1. Documentingreportingnursing informatics Communication is Vital! Technology is your friend!

2. Principles of Data Entry • Complete: • New or changed information • S/S, clients behavior • Nursing interventions • Meds given • Physicians orders carried out • Client teaching and response to therapy • Accurate: • Observations only • Do not use subjective words • Correct spelling, grammar & med terms

3. Principles of Data Entry • Consistent • Concise and brief using approved abbreviations • Objective • Important when documenting psychosocial and mental health issues • Legible • Writing must be clear and easily read by others • Line out errors: 100 cc clear yellow urine from foley • Organization • Use nursing process • Timelines • Document care, treatments, procedures and medications as soon as possible

4. documentation • Purpose of documentation: • Communication • Assessment • Care planning • Quality assurance • Reimbursement • Legal documentation • Research • Education

5. INFORMATICS • Technology in healthcare is advancing • Information will be managed electronically • Outcomes: • Safe patient care • Patient centered care • Improved outcomes • Ease of access to information • Workflow

6. EHR- a Standard Document The bedside chart has moved from a descriptive document to a data driven document • Forms use a standardized language • Radio buttons, drop-down boxes • Data driven • Mandatory fields • Charting by exception • Increases compliance • Alerts to abnormal findings • Able to document all aspects of nursing care

7. Technology will you encounter in the hospital and clinics • EHR/EMR • Monitoring • Imaging • Medication administration • Pharmacy • Clinical Decision Support Systems • ADT • CPOE • Central supply ordering systems

8. Health IT Systems and Human Error Elements that reduce human error: • CPOE • Bar Code • High Alert Medication Documentation • Point of Care Documentation • Mandatory Fields • Smart Pumps • Communication Tool

9. Common documents used by nurses • Clinical Pathways • Medication Administration Records (MAR) • Nursing Progress Notes • Patient education form • Acuity charting • Incident report • Does NOT go in pt chart! • Admission History and Assessment • Discharge Form • Nursing Care Plans • Flow Sheets/graphic sheets • Kardex

10. Vital signs

11. mar

12. Assessment form

13. Patient Summary Screen

14. Orders Screen

15. Medication administration

16. Other technology

17. Remember: HIPAA

18. Change of shift report Purpose Techniques Content

19. SBAR Background • What brought them to the hospital • Past medical history Situation • Pt name • Age • Physician’s name • Diagnois • Hospital day/POD #

20. SBAR Situation Background Assessment Recommendation/ Request • Often a framework for communication- calling MD, giving report, etc

21. SBAR Recommendation or Request • What needs to be done • What was done • Plan for discharge Assessment • State what you think is the problem • Give review of symptoms

22. Types of nursing notes- narrative • Information written in sentences or phrases usually time sequenced • Must write a narrative note q2 hrs • Many combined with flow sheets

23. Types of nursing notes- charting by exception • Document only findings that fall outside of “normal” • Flow sheet with check boxes • Assessment findings, routine care activities • Narrative notes only when there is an exception or abnormal finding • Eliminates redundancy