necessary to meet those needs • What needs to be done in respect to continuing care after patient is discharged.

  5. Nursing charting must contain: • Physical/psychosocial assessment to determine the need of care and the frequency for additional assessments • Assessment of patient nutritional assessment • Assessment of functional abilities/status to determine the need for post-discharge planning and rehabilitation

  6. The charting must reflect: • Age specific and appropriate assessment and interventions • On-going assessment of educational needs • Involvement of family and/or significant others when appropriate • Adjustments in the plan of care with changes in condition or diagnosis • Continual assessment of discharge planning needs

  7. All entries should reflect: • The care you have given • Adherence to MD orders or plan of care • Care should be consistent with standards of care (“Best Practice”) i.e. Your charting will be measured against what any other educated and prudent nurse would have delivered to the same patient in the same care situation

  8. Finding Time to Chart • Flow sheets help minimize the time required to document “routine” care however, Charting must also be individualized So, how do you find the time to do this??

  9. Multi-task ! • While assisting a patient to the BR who needs help getting back to bed…. • Combine care delivery with history taking, teaching, assessment. (Bed Bath) • While giving medications you can teach your patient about what they are receiving. • What other ideas do you have??

  10. Your Initial Assessment Examples: Identify pressure ulcers in detail when admitting a patient: • location, size, depth, drainage characteristics, integrity of tissue margins. • If this is not done, it must be assumed that the ulcer developed during the course of this hospital visit!!

  11. Patient at fall risk: • If a patient was to fall and fracture a hip, you have no evidence that steps were taken for the patient’s safety to prevent falls if you don’t document that you: • Instructed the patient NOT to get up to the bathroom without using the call light (and the call light was at the bedside) • Ensured that the bed was left in the lowest position

  12. Patient refusing medications: • Document the exact reason why the patient refused medication or treatment: Example: Mr. Dysphasia states, “I cannot swallow pills” You chart: “Instructed patient regarding importance of taking potassium replacement, with understanding verbalized. Call to Dr. Jones to notify of patients refusal and request liquid alternative” NOT “Patient refused.”

  13. A complete chart contains: • Identification of patient (stamp / sticker) • Date and time of assessment or intervention • Assessment of problem, knowledge deficit requiring teaching, patient concern etc. • Assessment contains subjective and objective information

  14. A complete chart contains: • Statement of problem or knowledge deficit • Measurable goals: outcomes • Implementation measures: interventions taken to correct the problem or knowledge deficit • Evaluation of patients response to interventions • Your signature!

  15. What about flow sheets?? * Excellent for recording repetitive data: Vital signs, I/Os, routine care

  16. Don’t forget to chart patient’s response to interventions: If pain is rated as 8/10, and you give a pain medication, be sure to: • Document their pain level or response (i.e. asleep) 30min-1 hour afterward.

  17. Common reasons for lawsuits involving nursing care : • Failure to question inappropriate physician’s orders • Failure to adequately monitor a patient • Failure to protect the patient from an avoidable injury • Failure to document care that was given in an adequate manner • Failure to properly administer medications • Failure to take a complete and appropriate nursing history

  18. Common reasons for lawsuits involving nursing care : • Failure to follow orders correctly and timely • Failure to perform procedures properly • Failure to protect patient confidentiality • Failure to assess an emergency situation properly and initiate appropriate resuscitative measures • Functioning outside the scope of nursing practice • Failure to request help when the nurse is unable to meet the needs of a patient

  19. Common reasons for lawsuits involving nursing care : • Failure to notify the physician of test results • Failure to follow hospital policy and procedure when restraining patients

  20. Why make such a big deal?? • Charting is a professional responsibility • Medical record may be scrutinized by insurance companies or Medicare or Medical and evaluated for errors • Length of stay justification • Quality of care assessment through chart review by accreditation organizations • Risk management reviews chart to evaluate safety concerns • To protect hospitals/nurses in the event of a lawsuit.

  21. What about handwriting?? • How you write is as important as what you write! Up to 25% of medication errors are related to illegible handwriting!


  23. You Should Never… • Never leave blank spaces for others to “catch up” • Never destroy or change any part of the medical record after it has been created. • Never chart in advance—watch out for flow sheets!

  24. You Should Never.. • Chart for others • Chart the observations that others have made. Ex. “patient fell on the floor” (NO) “patient found on the floor next to bed” (YES)

  25. Never chart in a way that could be determined as a negative assault on the patient’s character. i.e. “patient was a drunk and obnoxious jerk” • Instead chart specific behaviors: i.e. “The patient refuses to have x-rays performed, refused assessment, was observed to have a very unsteady gait while ambulating in the waiting room and urinated in the trash can in the waiting room.”

  26. Dangerous Abbreviations * Know where the list is located on your unit and in the Org. Wide manual. DO NOT USE THEM! * There is also a list of Acceptable Abbreviations in the OWM.

  27. Performance Improvement Regulatory Agencies, Occurrence Reports, Risk Management

  28. Performance Improvement • All nursing departments have a planned, systematic and ongoing monitoring and evaluation program to assess the quality of care delivered to patients • The Performance Improvement Coordinator as well as the unit managers, are responsible and accountable for assuring this process is in place and that consistent standards are used to monitor and evaluate patient care

  29. Performance Improvement • Performance Improvement data is presented to the staff during their staff meetings. • This is an opportunity for all to review the data, analyze the scores, and provide ideas for how improvements can be achieved. • The findings from the Performance Improvement activities are used to formulate continuing education programs for the staff.

  30. Regulatory Agency Umbrella CMS AOA JCAHO CDPH

  31. CMS • Centers for Medicare & Medicaid Systems • Reimbursement for Medi-Cal and Medicare patients • Reimbursements effected by performance • Improved Performance = Increased Reimbursement

  32. What does CMS do with info about our performance? • We are mandated to submit our performance • CMS publicly reports our performance compared with other hospitals • CMS pro-rates our reimbursement based on our performance and “grades” us on a scale with other hospitals • Rewards for being in top 10%

  33. CDPH Evaluation • California Department of Public Health • For State of California licensure • Investigates complaints and deficiencies • Deficiencies can incur fines

  34. OSHA: Occupational Safety & Health Administration • Federal and State • Primary concern: YOU • Safe work place

  35. How do Regulatory Agencies decide on what to focus on? • Focus on QUALITY • Focus on PATIENT SAFETY • Focus on BEST PRACTICE • Focus on PATIENT SATISFACTION • Input from: • Institute for Healthcare Improvement • National Quality Forum

  36. Why Participate? • Because QUALITY, BEST PRACTICES & Patient Safety are IMPORTANT! • And because we are rewarded for good practice

  37. What do we focus on here? • Best Practices around patients with: • Pneumonia • Heart Failure • AMI • Surgical patients • Quality in all the services we provide: • from food to diagnostic tests • Patient Satisfaction • All inpatients and outpatients are surveyed

  38. What do we focus on here? • Patient Safety • Culture of Safety • Recognition of unsafe conditions and environments • Recognition of situations that could result in a problem or undesired outcome • Talking about what we can do to make our workplace safer • Communication!

  39. What is it? Best Practices identified by CMS as contributors to better outcomes, decreased length of stay and decreased occurrence of readmission The diagnoses include: Heart Failure Pneumonia Acute Myocardial Infarction Surgical Care Improvement Project Core Measures

  40. Used for reporting unanticipated events such as: Equipment failures Patients leaving AMA Falls If you notice a potential problem: Isolate the problem (the piece of equipment, etc) Report the problem to your supervisor or the department that can fix the problem Occurrence Report

  41. Risk Management • Uses Occurrence Report information • Patient/Family complaints • If you hear a family or patient complaining, address the complaint if you can • If you can not address the complaint, report it to someone who can • “ABUSE” • “HARRASSMENT” • RED FLAGS!

  42. Cultural Awareness

  43. Cultural Awareness • Why learn about cultural awareness?

  44. Cultural Awareness • Help patients receive more effective care. • Improve your job performance and your job satisfaction. • Meet expectations of regulatory agencies.

  45. Cultural Awareness • What is Cultural Awareness?

  46. Cultural Awareness • Considering every patient’s culture when giving care. • Treating every patient, family member, visitor and co-worker as an individual.


  48. A Healthy Back • Composed of 24 movable bones called vertebrae • Disks act like cushions • Muscles and ligaments support the back • Injury or disease = PAIN

  49. A Balanced Back • Cervical, Thoracic, and Lumbar curves must be aligned • Ears shoulders and hips stacked • A healthy back is also protected and supported by well conditioned muscles

  50. Preventive Back Care • Always warm up • Exercise the muscles that support your back • Stretch to improve flexibility • Posture is important

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