Lecture 2 Documentation Flashcards
Documentation
- Detailed account of quality of care
- Communicate pt info accurately and timely effective manner
- Didn’t chart it, didn’t happen
- Record = Chart
- Confidentiality
Confidentiality
Legal and Ethical obligations
Protect info:
- Don’t leave it in a public area
- Sign off the computer
- Don’t be yapping around
- Don’t leave anything that has your patient’s info
- Don’t email client info
- Shred all the proper information don’t take anything home
- Don’t speak to anyone over the phone
- Don’t post anything on social media
Health information privacy act (HIPA)- provincial legislation
Health information privacy act (HIPA)
-Came about in 1997
-Proclaimed in court in 2003
-Protecting the privacy of your health information
•States the rights of individuals and obligations of workers in a health system remains confidential
Purpose of a Health Record (chart):
More then just communication and care planning
- Legal Document
- Education (using data for audits)
- Funding and Resource Management
- Research
- Quality Review
Health Records contain the following:
o Patient demographics o Admission nursing database o Nursing care plans o Nursing notes o Medical history o Medical diagnosis o Orders o Progress notes o Test reports o Operative notes o Discharge plan and summary
Types of Records
Source orientated Record
Problem Orientated
Source Orientated Record
- Organised under separate disciplines
- Each discipline has section
- Not chronological
- Must go to different sources to read same topic
- Repetitive
Problem Orientated
- data organized by pt problems
- medically based format
- Health Care members contribute to a single list of identified pt problems:
- chronically ill pt
- Pt with many problems
- All members take care of same problem
- Comprehensive individualized care
- Issue: Multiple problems with the same symptoms
- Problem focused
Ways to document nursing care
- Narrative (source)
- SOAP (problem)
- PIE (problem)
- Focus Charting (problem)
- Chart by exception (problem)
- Case management
Narrative (source)
- Story
- time consuming
- Lots of info
- What is relevant
- Client Reponses
- Oriented = Person place and time
- See Mar = see medication record
- O/M = Observation and measurement
SOAP (problem)
Subjective (pt remarks)
Objective (vital signs)
Assessment (nursing diagnosis)
Plan (resolution)
SOAPIER (problem)
Subjective Objective Assessment Plan Intervention Revision
PIE
Problem (diagnosis)
Intervention
Evaluation
Focus Charting (problem)
Based on pt Concerns
Uses DAR:
Data
action
Response
Pt Centered
Used for narrative
Flow chart
Chart by exception (problem)
Document deviations from the normal (saves time)
CBE
Based on set standards that have been met
Case management
Critical pathway = care maps
Multidisciplinary
Efficient
Computerized
Tailored to specific disease
Admission Database
Complete initial nursing assessment of pt on admission
Standardized Care plan:
Standardized form with some individualization
Kardex (temp record)
Basic pt care summary
Flowsheets and graphic records:
Records for quick data entry
Discharge Summary:
Includes discharge info and instructions
Incident Reports
Involved in or witness near miss no blame -med errors -incidents
What do we document:
- Care that you have provided
- Patient status (vital signs)
- Changes in patient status
- Medication administration
Documentation guidelines
• Date and time (24-hour clock) • Be timely • Use logical order • Meet set standards • Write legibly in blue or black ink • Use accepted Abbreviations/symbols • Spelling and grammar • Sign all entries o Name and title: S. Akinfiresoye, UofS NS • Stick to the facts o Descriptive and objective • Be current and organized o Timely and well laid out • Be compliant with standards o Documenting what is done • Be accurate, specific, complete
DO NOT:
• Never erase or use whiteout
• Janet IV was displaced after her shower is in situ.
Error O, Akinfiresoye NS Sept 13/18
• Never leave blank spaces in your notes
• Only chart your own actions – if you did not give the med you do not sign off on it
• DO not “prechart”
• Begin with date and time, end with signature and role (ie O. Akinfiresoye, UofS, NS)
