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  2. Objectives • Identify three of the most common forms of documentation of patient care in skilled nursing facilities. • Identify the main components of an audit of a medical record. • Identify the common “Do Not Use” abbreviations as supplied by The Joint Commission. • Identify strategies for assisting the nursing staff to document the observations and care provided for the residents in Skilled Nursing Facilities.

  3. Our prime purpose in this life is to help others.  And if you can't        help them, at least don't hurt them.                                   - The Dalai Lama         

  4. First Things FirstHow is Your Memory?Your memory is the basis for any documentation!

  5. Hill Elephant Stranger Boat Cup Swimming Book Hole Happy Lamp

  6. How Are Your Powers of Observation?

  7. Now:Write down as many of the words we just saw 2 slides ago.

  8. Litigation • Average time between occurrence and a claim is about 16 months. • Average time from claim to resolution is between three to five years.

  9. Can any of us really recall, recollect, or remember ALL details 16 months to 3 or even 5 years later?

  10. What is the Best Type of Documentation? • When deciding which type of form to use for nursing documentation, first weigh the inherent positives and negatives of each general type--narrative, template, and electronic. • Above all, documentation forms must be efficient, comprehensive, and reasonable, and must prompt nurses to document appropriately

  11. Documentation Do’s “?” • Key Things to Look for in Audits • Correct chart? • Documentation reflect the nursing process? • APIE • Reflect that nurses professional capabilities? • Legible? • Response to medications? • Precautions or preventive measures used documented? • EACH phone call to a physician, including the exact time, message, and response documented?.

  12. Documentation Do’s “?” • Key Things to Look for in Audits • Patient care documented at the time provided • Late entries noted per policy? • Is the entire story told? • Use of “quotations” if observations being attributed to someone else (family too) • If it’s not charted, it wasn’t done • Continually challenge your nurses on that! • Objective charting, factual information only • Subjective: “Patient drinking well • Objective: “Consumed 1500 cc liquids between 8 am-12 pm.”

  13. Documentation Don'ts • Charting symptoms without interventions • Altering a patient's record • Non approved shorthand or abbreviations • Imprecise descriptions • Early documentation • Charting “parties” • Use of negative patient labels • “Resident is a whiner” • Disciplinary documentation • Noting that a nurse forgot something

  14. Types of Documentation • Narrative documentation • Blank canvas which SOULD be based in SOAP (Subjective, Objective, Assessment, and Planning) template. • Pro • Flexible, especially for documenting complications, new diagnoses, and other unforeseen occurrences • Con: • Completely up to the nurses to decide what they document, • Inefficient and leads to a lot of documentation errors

  15. Narrative Nurses Note courtesy of MedPass

  16. Types of Documentation • Checkbox/template • Template form of documentation, combines a string of checkboxes with an area for narrative notes- • Pro • Convenient, efficient, and comprehensive approach. Reminds staff what they need to document. • Narrative area allows nurses to make extra comments about the care or any unforeseen complications. • Con • Paper based • Nurses stop thinking for their residents

  17. Check Box / Template Skilled Nurses Note courtesy of MedPass

  18. Types of Documentation • Electronic documentation • Despite the fact that many nursing homes have not yet made the transition to electronic health records (EHR), this is the preferential means of documentation. • Pro • EHRs may be customized to capture whatever information your facility deems necessary. • Promotes the capture of uniform documentation. • Eliminates the filing of loose paper • Optimum for fighting litigation (paper trail) • Con • Start Up Cost • Flexibility to alter once set up

  19. But don’t let the computer be your master! You still need to use your critical thinking skills!

  20. Documentation Pitfalls(Litigation) • Bad documentation can make a good case look bad and a bad case look even worse. • One questionable entry can harm the integrity of the entire record. • Inconsistency = credibility issue. • So what can we look for?

  21. Altering of a Medical Record “1/2 side rails x 2 indicated”

  22. Late Charting, Altering of the Situation Nursing Note 10/7/99 10:45 p.m. : “Patient found with right lower leg caught in lowered side rail and left foot caught under…error FD 10/7/99 11:45 p.m.” “Resident stated he crawled over the side rail and fell on the floor on right side…..patient resting in bed…incident happened at 5:05 p.m….”

  23. Failure to Follow Physician Orders Order: “Cipro 500 mg PO QD x 3 days UTI” MAR: Administered Cipro only 1 day

  24. Example of Medication Errors Pt. Narcotic Record: Vicodin administered 2/21/01, 2/22/01, 2/25/01 Vicodin “d/c’d 2/15/01”

  25. Care Plan dated 8/1/00 Resident not admitted until 8/2/00 Inaccurate (“Sloppy”) Charting Care Plan: “8/1/00”

  26. “Copy Cat” Charting? 7/16/05-7/31/05 ADL Flow Sheet: Charted foley care 15 x after foley d/c’d 7/10/05 Order: “D/C Foley”

  27. Defensive Documentation – Example of Inaccurate Charting Note the omissions…

  28. Defensive Documentation – Example of Inaccurate Charting Notice how the acuity level is different on the activity assistance level?? Independent vs. Extensive Assistance

  29. Example of Failure to Notify -Culture results received by facility 6/24/06 -Faxed to MD 6/25/99; no response received -Infection resistant to Cipro -No follow-up by facility until 10 days following initial UA and 4 days following culture report

  30. Accurate Narrative Charting Notice the Times Entered

  31. Auditing For Acceptable Practice • The practice of nursing is an art. Acceptable practice is guided by your education and your “community” standard.

  32. “…roasted like chicken…”

  33. Documenting Incidents, Adverse Events and Meetings • Patient Record • Document only the details of the event • No blame, the record is NOT and Incident Report • Incident Reports • Must be complete, they are your record of findings • Meetings • QA&A (PI) is the most important aspect. All adverse events MUST be noted in a PI format and reviewed for changes in system as required

  34. Abbreviations • Each facility / organization should adopt their own approved abbreviation list • Update annually • Compare to the Joint Commission list next (small) • Key is to utilize and audit to such

  35. “Unofficial” Do Not Use List • FTD • GLM • GOMER • POA • FLK • OG-FROG • WOW

  36. What Can I Do? • Master log of initials, identify who did the documentation 5 years AFTER the incident • Sample audit, amend to YOUR documentation system • If able, begin to move towards an EMR that is intuitiveto nursing “critical thinking” skills • Stand firm, recognize excellence, correct observed opportunities • And remember…..

  37. "The most important practical lesson than can be given to nurses is to teach them what to observe."- Florence Nightingale

  38. Questions and answers