Documentation Flashcards
Standards Applicable to All Nurses
Accurately and completely report and document:
-Client’s status including signs and symptoms
-Nursing care rendered
-Administration of medications and treatments
-Client’s response(s): and
-Contacts with other health care team members concerning significant events regarding client’s status
Document Relevant data
accurately and in a manner accessible to the interprofessional team.
Document Problems and Issues
in a manner that facilitates the determination of the expected outcomes and plan.
Document Expected outcomes
as measurable goals
Document The Plan
using standardized language or recognized terminology
Document Implementation and
any modifications, including changes or omissions, of the identified plan
Document The Coordination of
Care
Document The Results of the
evaluation
Document Nursing Practice in
a manner that supports quality and performance improvement initiatives.
Patient Records Contain
-Patient identification and demographic data
-Informed consent for treatment and procedures
-Admission data
-Nursing diagnoses or problems
-Care plans
-Record of nursing care treatment and evaluation
-Medical History
-Medical Diagnosis
-Therapeutic Orders
-Progress notes
-Physical assessment findings
-Diagnostic study findings
-Patient education
-Summary of operations
-Discharge plan and summary
The Purpose of Records Includes
Communication
Legal document
Reimbursement compliance
Education
Research
Auditing and monitoring Supports compliance with standards of care
The chart is a very persuasive witness because
it is the description of the facts at the time
Communication is
- Multi-Disciplinary
-Critical for Continuity and Risk Reduction
current status/ needs
progress
therapies
consultations
education
discharge planning
Documentation must be
-Factual
-Accurate
-Complete
-Current
-Organized
Factual documentation is
Objective
Descriptive
Subjective (quotes)
NO ASSUMPTIONS OR OPINIONS
Accurate documentation is/has
Exact measurements
Clear
Understandable
Standard Abbreviations only
Timed, dated with signature and title
Correct spelling
Complete documentation
-Condition change
Onset, duration, location, description, precipitating factors, behaviors
-Do not leave blanks. Use N/A
-Communication with patient and family
Anyone reviewing the chart must be able to understand an accurate, clear and comprehensive picture of
-Patient’s needs
-Nurse’s interventions
-Patient outcome
Current documentation
-As soon as possible
-Time of occurrence
-Military clock
-Never pre-time,Pre-date, pre-chart. (this is illegal falsification of the record)
1pm
1300
2pm
1400
3pm
1500
4pm
1600
5pm
1700
6pm
1800
7pm
1900
8pm
2000
9pm
2100
10pm
2200
11pm
2300
12am end of day (midnight)
2400
12am begging of day
0000
Organized documentation
Chronological order
Concise
Clear
To the Point
Complete sentences not needed
Terms to Avoid
Accidentally
Apparently
Appears
Assume
Confusing
Could be
May be
Miscalculated
Mistake
Somehow
Unintentionally
Normal
Good
Bad
Documentation “Don’ts”
-Don’t document a patient problem without charting what you did about it.
-Don’t alter a patient’s record – this is a crime.
-Don’t write imprecise descriptions, such as bed soaked, large amount…
-Don’t chart what someone else heard, felt or smelled unless information is critical. Use quotations and attribute remarks appropriately.
-Don’t chart care ahead of time. It’s fraud.
Narrative
-written in order of patient experience happens.
-Provides details of patient’s care, status, activities, nursing interventions, psychosocial context and response to treatment.
Charting by Exception
Problem-Intervention-Evaluation (PIE)
Nursing focused instead of medical focused and eliminates need for separate care plan
SOAP/SOAPIE/SOAPIER
S - Subjective data
O - objective data
A - assessment
P - plan
I - intervention
E - evaluation
R - revision.
DAR
D - Data
A - Action
R - Response
Forms
-Nursing admission data forms
-Discharge summary
-Flow sheets and graphic sheets
-Medication Administration Records
-Kardex
Flow sheets and graphic sheets
-Check list - assessment
-Vital signs
-Intake and Output
Medication Administration Records
Scheduled meds
unscheduled meds
drug allergies
single order medications
Kardex
Not a permanent record.
A summary of patient needs and care.
Usually Contains:
- Patient’s data (name, age, marital status, religious preference, physician, family contact).
- Medical diagnoses: listed by priority.
- Allergies.
- Medical orders (diet, IV therapy, etc.).
- Activities permitted.
Rules For Paper Charts
- Print or Script
- BLUE or BLACK Ink
- NEVER Use White-Out
- NEVER Use Erasable Ink
- NEVER Obliterate
- NEVER erase – NO Pencils
Flow Sheets/Forms
Vertical or horizontal columns for recording dates and times and related assessment and intervention information:
- Vital Signs
- Intake and Output
- Assessment
Nurse’s Progress Notes/Narrative
Patient’s condition, problems, and complaints.
Interventions.
Patient’s response to interventions.
Achievement of outcomes.
Additional assessment
***Report given, and report received
Time
Nurse’s name
Important information
As a STUDENT in Clinical
Confidentiality and compliance with HIPPA are part of your practice
-Do not share information with classmates unless in clinical conference
-Do not access medical records of other patients
-Electronic health records are traceable through login
-CAN cause disciplinary action by employers and dismissal from work or nursing school
Students paperwork in clinical practice should not include
patient identifiers
Ex. Room number, DOB, demographic information, name
Components of Good Documentation
Who
What
When
Where
How
Outcome
What
Assessment findings?
Patient’s complaint
Care you provided
When
The time when you provided care
Where
Where did event take place
Where was the treatment given or medication administered
How
How was treatment completed?
How did the resident tolerate the procedure/treatment
Outcome
Outcome of the procedure/treatment
Follow-up
What type of follow-up needed (retaking BP. Pain level…)
Accuracy
Exact measurements (don’t use about or approximately
Specific Aspects of Care
-Critical diagnostic results
-Fall reduction
-Infection prevention
-Medications and reconciliation of medications
-Non-conforming patient behavior
-Pain assessment and management
-Patient and family role in safety
-Restraints
-Skin care
-Suicide
Notifiying the Provider
INCLUDE the full name of the provider.
NOTE the exact time that you notified the provider
STATE the specific laboratory result, symptom, or other assessment data that you reported.
RECORD the provider’s response, using exact words if possible.
INCLUDE any orders which the provider gives. If the provider gives no orders, note this - especially if you anticipated an order. For example, “Dr. Sara Jones informed of oral temperature of 104o F. No orders received.”
In your complete note of the event, include the patient’s other vital signs, relevant observations and any nursing interventions you performed
Notifying the Provider Continued
Include the commitment for necessary follow-up by provider, such as, “Will visit patient at 0600.”
Include symptoms and parameters such as changes in vital signs, level of consciousness, or pain that the provider defines as indicators for nurses to use in deciding to call the provider again.
It is essential that you note your own actions to assist the patient in addition to documenting your contacts with the provider.
If a provider fails to respond to a page, a telephone message, or fails to order an intervention and thereby creates a risk for the patient, pursue the chain-of-command and notify your direct supervisor.
Record all your actions.
Never use labels to
describe a patient or patient’s behavior
- ex: Obnoxious, belligerent, rude…
Instead of labels
Describe patient’s behavior
Document Patients rufusal,
reason for refusal and what you did about it.
Correct
all errors promptly, using the correct method.
Record
all facts; do not enter personal opinions
If an order was questioned
record that clarification was sought
Chart only for
yourself, not for others.
Keep your computer password
secure.
Avoid
generalizations.
Rules for Paper Charting
Begin each entry with the date/time and end with your signature and title.
Do not leave blank spaces in nurses’ notes
Write legibly in permanent black/blue ink.
Accurate documentation is the best defense for
legal claims
Must describe exactly what happened to patient and how nurse followed
agency standards
Try to chart
immediately following care provided
Care Not Documented is
CARE THAT WAS NOT PROVIDED
Common Mistakes requiring Legal Action
Failing to record health information/drugs
Failing to record nursing actions
Failing to record medications that was given
Failing to record drug reactions/ or change in patient condition
Failing to write legibly or complete
Failing to document discontinued/refusal medication
Failing to notify Dr., nurse, family and recording exact conversation
Failing to record a late entry correctly
Failing to record referrals
Failing to record patient teaching
Correct Errors in a paper chart
using a single line through entry and your initials (no erasing, “white out”- do not write error or mistake)
Make sure you have the right chart!!
Correct Errors in EMR
new entry. Explain error.
Make sure you have the right chart!!
For a Late Entry in a Paper Chart
-Add the entry to the first available line, and label it “late entry” to indicate that its out of sequence, according to facility policy
-Record the date and time of the entry and, in the body of the entry, record the date and time it should have been made
For a Late Entry in an EMR
change date and time and then document. However…
Overall, Documentations SHOULD be
-Accurate
-Bias-free
-Complete
-Detailed
-Current
-Organized
-Easy to read and understand
-Factual
-Harmless (legally)
Two out of three most frequent allegations against nurses in medical liability claims deal with
Documentation: either
absence of documentation (NOT CHARTED = NOT DONE) or
Timing of Documentation (Late entries)
