Documentation
Accountability
- professional (CNO, WRHN), legal
- clear, complete, accurate
- flowsheets, medication & specimen scanning
- logging in and out
- result copy
Contemporaneous
chart as soon as possible after the care or event occured
never before care provided
higher validity, reliability, credibility
Evaluating EFM
Errors
unchart and rechart values - dates/times, weights
correct patient chart
FetaLink - call helpdesk to correct linkage
logging in and out
Refusal
- refusal of Vitamin K
- refusal of EFM
- refusal of AVB, CS
Late
include reason if something is being charted significantly after the fact
Factual
accurate, concise, objective
no opinion, judgement or bias
correct dates, times, values; not approximating
not raising suspicion, not contradicting (yourself or others)
Disagreement
- Disagreement with Plan of Care guideline
- primary nurse / charge nurse
- nurse / resident
- nurse / physician
- team - not throwing anyone under the bus
Risk
- contemporaneous
- not documenting relevant care, events or interactions may lead to the conclusion that the care, events or interactions did not occur
- patients have the right to access their own PHI
Translation
- use of proper medical translation services for consent, discharge teaching, or anything that the patient does not appear to understand
Orders
Types - Phone with read back, Verbal with read back, Initiate Plan, Paper or Fax, Electronic, Policy/Clinical Scope, Medical Directive
If you take a verbal order, it needs to be documented in the order section of the chart
Standard
- meeting standards of care
- following program guidelines
- College of Nurses
"Notified"
"charge nurse notified"
"physician notified"
- what were they notified of?
- what was the response?
Privacy
circle of care
to protect personal health information
only using your own access credentials to access chart, accudose, etc
not leaving chart open when unattended; not having tracking board or others' EFM visible in a patient room
Integrity
data integrity - BORN clean up
non-associated EFM (OR or off unit)
Careplans and external paperwork/consults
Antenatal records (up to date)
no personal notes outside of the chart
Communication
with providers, patient, family, other HCP
timely, factual, include what was communicated
verbal, phone
location - at the bedside, called in main OR,
name of who you communicated to
appropriate person - OB vs resident
actual and attempted
patient education