Documentation types
Purposes of nursing documentation
What are:
Communication among health professionals across the continuum of care
Record of patient care
Reflection of Nursing Practice Standards
Legal documentation
Audits
Education of health professionals
Financial/reimbursement
Research
Narrative format
Tells the story of the client’s experience in a chronological format. Client status, activities, and response to treatment may all be included in narrative charting.
Paper documentation types
Nursing admission data forms, discharge summaries, nurses’ notes, flow sheets, graphic records, checklists, intake and output records, medication administration records, Kardexes® or patient care summaries, integrated plans of care (IPOCs), and occurrence reports.
Types of hand-off reports
Bedside
Face-to-face
recording
SBAR
PACE (Patient/Problem, Assessment/Actions, Continuing/Changes, and Evaluation)
What should you do if you forget to make an important entry?
Add entry and mark as "late entry"
Notify nurse manager
Follow agency's policyPIE Format
Is organized according to problem, interventions, and evaluation. Problems are identified at the admission assessment. Subsequent entries begin with identification of the problem number. This type of charting establishes an on going care plan.
Which documentation forms are not part of patient record.
Occurrence forms and the Kardexes. They are used to document unusual events(occurrence forms) or to summarize care (Kardexes) but not included in pt record.
Included in a hand-off report
• Client’s name, age, and room number
• Client’s admitting diagnosis (one or several may exist)
• Client’s relevant past medical history
• Treatments the client has received at this admission(surgery, line placements, breathing treatments)
• Upcoming diagnostics, surgeries, or treatments
• Restrictions on the client (diet, bed rest, isolation)
• Plan of care for the client (IV therapy, pain management, wound care, family concerns)
• Significant assessment findings from the previous shifts
What else should you document when you chart a symptom
SOAP charting
Organized according to subjective data, objective data, assessment, and plan.This format may be used to address single problems or to write summative client notes.
(IER) intervention, evaluation, revision
When would you use an occurrence form
Reportable events such as:
Falls or other pt injury, loss of patient belongings, theft or any criminal activity, or administration of the wrong medicine.
When should verbal orders be used?
In an emergency
What should you avoid when documenting
Judgments, assumptions, opinions, spelling and grammar errors, what someone else heard or did
Focus charting
Not necessarily organized according to problems. It can highlight the client’s concerns, problems, or strengths. Charting occurs in three columns. The first column contains the time and date. The second column identifies the focus or problem addressed in the note. The third column contains charting in a DAR format.
DAR is an acronym for Data, Action, and Response.
Documentation ABCs (A-H)
Accurate Easy to read
Bias-free Factual
Complete Grammatical
Detailed Harmless (legally)
What should be included in a transfer report
-Your name, facility, phone number
-Pt name age gender admitting and current diagnosis, and current status, and HCP
-Last set of vitals
-Procedures or surgeries performed (related to current prob)
- Tubes in place (IV, cath)
-Wounds
-Contact info for family
-Directives (code status, precautions)-Reason for transfer
If an error is made in nursing documentation, what should the nurse do?
The entry is noted as being an error, and an addendum with correct information is added.
Long-term care documentation must include
(a) a comprehensive assessment using the Minimum Data Set for Resident Assessment and Care Screen-ing (MDS) within 14 days of admission and up-dates every 3 months with any significant change in client condition, (b) a report of any changes in a client’s condition to the primary care provider and the client’s family, and (c) a summary by an LVN/LPN or RN either weekly for clients receiving skilled services or every 2 weeks for clients receiving intermediate care services
CBE
Uses pre-printed flow sheets to document most aspects of care. CBE assumes that unless a separate entry is made an exception all standards have been met with a normal response. CBE flow sheets vary by specialty and in some cases even by diagnosis.
Do not use Abbreviations
"U” or “u”
“IU”
Q.D., QD, q.d., qd
Q.O.D., QOD, q.o.d., qod
MS, MSO4, and MgSO4
The trailing zero for medications (X.0 mg)
Lack of leading zero (.X mg)
Steps to take when receiving telephone / verbal orders
- Have second nurse listen if possible
-Document only when you hear it
-Repeat back
-Spell unfamiliar names / words
-Pronounce digits separately
-Make sure it makes sense for patient
-Transcribe into chart asap
-Have providers name and number
-Get countersigned within 24 hrs
Can documenting be delegated?
Each member of the team is responsible for documenting her part in the care of the client. You are responsible for documenting the care you provide. Never chart the actions of others as if you performed them.
Advantages of Electronic Health Record
• Reduce documentation time
• Information can be stored and retrieved quickly, easily accessed remotely, and accessed the same time by multiple hcp
• Embedded protocols improve consistency of care and adherence to clinical practice guidelines.
• Medical errors are minimized or prevented through programmed alerts and clinical reminders
• Repetition and duplication are reduced.
• Communication is improved between health care providers.
• Information is permanently stored
• Confidentiality of client information is protected
FACT system
Similar to CBE in that it include sonly exceptions to the norm. Four key elements: (1) Flow sheets individualized to specific services; (2) Assessment features standardized with baseline parameters; (3) Concise, integrated progress notes and flow sheets documenting the client’s condition and responses; and (4) Timely entries documenting when care is given.
Medication administration times
STAT- immediately
Scheduled - regularly
Unscheduled - appropriate time (pre-op meds before pt goes into or)
Continuous - IV infusions
Single order - once at a prescribed time but not necessarily immediately
Under what circumstances should documentation occur prior to a procedure being done?
Charting ahead should never be done.
Why do long-term care clients require less frequent charting than clients in acute care settings?
Clients in long-term care (LTC) usually are receiving less intensive nursing care than those in acute care hospitals.
Advantages of paper healthcare record
Advantages
- Familiar
- Does not require large database or secure network
- No downtime (power outage)
-Inexpensive
When should care be documented?
Documentation should be performed as soon as possible after you make an observation or provide care.
Additional information for charting medication
- Type and site of injections
- Assessment before administration (bp meds, heart meds, insulin, anticoagulants)
- Patient reaction to medication
- Patient refusal
- Omitted or delayed meds
Benefits of large systems using electronic health records
To develop better disease treatment methods
To understand disease causes and progression
To determine outcomes for various populations
When should a nurse complete a discharge summary
Pt is moved to a different unit, facility, or home