Documentation Flashcards
If you are sued as a nurse…when will you actually be called into court?
at least TWO years!!
Why do we Document?
- Communication (with other nurse/HCP)
- Billing
- Education
- Assessment
- Research
- Auditing/monitoring
- Legality “If it’s not documented, it wasn’t done”
What’s the 3 purpose of Documenting?
- To facilitate communication
- To promote good nursing care
- To meet professional & legal standards
Charting must be what?
- Factual
- Accurate (as accurate and complete/detailed as u can)
- Complete (DON’T LEAVE ANY BLANKSS!)
- Timely (Chart at the appropriate time!!! Don’t chart smth that’s already hoursss ago! always chart on timee! don’t back charting)
- Current
- Organized
- Confidential
- if there’s section that’s not applicable to your patient, you can write N/A.. Don’t leave it blank*
What are the Advantages and Risks of Electronic Health Record (EHR) have on the nursing care?
ADVANTAGES:
1. Allows for ordering of supplies & services from other departments (instead of having to leave the patient’s bedside, you can just shoot off a little note from ur computer & it’ll go to the department that needs it)
2. CPOE (computerized physician order entry) orders are integrated in record & sent to the appropriate departments
3. Multiple HCPs can access chart @ the same time
4. All patient info is stored in one record.
5. Nurses can compare current clinical data w/ previous admissions
6. Legible documentations
RISKS:
1. Privacy
- DON’T share passwords (bc they can sign in under you & DON’T leave computers open unattended)
- Legal ramifications/consequences
2. Computers breakdown (computers/the system can breakdown at times)
3. Substandard nursing care can result (everything that the 1st nurse assess, for ex, is going to be there. so if you have a nurse who isn’t as good as she should be, they might not assess their patient but just carry over the previous nurse’s assessment. You DON’T want to have anything charted under your name that you did NOT assess.)
What are the 2 charting formats?
- Narrative:
- Story like, allows for detail description
- Free text entry - Charting by Exception
- Chart only standards patient does NOT meet (DON’T chart stuff that’s normal. to stop wasting time)
- Check boxes on EHR when standard not MET
What is a SOAP note?
S = subjective data/info
O = objective data/info
A = assessment
P = plan
When should Narrative notes be written?
- Opening note (Ex: who you got report from and that you’ve reviewed the chart together and are on the same page)
- Any change in patient’s condition: subtle or dramatic
- Phone calls to health care providers
- Any time the patient arrives or leaves the floor/unit
- When PRN medications are given
- Reassessing the outcome of the PRN medication – did it work?*
- End of shift closing note (when you’re ending ur shift and say that ur leaving ur patient on stable condition)
- Refusal or noncompliance with treatment by patient (patients are ALLOWED to refuse treatments)
What are the Legal considerations: privacy and confidentiality?
- HIPPA (provides the privacy of patient’s info)
- PHI (as a student, you cannot be talking abt the info of the patient you’re caring for)
- YOUR role as a student nurse
What are the types of reporting?
- Handoff reports –> @ the end of your shift for the next nurse
- Telephone reports
- Incident reports
What are the do’s and dont’s in change-of-shift report or handoff report?
DO:
- essential background
- give medical dx/nsg dx (disgnosis/nursing diagnosis)
- describe abnormal assessment/responses
- significant family info
- discharge plan
- teaching/response
- evaluations
- priorities
DON’T:
- review routine care
- review biographical data
- criticize
- assume
- gossip
- generalize
What are the systems approach to reporting?
- demographic info and events that lead up to hospitalizations & major event during stay
- NV (neurovascular: are they alert&oriented, can they move everything?)
- CV (cardiac : vitals, IV lines, & drips)
- PUL - (pulmonary: lung sounds, resp. rate, 02 sat)
- GI/GU - gastrointestinal/genitourinary: diet
- skin
- relevant labs/diagnostic test results
- family concerns
- new orders
What are the things you need to fill out and know when completing Incident reports?
it needs to be filled out anytime smth goes wrong like: if the patient was given the wrong medication, patient fell, etc
- WHO was involved?
- WHAT was involved?
- WHEN did it happen?
- HOW
- Completed by the WITNESS (if ur the nurse who walked in & found the patient on the floor, ur the one who has to complete the incident report)
- Routed to Safety Committee
- NEVER WRITE IN chart that an “incident report was filled out” (bc that’s just you asking for lawyers to sue you)
When doing Telephone calls to HCP, what must you do?
ISBARR
Introduce = your name, ask their name
Situation - admitting & secondary medical diagnoses, problem the pt is having as the current issue
Background = medical history, lab tests, treatments, psych issues, allergies, code status related to this issue
Assessment = significant physical assessment findings, vital signs, lab, pain status
Recommendation = youu suggest a plan of care
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