Documentation Flashcards
Tx Administrative Code Title 22 Tx Board of Nursing
standards applicable to all nurses:
accurately and completely report and document:
- client’s status including signs (see or discover when doing the assessment) and symptoms (the patient tells you)
- nursing care rendered
- administration of medications and treatments
- client’s response(s): how did they respond to treatment
- contacts with other health care team members concerning significant events regarding client’s status: physical therapy, resp. therapist, doctor, social work, chaplain or anyone else on health care team
ANA standards for documentation
- Relevant data accurately and in a manner accessible to the interprofessional team.
- Problems and issues in a manner that facilitates the determination of the expected outcomes and plan.
- Expected outcomes as measurable goals: patient’s pain to come down from 8 to 3
- The plan using standardized language or recognized terminology
- Implementation and any modifications, including changes or omissions, of the identified plan
- The coordination of care: other healthcare team members
- The results of the evaluation: did the patient’s pain come down
- Nursing practice in a manner that supports quality and performance improvement initiatives.
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
purpose of records
includes:
- communication
- legal document: why you have to document correctly
- reimbursement compliance
- education: student nurses, med students
- research
- auditing and monitoring support compliance with standards of care
- the chart is a very persuasive witness bc it is the description of the facts at the time
communication
multi-disciplinary
critical for continuity and risk reduction
- current status/needs
- progress
- therapies
- consultations
- education
- discharge planning
documentation needs to be
- factual
- accurate
- complete
- current
- organized
factual
- objective: what you see, observe
- descriptive
- subjective: quotes, what the patient tells you
- no assumptions or opinions:
– ex: don’t record a patient fell out of bed unless you actually see them fall, record found patient on floor, if patient tells you they fell record that. if you heard a thud and went to the room and found patient on floor record that
accurate
- exact measurements: measure wound size
- clear
- understandable
- standard abbreviations only
- timed, dated with signature and title
- correct spelling
complete
- condition change:
– onset: when did it start
– duration: how long has it been
– location: where is it
– description: is it dull or sharp? radiating?
– precipitating factors
– behaviors - do not leave blanks, use N/A
- communication w/patient and family: what did you teach them? remind them? explain to them?
current
- as soon as possible
- time of occurrence
- military clock
- never pre-time, pre-date or pre-chart (this is illegal falsification of the record)
organized
- chronological order: EMR does this for you
- concise
- clear
- to the point
- complete sentences not needed
the whole picture
anyone reviewing the chart must be able to understand an accurate, clear and comprehensive picture of:
- patient’s needs
- nurse’s interventions
- patient outcome
avoid these terms
- accidentally: places blame
- apparently: making an assumption
- appears
- assume: making an assumption
- confusing: wouldn’t put that in the chart
- could be
- may be
- miscalculated
- mistake
- somehow
- unintentionally
- normal, good, bad: explain what you are actually seeing (ex: lung sounds clear bilaterally)
don’t
- 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
common formats
could do any or free write
narrative: we use this
- 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:
- nursing focused instead of medical focused and eliminates need for separate care plan
SOAP/SOAPIE/SOAPIER:
- subjective data, objective data, assessment, plan, intervention, evaluation, revision
DAR:
- data (patient situation, health assessment), action (intervention), response (did the intervention do what it was supposed to, how did the patient respond)
forms
- nursing admission data forms
- discharge summary
- flow sheets and graphic sheets: check list: assessment, vital signs, intake and output
- medication and administration records: scheduled meds, unscheduled meds, drug allergies, single order medications
- Kardex: not a permanent record, a summary of patient needs and care
on paper charts
- print or script
- blue or black ink
- never use white-out
- never use eraseable ink
- never obliterate: don’t cross out
- never erase: no pencils
Kardex
a summary worksheet reference of basic information that traditionally is not part of the record. 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.)
- activites permitted
flow sheets/forms
vertical or horizontal columns for recording dates and times related to assessment and intervention information
- vital signs
- intake and output
- assessment
HIPPA as a student in clinical
confidentiality and compliance with HIPPA are part of your practice
- don’t share info with classmates outside of clinical conference
- don’t 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
- don’t include patient identifiers on paperwork: room number, DOB, demographic information, name
- never print material from EMR for personal use
components of good documentation
- who
- what: assessment findings, patient’s complaint, care you provided
- when: the time you provided care
- where: where did the event take place, where treatment given or med 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 (ex: retaking BP, pain level)
- accuracy: exact measurements (don’t use about or approximately)
- objective vs. subjective: objective = what you see, subjective = what patient tells you
specific aspects of care
- critical diagnostic results
- fall reduction: non-slip socks, call light in reach, set bed alarm
- infection prevention
- medications and reconcilations of medications: normally on admission, that they’re taking everything they’re supposed to like daily meds not related to their chief complaint
- non-conforming patient behavior
- pain assessment and management
- patient and family role in safety
- restraints
- skin care
- suicidal: precautions like a sitter
notifying provider
- include 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 no orders are given, note this, especially if you expected an order. (ex: Dr. Sara Jones informed of oral temperature of 104F. No orders received.)
- include in your complete note of the event, the patient’s other vital signs, relevant observations and any nursing interventions you performed.
- 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.
- note your own actions to assist the patient in addition to documenting your contacts with the provider.
- pursue the chain of command and notify your direct supervisor 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.
- record all your actions
some rules
- don’t use labels like obnoxious, belligerent, rude, write what makes you think they are that way (ex: yelling, cussing, waving their arms, told you to leave the room, refusing meds or not allowing you to enter, won’t speak)
- describe patient’s behavior
- document patient’s refusal, reason for refusal and what you did about it
