Documentation

1. Documentation PN 103

2. Introduction • The “chart” = health care record • LEGAL record • The process of adding written information to the chart is called: • Charting • Recording • Documenting • 24 hr record-keeping system • To consolidate nursing records

3. Introduction • Good documentation reflects the nursing process • Documentation is an integral part of the implementation phase of the nursing process • It is necessary for the evaluation of patient care and reimbursement from payor sources

4. Purposes of Patient Records • 1. Provides written communication • 2. Permanent record for accountability • 3. Legal record of care • 4. Teaching • 5. Research and data collection

5. Basic Guidelines for Documentation • Hand-out: FON Box 7-1

6. Legal Guidelines for Documentation • Hand-out: FON, Table 7-2

7. Methods of Recording • The Traditional Chart • Divided into sections - eg. Admission sheet, physician orders, progress notes, etc. • Nurses use: flow sheets, graphics, and narrative charting • Narrative Charting – the recording of patient care in descriptive form to chart observations, care, and responses • Abbreviated story form • Information obtained from nursing assessment is clustered and organized in a head-to-toe manner

8. Methods of Recording • Problem-oriented Medical Record (POMR) • Database: accumulated information from the medical history, physical exam, and diagnostic tests • Problem list: of active, inactive, potential, and resolved problems • SOAPE documentation

9. Methods of Recording • SOAPE format: • S = subjective information • What the patient states or feels • O = objective Information • What the nurse can measure or factually describes • A = Assessment • A potential diagnosis of the cause of the patient’s problem or need • P = Plan • Of care to be given or action to be taken • E = Evaluation • And appraisal of the the response and effectiveness of the plan

10. Methods of Recording • Focus Charting Format • “DARE”: • D = data • Subjective and objective • A = Action • Combination of planning and implementation • R = Response and evaluation • Of the patient; evaluating the effectiveness of the actions • E = Education and patient teaching • As needed

11. Methods of Recording • Charting by Exception = CBE • Will chart per usual at the beginning of each shift : • complete physical assessments • Observations • VS • IV siteand rate • other pertinent data

12. Methods of Charting • Charting by Exception cont. • The only other notes the nurse will make will be: • Additional treatments done • Planned treatments withheld • Changes in patient condition • New concerns • Notations re: progress or revisions for all active nsg. dx.

13. Case Study Exercise • Index Cards • Progress Notes

14. Record-Keeping Forms • P. 146-148 FON • “Kardex” – term for a card or paper system used to consolidate patient orders and care needs in a centralized and concise way • Usually kept in the nurse’s station for quick reference

15. Incident Reports • An “incident” refers to: • An event not consistent with the routine operation of a health care unit or the routine care of a patient, or • Other hospital / facility notification form when the patient care delivered is not consistent with the facility or national standards of expected care • Eg. Giving an incorrect dosage of a drug or a wrong drug

16. Incident Reports • Also completed for any unusual event in the hospital or facility: • Needle stick • Patient/visitor/hospital personnel injury • This information helps the facility risk manager and unit manager prevent future problems through education and other corrective measures

17. Incident Reports • FON P. 150, Fig. 7-9/Table 7-3 • When filling out: • Give only objective, observed information • Do not admit liability or give unnecessary information • Do list time, date, care given to the person and name of physician notified (if it was a pt.) • When charting in the progress notes, do not mention that an incident report was made

18. Acuity Charting • 24 hr scoring system • Rates each patient by the severity of their illness • Helps to determine staffing patterns

19. Home Health Care Documentation • Box 7-4 Documentation Forms Used • 50% of nursing time! • Documentation has different implications in the home health system: • Fewer witness to the majority of care • Accurate communication to all team members • Some forms left in the home; others at the agency • Quality control and justification for reimbursement • Computer influence

20. Computer Influence • Communication and assessment via modem linkage • Phone and visual visits • Promotes integration of chart • some parts of the chart left in the home; some in the chart • Various healthcare disciplines need access • Box 7-5 p. 155 FON “Guidelines for Safe Computer Documentation

21. Long-Term Health Care Documentation • MDS – Minimum Data Set • Dictated by Medicare and Medicaid • OBRA 1987 • Regulated standards for resident assessment, individualized care plans, and qualifications for healthcare providers

22. Practice • P. 156, 157 FON Practice NCLEX questions • SG – Ch. 6 and 7