Documenting and Reporting Flashcards
what is documentation
The act of recording client assessments and care in written or electronic form
Creating a record of client assessments and care
what is the purpose of the written record
Communication between providers Educational tool Legal documentation of care Quality improvement Research Reimbursement Education
what is source-oriented documentation
Disciplines charted separately
Variety of sections (e.g., admission, H&P, diagnostic, graphic, nurses’ notes, progress notes, lab, rehab, DC plan, etc.)
Data scattered; may lead to fragmentation
what is problem-oriented documentation
Organized around client problems
Four components: database, problem list, plan of care, and progress notes
Allows greater collaboration
what is common types of charting
Narrative PIE SOAPIER Charting by Exception (CBE) Electronic entry format
what is narrative charting
Can use with source- or problem-oriented system
“Story” of care in chronological format
Tracks the client’s changing status
Can be lengthy and disorganized
what is PIE charting
Problem
Interventions
Evaluation
Used only in problem-oriented charting
Establishes an ongoing plan of care
what is SOAP charting
Subjective data
Objective data
Assessment
Plan
Some Add IER
Intervention
Evaluation
Revision
what is charting by exception
Chart only significant findings or exceptions to norms
Streamlines charting and saves time
Uses preprinted forms and checklists
Inadvertent omissions are biggest problem
what is electronic health records
Many different types due to differences in software
Can be cumbersome to learn all entry methods and pathways
Often can be accessed from MD office and shared between departments
what is a nursing admission assessment
Record of baseline data from which to monitor change
Helps forecast future needs
what is included in the admission database
Chief complaint or reason for admission
Physical assessment data
Vital signs
Allergy information
Current medications
ADL status and discharge planning information/ needs
Data about client support system and contact information
what are flow sheets
Record routine aspects of care (hygiene, turning)
Document assessments; usually organized according to body systems
Track client response to care (wound care, pain, intravenous fluids)
Graphic records - used to record vital signs
Intake and output record
what are MARS…Medication administration records
Comprehensive list of all ordered medications
Provides information on client’s medication allergies
Documents scheduled/routine, PRN, STAT, or omitted doses
Additional explanation may be required for nonroutine or omitted medications
what is in a KARDEX or client care summary
Demographic data Ordered treatments (wound care, physical therapy), surgery, laboratory, and tests A summary of medications ordered Medical diagnoses Allergies Diet/activity orders Safety precautions Intravenous therapy orders
what is reporting
Informing other caregivers about the client condition
Nurse to nurse; nurse to physician
Passage of vital information related to the client’s status/plan of care
what are occurrence reports
Formal record of unusual occurrence or accident
Not a part of patient’s health record
Quality improvement
what is included in Hand-off report
Verbal, Through walking rounds, Audio-recorded report (not the preferred method)
Client demographics and diagnoses
Relevant medical history
Significant assessment findings
Treatments (e.g., wound care, breathing treatments)
Upcoming diagnostics or procedures
Restrictions (e.g., diet, activity, isolation)
Plan of care for the client
Concerns
what are in transfer reports
Your contact information
Client demographics, diagnoses, reason for transfer
Family contact information
Summary of care
Current status, including medications, treatments, and tubes in the client
Presence of wounds or open areas of the skin
Special directives, code status, preferred intensity of care, or isolation required
Always ask if the receiver has any questions
what is in a discharge summary
Time of departure and method of transportation Name and relationship of person(s) accompanying client at discharge Condition of client at discharge Teaching conducted and handouts/informational matter provided to client Discharge instructions (including medications, treatments, or activity) Follow-up appointments or referrals given
how do you document client care
Be familiar with facility forms
Chart in the required format
Include all aspects of care
Be accurate, complete, and consistent
Long term care documentation
Minimum data set (MDS) for resident assessment and care screening must be completed within 4 days of admission and updated every 3 months
what is a long-term care weekly summary
A summary of the client’s condition
An evaluation of the client’s ability to perform ADLs
The client’s level of orientation and mood
Hydration and nutrition status
Response to medications
Any treatments provided
Safety measures used (e.g., bed rails)
Documentation Do’s and Dont’s
Be accurate and nonjudgmental
Adhere to the requirements for reimbursement
Provide details about the client’s condition, nursing interventions provided, and client response
Document legibly and as soon as possible
what are some more documentation Do’s & Dont’s
Record significant events or changes in condition
Record any attempts you have made to contact the primary care provider
Chart teaching performed
Chart use of restraints, including reason for use, type of restraints, and frequent checks of the client
Documentation Do’s and Dont’s
Do not chart that you have filled out an occurrence report
Chart any client refusal of treatment or medication
Document any spiritual concerns expressed by the client and your interventions
Documentations Do & Dont’s
Always use black or blue ink for handwritten notes Date, time, and sign all notes Avoid subjective terms Use proper spelling and grammar Use only authorized abbreviations Document complete data about medications
what to Document if a client refuses medication
Record on the medication administration record in narrative form; chart the reason given
Do not leave blank lines
If you make a mistake, draw a single line through the entry and place your initials next to the change
Sign all your charting entries
