Documentation and Informatics in Nursing

Documentation and Informatics in Nursing Entry Into Professional Nursing NRS 101

Why Document? • Accreditation (TJC) • Reimbursement (DRG’s, Medicare) • Communication (Continuity, education) • Legal (Not documented, not done)

Multi-Disciplinary Communication • Reports-Oral: End of shift • Written • Record-Chart: Permanent, legal, healthcare management on-going account • Healthteam: All disciplines, nursing, social workers, discharge planning PT, OT, RT

Documentation • Anything written or printed that is relied on as a record of proof for authorized persons • Reflects quality of care • Provides evidence of healthcare team members care rendered

Purposes of Records • Communication • Legal Documentation • Financial Billing • Education • Research • Audits-Monitoring

Guidelines for Quality Documentation & Reporting • Factual • Accurate • Complete • Current • Organized

Follow TJC Standards • Physical • Psychosocial • Environmental • Self-care • Client education • Discharge Planning • Evaluation of outcomes • Nursing Process oriented

Types of Documentation • Narrative • POMR • Source records • Charting by Exception • Critical Pathways • Record Keeping Forms • Acuity Recording Systems • Standardized Care Plans • Discharge Summary Forms

Types of Documentation • Discharge Summary Forms • Home Health • Long Term care • Computerized

Narrative • Traditional type of nursing charting • Story-like, repetitive • Time consuming

Problem-Oriented Medical Records • Data organized by problem or diagnosis • Ideally all healthcare team members can contribute to list • Coordinated plan of care • POMR Components: Database, problem list, NCP, progress notes

POMR Database • History and physical • Nursing admission assessment • On-going assessment • Labs • Radiology reports • Record of each hospital visit

POMR Problem List • Holistic needs based on data • Chronological list on front of chart • Dates when problem resolved or new problem occurs

POMR Progress Notes • SOAP/SOAPIE Notes: Subjective data, objective data, assessment, plan, intervention, evaluation • PIE Charting: Problem-Intervention-Evaluation • Focus Charting/DAR-Data (subjective and objective) Action (intervention) Response of Client (evaluation)

Source Records • Chart is so organized that each discipline has own section to record data • Sections can be easily located • Disadvantage: Not organized by client problems • Narrative style notes

Charting by Exception • Streamlines documentation • Reduces repetition, saves time • Short version to document normals, routine care items • Based on established standards • Progress note when standard not met • Assumes all standards are met unless otherwise charted • Exceptions must be noted

Critical Pathways • Multi-disciplinary care plans used in case management • Key interventions, expected outcomes, time frame • Variances charted and analyzed

Record Keeping Forms • Admission Assessment/Nursing history • Graphic Sheets (Vitals, weights, I&O) • Nursing Kardex • Medication Administration Records

Acuity Reporting Systems • Staffing patterns based on acuity of patients • Numeric rating for interventions • Varies per unit and standard • Update every 24 hours and justify

Standardized Care Plans • Pre-printed established guidelines • Based on health problems • Need to modify based on individual assessment, update and use judgement • Standards of care are known, promotes continuity, staff knowledge

Discharge Summary Forms • DRG’s encourage early discharge, but must ensure good patient outcomes • Necessary resources, Client and family involved in process • Begins at admission • Client education integral to process (food-drug interactions, rehab referrals, medications, disease process)

Home Health • Medicare/Medicaid Guidelines • 50% of nursing time is documentation • Care witnessed by client and family • Good assessment skills • Health care team focused • Direct care in home • Use of laptops for documentation

Long Term Care • Residents not clients • Governmental agencies: Many standards and policies regarding assessments, individualized plan of care • Dept. of Health in each state determines frequency of charting • Skilled Nursing Units

Nursing Informatics • Computer based patient care record • Assessments, care plans, MAR’s physician orders • Maintain confidentiality with pass codes, looking at other records • Nursing Information Systems • Clinical Information Systems • Electronic Medical Record

Reporting • Oral or written • Change of shift • Nurse to nurse • Promotes continuity • Report on client health status, care required for next shift, significant facts, head to toe assessment, pertinent labs, priority needs, treatments, family issues

SBAR Technique for Communication • S- Situation • B- Background • A- Assessment • R- Recommendation

End of Shift Report • Keep professional • Avoid judgemental language • Include assistive personnel

Telephone Reports • Inform physician of changes • Client transfers to different units • Result reports from lab or radiology • Client transfers to different institutions • Info needed: When call made, to whom, info given • Keep clear, accurate, repeat info if necessary

Telephone Orders • Physician to RN • Physician must co-sign within 24 hours • Nightime, emergency orders • Guidelines and procedure per institution • Be careful, precise and accurate with order • Write order as said by physician, repeat it back

Transfer Reports • Unit to unit report • Phone or in person • All pertinent data about patient • Send all belongings with client • Review clothing/belonging list prior to transfer • Transfer Sheet Documentation

Incident Reports • Any event not considered routine (falls, needlesticks, med errors, accidental omissions, visitor injury) • Risk Management will analyze trends • Changes in policy/procedure, educational programs may be related to findings • Notify supervisor, physician of incident • Nurse who witnesses makes out report • Do not assign blame, be objective, facts only

Tips for Documentation • Accurate, timely, thorough, factual, neat • Use only approved abbreviations & terms • Blue or black ink • Always get and give report • Focus on a team approach • Date, time each entry, do not block chart • Document in a timely fashion • Follow the nursing process • Use appropriate forms

Documentation Tips • Correct errors promptly, using proper technique • Write on every line, leave no spaces • Sign each entry with full signature and correct title • Follow institution policy and procedure for charting • Military vs standard time

Documentation and Informatics in Nursing