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Why Document?No one ever looks at our notes
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2. Why Document?
No one ever looks at our notes
Until they are subpoenaed and then its too late!
We dont do head to toe assessments
You should be completing system assessments
I see too many students to chart details
The attorneys and The Board of Nursing does not accept excuses for poor documentation
3. Why Document?
Risk Management
Nurses notes are used disciplinary
reviews
Used in Board of Nursing Reviews
4. Why Document?
Professional Accountability
Its imbedded in the Standards of
Professional Nursing
TAC - Rule 217.11
5. Why Document?
Legal Document
Entered as evidence in trials
Determines if appropriate care was
rendered
6. Why Document?
Research
Nurses notes serve as a valuable
resource for data
assessing effectiveness of
interventions
evaluating outcomes
7. Who Should Document?
Those with first hand knowledge
8. What Should I Document?
Chief or Presenting Complaint
Assessment (system or head to toe)
Intervention or Plan of care
9. What Should I Document?
Evaluation
Time of arrival, parent contact and
discharge
Where patient was discharged (home,
class, etc..)
10. What Should I Document?
If applicable, physicians orders
If applicable, contacts with other health
team members concerning significant
events regarding students status
11. Dos and Donts
Use black ink
Legible writing
Dont leave blank spaces
Correct mistaken entries
Use approved abbreviations only
Document in students own words
12. Dos and Donts
Document as soon as possible after
the event occurred
Late entries must be clearly identified
If charting electronically, never share
your password
Document objective findings
Dont document subjective findings
13. Documenting the Assessment
Assessment - General
When did the problem start?
Have they been seen by a physician?
What are they doing for the problem?
(medications, ointments, etc.)
Did they tell their parents/guardian about
about the problem?
14. Assessment Illness Related
Objective description of the symptoms
System assessment
(i.e. sore throat pharynx red, tonsils
2+, lymph nodes not enlarged)
15. Assessment Injury Related
Objective description of the injury
Injury assessment
(i.e. left ankle no redness, swelling
noted, good ROM in all directions
without complaints of tenderness,
good muscle strength, gait within
normal limits, no limping)
16. Intervention Plan of Care
Document care given i.e.
Rest
Elevated limb on pillow, icepack to
ankle
Medication per orders
17. Intervention Plan of Care
Document teaching i.e.
Discussed care wound care and signs and symptoms of infection
Student to return to clinic after lunch if continues to feel bad
18. Evaluation
Evaluation the students response to and attainment of desired outcome from the intervention
Document in objective terms the outcome of the intervention i.e. Student reports stomach feels or better swelling and redness decreased
19. Types of Documentation
Narrative
By exception
Problem oriented
SOAP/SOAPIE
20. Documentation Examples
21. Whats Missing?
SA. Rested. Back to class.
22. Whats Missing?
ASSESSMENT
EVALUATION
23. Whats Missing?
c/o headache, feeling tired and not well.
grandmother notified. requested Tylenol.
oral med. administered at grandmother's
request. will check on when returns home.
24. Whats Missing?
ASSESSMENT
EVALUATION
25. Whats Missing?
Stomache hurting all morning. Started
before school. Actually hurt last night.
Took some pink medicine last night. Ate
cinnamon rolls for breakfast. Rest No
improvement, Called dad, he'll pick up.
26. Whats Missing?
ASSESSMENT
EVALUATION
27. Whats Missing?
Poked self in left eye. Ice.
28. Whats Missing?
ASSESSMENT
EVALUATION
29. Whats Missing?
"I scraped my finger on the field trip." Left
pinkie small superficial abrasion. Area
washed thoroughly with soap and water,
antibiotic ointment and band aid applied,
student expressed increased comfort and
sent back to class.
30. Whats Missing?
NOTHING!!!!!
31. Whats Missing?
"I scraped my finger on the field trip." Left
pinkie small superficial abrasion. Area
washed thoroughly with soap and water,
antibiotic ointment and band aid applied,
student expressed increased comfort and
sent back to class.
32. Whats Missing?
Student states he was working out and just feels terrible.
Achy all over, HA, weak. Feels warm to touch and cold
to himself. Throat started hurting last pm. Is a little red
and tonsils are mildly swollen. Rest in clinic and tried to
rehydrate. Gave Gatorade and water. Student drank the
Gatorade, but not much of the water. Not much better
after rest and drink. Student states he is having a lot of
allergy issues. Called mom to let her know what we have
done and sx. We did discuss that strep does cause
some of these sx and she said student does have a
tendency to get strep. She states he can come home
and rest, she may try to get DR. appt.
33. Whats Missing?
NOTHING!
34. Whats Missing?
Student states he was working out and just feels terrible.
Achy all over, HA, weak. Feels warm to touch and cold
to himself. Throat started hurting last pm. Is a little red
and tonsils are mildly swollen. Rest in clinic and tried to
rehydrate. Gave Gatorade and water. Student drank the
Gatorade, but not much of the water. Not much better
after rest and drink. Student states he is having a lot of
allergy issues. Called mom to let her know what we have
done and sx. We did discuss that strep does cause
some of these sx and she said student does have a
tendency to get strep. She states he can come home
and rest, she may try to get DR. appt.
35. Whats Missing?
Student c/o earache, Backache, HA, SA
sore throat, and neck ache. Can easily
touch chin to chest without causing more
pain. Throat is red and some tonsilar
swelling, more pronounced on R side.
SWG. Helped some . Rest in clinic. A little
better. Does not want to go home. Back
to class.
36. Whats Missing?
NOTHING!
37. Whats Missing?
Student c/o earache, Backache, HA, SA
sore throat, and neck ache. Can easily
touch chin to chest without causing more
pain. Throat is red and some tonsilar
swelling, more pronounced on R side.
SWG. Helped some . Rest in clinic. A little
better. Does not want to go home. Back to
class.
38. Whats Missing?
Student states she has a "very bad sore throat".
rates pain a 7 on 1-10 pain scale. Unable to fully
visualize throat. Elevated temp. Describes pain
in throat as swollen feeling and it hurts to
swallow. SWG done. Student reports it really
didn't help. Attempted to call dad. unable to
reach. Student will go back to class. Instructed
her to return if she is feeling worse or if she
wants to try dad again.
39. Whats Missing?
NOTHING!
40. Whats Missing?
Student states she has a "very bad sore throat".
rates pain a 7 on 1-10 pain scale. Unable to fully
visualize throat. Elevated temp. Describes pain
in throat as swollen feeling and it hurts to
swallow. SWG done. Student reports it really
didn't help. Attempted to call dad. unable to
reach. Student will go back to class. Instructed
her to return if she is feeling worse or if she
wants to try dad again.
41. Yes, good documentation is more
lengthy and time consuming
But, its your license and
lively hood at stake.
42. Can you remember what you did two years ago or eighteen years ago?
I cant. Remember whats not documented is not done!