Documenting and Reporting Flashcards
Characteristics of Effective Documentation
Consistent with professional and agency standards Complete Accurate Concise Factual Organized and Timely Legally prudent Confidential
Elements of documentation
Documentation should be factual and objective (not judgmental)
Must be accurate
Should demonstrate what you did and why you made the decisions you did
Care plans need to be pertinent and updated
Correct errors according to institutional policy - no white out, scribbling over, writing over, cutting off
Never document in anticipation of doing something
Use military time
Rules of Documentation
Date and time all entries (24-hour time)
Should be timely
Entries should be legible, grammatically correct and spelled correctly
Documentation should enable the reader to know what occurred - who called whom, what info was conveyed, and what was the response
Abbreviations sould comply with institutional policies and have enough contextual information to allow proper interpretation
Should specify who performed procedures if they were not done by person documenting
Notes should be objective and describe what you heard and saw - don’t speculate!
Descriptions should include quotes and descriptions of actions rather than labels
Don’t leave blanks
Saying “at 1/2 the meal and drank 80 ml of fluid” is the correct way to document
TRUE
Confidential information
Name, Address, phone, fax, SSN
Reason Person is sick
Treatments patient receives
Information about past health conditions
Potential breaches in patient confidentiality
Displaying information on a public screen
Sending confidential email messages via public networks
Sharing printers among units with differing functions
Discarding copies of patient information in trash cans
Holding conversations that can be overheard
Faxing confidential information to unauthorized persons
Sending confidential messages overheard on pagers
Patients have the right to:
See and copy their health record Update their health record Get a list of disclosures Request a restriction on certain uses or disclosures Choose how to receive health information
Policy for receiving verbal/telephone orders
Record the orders in the patient’s medical record
Read back the order to verify accuracy
Date and note the time orders were issued
Record telephone orders, a full name and title of physician or NP who issued orders
Sign the orders with name and title
Document the following verbal order:
Dr. Lynch calls and says give 650mg of IV Tylenol Now
VO from Dr. Lynch 9/27/2921 @9:00: Tylenol 650 mg IVP x 1 NOW. Received by Super Student, RN
What is the purpose of recording data
Facilitates quality, evidence based patient care
Serves as a financial and legal record
Help in clinical research
Support decision analysis
Problem-Oriented Medical Record
Components
Defined database Problem List care plans progress notes SOAP Format: Subjective data, Objective data, Assessment (caregiver's judgment about situation), Plan
Formats for nursing documentation
Initial nursing assessment Care plan; patient care summary Critical collaborative pathways Progress notes Flow sheets and graphic records Medication record Acuity record Discharge and transfer summary Long-term care and home health care documentation
ISBARR (Hand off communication)
Identity/Introduction
Situation- symptom/problem, patient stability/level of concern
Background- history of presentation, date of admission, dx, releven past medical hx
Assessment - what is your dx/impression of situation? What have you done so far?
Recommendation - What you want done; treatment/investigations underway or that need monitoring; Review: by whom, when and of what?; plan depending on results clinical course
Read back of orders/response
Shift change/hand-off reports
Basic identifying information about each patient: name, room number, bed designation, dx, and attending and consulting physicians
Current appraisal of each patient’s health status
Current orders (especially any newly changed orders)
Abnormal occurrences during shift
Any unfulfilled orders that need to be continued onto the next shift
Patient/Family questions, concerns, needs
Reports on transfers/discharges
Telephone/Telemedicine Reports
Identify yourself and the patient and state your relationship to the patient
Report concisely and accurately the change in the patient’s condition that is of concern and what has already been done in response to this condition
Report the patient’s current vital signs and clinical manifestations
Have the patient’s record at hand to make knowledgeable responses to any physician’s inquiries
Concisely record time and date of the call, what was communicated and physicians response
