Unit 9 - Documentation Flashcards
Documentation is defined as written evidence of:*
1.
2.
3.
Written evidence of:
- interaction between all people and organizations
- administration of test procedures, treatments and client education/ TAKING TEST/DATA
- the results of client response to diagnostic test and interventions/ EXPLAINING TEST/DATA AND INTERVENTIONS
What is reporting?*
when two or more people share information about client care verbally, email, telephone, report
when two or more people share information about client care verbally, email, telephone, report
Written Communication: What is the purpose of the client record?*
- Communication – interdisciplinary
- Assessment –History, client record
- Care Planning - Nursing care plan
- Quality Assurance -
Institutional and The Joint Commission
Insures standards of care are met - Reimbursement
- Legal Document
- Research – collect significant data of course of diseases and treatment responses
- Education
Principles of Data Entry & Management*
- Accuracy*
- Be complete*
- Be concise
- Be objective
- Be organized
- Be timely
Principles of Data Entry & Management: Accuracy
- Accuracy - unless otherwise noted it is assumed you witnessed data. So correct errors (do not erase) and be precise.
Principles of Data Entry & Management: Be Complete
Means include what information?
New or changed information Signs and symptoms Client behaviors Nursing interventions Medications given Physician’s orders carried out Client teaching and responses
Principles of Data Entry & Management: Be Concise
Use phrases rather than complete sentences (he/she. Pt. client , nurse are assumed)
Use acceptable abbreviations
If unsure write it out
Watch caps and small letters in abbreviations
Avoid abbreviations with 2 meanings
Principles of Data Entry & Management: Be Objective
Identify source or context of subjective information- do not interpret statements
Chart what you observed or what was said
Avoid derogatory terms
Principles of Data Entry & Management: Be Organized
Be sequential or categorical –
Same information does not need to be charted multiple times
Don’t stop part way through note with plan to finish later
Principles of Data Entry & Management: Be Timely
Record medications when given
Record changes in condition – may need record of changes in emergency
Indicate time of documentation – if information occurred before that time indicate time –
Military time
Prioritize Documentation
High Risk Errors in Documentation
- Falsifying client records
- Failure to record changes in clients condition
- Failure to document that physician was notified when clients condition changed
- Inadequate admission assessment
- Failure to document completely
- Failure to follow agency standards or policies on documentation
- Charting in advance
Electronic Medical Records
- What is it?
- What does it limit?
- What does it allow?
- When is it available?
- How many people is it available for at any given time?
- When can information be documented?
- What can be standardized?**
- What can data be used for?
- electronic format for client records, it is a database with variety of information
- limits access information to specific healthcare personnel
- allows accessibility beyond the primary institution (other facilities you visit can see it) because it is accessed by entire system (advocate)
- available immediately
- more than one
- immediately documented at point of care
- terminology and format for easy access to info needed
8, billing, pharmacy, quality assurance, restocking units
Computer Based Patient Record CPR
- Where is it accessible
- Who does it follow
- What are the 3 benefits
- accessible outside of primary institution
- follows patient
- Benefits:
- Clients share health care information with any practitioner
- Travel
- Emergency
What is Point of Care
Documentation at the bedside
Portable computers COWS WOWS
Plan of Care *
- What does it contain
- May be ___ plans that are ___ to the ___.
- Should be ___ at ____.
- Recorded on ___ ___.
- Contains nursing diagnoses, goals, outcome criteria, interventions and evaluations criteria
- May be standardized plans that are individualized to the client
- Should be initiated at admission
- recorded on client record
Kardex Patient Care Summary
- May be __ ___ ___ out.
- Describes:
- The goal of it is to do what?
- If hand written use __ __ for non-___ items & ___ for ___ items.
- ___ warnings
- computer generated print out
- basic - up to date information needed for client care
- To provide continuity of care
- If hand written use black ink for non-changing items & pencil for changing items
- Highlight warnings ALLERGIES
Types of progress nursing note
narrative
Narrative
1. ___ accoun of clients day
2. ___ and ___ care and ___ care included
3. may be used in combination with a __ ___.
Advantage:
Disadvantage:
- Sequential account of client’s day
- Assessment and nursing care and maintenance care included
- May be used in combination with a flow sheet
Advantage: Time sequence maintained
Disadvantage: Lengthy, difficult to identify progress towards goals when evaluating client’s progress
SOAP, what does it mean? Define each letter.
S Subjective
Direct quotes
information elicited from client that only he/she knows
May be none – left blank
O Objective
Health assessment, treatments completed, Lab Data, Anything measurable, visible, palpable, audible
Anything done to or for the client (e.g. MD notified of labs)
A Assessment / Analysis
Interpretation of the conclusions drawn about the subjective and objective data
Initial assessment states the problem After that the A should describe the client’s condition and level of progress rather than merely restating the problem
P Plan
The plan of care designed to resolve the stated problem
What will you and other nurse do
When , How
SOAP
- only relates to __ ___
- who uses it?
- Start with __ ___ must have a __ ___.***
- Not associated with _ _ _ _ _.
- one problem
- all healthcare members
- starts with problem statement, must have a problem list.
- not associated with NANDA
SOAP
- Advantages:
- Disadvantages:
- Alternative:
1. Advantages : Interdisciplinary easy to track progress of one problem 2. Disadvantages Difficult to master Can not chart general information since Problem focused 3. SOPIER
PIE define & explain**
P Problem - Nursing Diagnosis usually referred to by number #
I Interventions : Completed to deal with the problem
E Evaluation : effectiveness of the interventions
PIE:**
- _____ must be ___ into this charting - since ___ is not included in format.
- Advantages
- Disadvantages:
- Allows what data to be added to charting?
- Flowsheet/incorporated/assesment
- Advantages: Problem centered, shorter than SOAP format
- Disadvantage:
Assessment not related to problems
Not multidisciplinary - Assessment data
Focus Charting/DAR
- Define & explain DAR
- list advantages
- list disadvantages
- intended to make the client and client concerns the focus of care
D Data
Combines objective, subjective, health assessment, lab data etc
A Action
Planning and Interventions includes immediate and future plans
R Response
Effects of your interventions on client, state if not enough time to evaluate, new problems
- Advantages: Focus selected on priority basis, easy to understand
Holistic view of client and needs
Easy to use since all three components do not need to be recorded
each time - Disadvantages: Problems may be lost since active problems not always focus of note Change of plans not reflected, Time sequence may be lost, Action part may be redundant to NCP or flow sheets – Not Multidisciplinary
Flow Sheets
- What does it allow for
- Advantages**
- Disadvantages**
- Allows immediate documentation of routine care if WNL
info included: Assessments, Treatments, Graphic Vital Signs
Intake and Output IV’s - Advantages: Thorough , space efficient , readily available, encourages immediate documentation
- Disadvantages: categories missing or inappropriate, lines small, limited specificity
Types of flow sheets
Graphic record
24-hour fluid balance record
Medication record
24-hour patient care records and acuity charting forms
Charting by Exception (CBE)**
- When is it required?
- Disadvantage: ___ must have clearly __ ___ of care and everyone must ___ upon them.
- Charting required only for incidents that fall outside the parameters set by standards of care or normal assessment findings
- Disadvantage: Agency must have clearly state standards of care and everyone must agree upon them
Critical Pathways**
- Used for
- Based on
- Used by
- Additional charting used only if…
- Who initiates the pathway?
- When does the nurse sign?
- Used for clients with predictable conditions
- Based on Best practice criteria
- Utilized by multidisciplinary team
- Additional charting used only if exception to pathway occurs
- MD initiates pathway
- Nurse signs when intervention when standard pathway interventions are completed on the date indicated
Discharge
What does documentation include?
Documentation includes discharge orders and teaching completed
Includes diagnoses at discharge, medications and prescriptions if needed , treatments needed at home with instructions and supplies needed and given to client , diet, special care instructions – shower , next clinic appt , emergency numbers and names , activity orders esp return to work or school
Discharge
- Why does the patient sign discharge summary?
- What does the client receive?
- Patient signs discharge summary to acknowledge that information was given to him at discharge
- Client receives a copy of the discharge summary
Incident Report
- What is it used for?
- What does it evaluate?
- What does it described?
- How is and isn’t it documented?
- Risk managment and is a Confidential document used for internal review by legal, insurance, and quality assurance committees
- Evaluates the effectiveness of hospital policies and procedures
- Describes :
How the incident occurred
Impact on the client
Outcome of the incident - Incident is objectively documented according to hospital policy. Is not placed in client medical records.
5 methods of Reporting
Face-to-face meetings – bedside reporting Telephone conversations Written messages Audio-taped messages Computer messages
Verbal Handoff
Change of shift bedside reporting reports include
- Name, age, room number of client
- Medical diagnoses, major procedures or surgery (date)
- Name of physician/group
- Significant nursing diagnoses and progress toward goals
- Significant assessment data
- New diagnostic or laboratory test results
- Specific treatments
- IV type, rate, and amount remaining
What are ways to confer about care? 3
- Consultations and referrals - provides assessment and treatment plan for other MD or healthcare workers
- Nursing and interdisciplinary team care conferences
- Nursing care rounds
- discuss the plan of care
- nurse is responsible for advocating for clients needs and providing nursing assessment and plan
When reporting to primary care provider via telephone the nurse should:
- ___ nursing assesment
- Have…
- Provide
- Document..
- Focused nursing assessment
- Have client’s record on hand for reference
- Provide status report
Signs & Symptoms, changes in assessment
VS, Lab data – treatments and response - Document conversation in client record
Template for Communication: SBAR
- what does SBAR mean?**
- When is it used?
- SBAR :
S - Situation: statement about problem/ whats going on
B - Background: what is the clinical background information that is pertinent to the situation
A - Assessment - what did you find? analysis and considerations of options
R - Recommendations: what action/recommendation is needed to correct that problem? what do you want to happen for this patient? - Used in all communication hand offs; shift change, ER reports, transfers Charge nurse to charge nurse, Nurse to MD
