Documentation and Informatics in Nursing

1. Documentation and Informatics in Nursing Entry Into Professional Nursing NRS 101

2. Why Document? Accreditation (TJC) Reimbursement (DRG�s, Medicare) Communication (Continuity, education) Legal (Not documented, not done)

3. Multi-Disciplinary Communication Reports-Oral: End of shift Written Record-Chart: Permanent, legal, healthcare management on-going account Healthteam: All disciplines, nursing, social workers, discharge planning PT, OT, RT

4. Documentation Anything written or printed that is relied on as a record of proof for authorized persons Reflects quality of care Provides evidence of healthcare team members care rendered

5. Purposes of Records Communication Legal Documentation Financial Billing Education Research Audits-Monitoring

6. Guidelines for Quality Documentation & Reporting Factual Accurate Complete Current Organized

7. Follow TJC Standards Physical Psychosocial Environmental Self-care Client education Discharge Planning Evaluation of outcomes Nursing Process oriented

8. Types of Documentation Narrative POMR Source records Charting by Exception Critical Pathways Record Keeping Forms Acuity Recording Systems Standardized Care Plans Discharge Summary Forms

9. Types of Documentation Discharge Summary Forms Home Health Long Term care Computerized

10. Narrative Traditional type of nursing charting Story-like, repetitive Time consuming

11. Problem-Oriented Medical Records Data organized by problem or diagnosis Ideally all healthcare team members can contribute to list Coordinated plan of care POMR Components: Database, problem list, NCP, progress notes

12. POMR Database History and physical Nursing admission assessment On-going assessment Labs Radiology reports Record of each hospital visit

13. POMR Problem List Holistic needs based on data Chronological list on front of chart Dates when problem resolved or new problem occurs

14. POMR Progress Notes SOAP/SOAPIE Notes: Subjective data, objective data, assessment, plan, intervention, evaluation PIE Charting: Problem-Intervention-Evaluation Focus Charting/DAR-Data (subjective and objective) Action (intervention) Response of Client (evaluation)

15. Source Records Chart is so organized that each discipline has own section to record data Sections can be easily located Disadvantage: Not organized by client problems Narrative style notes

16. Charting by Exception Streamlines documentation Reduces repetition, saves time Short version to document normals, routine care items Based on established standards Progress note when standard not met Assumes all standards are met unless otherwise charted Exceptions must be noted

17. Critical Pathways Multi-disciplinary care plans used in case management Key interventions, expected outcomes, time frame Variances charted and analyzed

18. Record Keeping Forms Admission Assessment/Nursing history Graphic Sheets (Vitals, weights, I&O) Nursing Kardex Medication Administration Records

19. Acuity Reporting Systems Staffing patterns based on acuity of patients Numeric rating for interventions Varies per unit and standard Update every 24 hours and justify

20. Standardized Care Plans Pre-printed established guidelines Based on health problems Need to modify based on individual assessment, update and use judgement Standards of care are known, promotes continuity, staff knowledge

21. Discharge Summary Forms DRG�s encourage early discharge, but must ensure good patient outcomes Necessary resources, Client and family involved in process Begins at admission Client education integral to process (food-drug interactions, rehab referrals, medications, disease process)

22. Home Health Medicare/Medicaid Guidelines 50% of nursing time is documentation Care witnessed by client and family Good assessment skills Health care team focused Direct care in home Use of laptops for documentation

23. Long Term Care Residents not clients Governmental agencies: Many standards and policies regarding assessments, individualized plan of care Dept. of Health in each state determines frequency of charting Skilled Nursing Units

24. Nursing Informatics Computer based patient care record Assessments, care plans, MAR�s physician orders Maintain confidentiality with pass codes, looking at other records Nursing Information Systems Clinical Information Systems Electronic Medical Record