week 2 documentation Flashcards
documentation
Besides delivering the standard of care, documentation can protect you against medical malpractice claims You can be sure that whenever a patient consults an attorney, the nurse’s notes will be scrutinized The nurse’s notes are where the most detailed account of the patient’s care is located
purpose of MR
Communication between other health care professional Business record to justify services rendered (DRG’s) Legal record used to evaluate a patient’s claim of disability as well as serve as a foundation for medical malpractice Most states have statutes that dictate what a medical record should contain JCAHO has set standards that most hospitals in the country follow
If attorney feels the case
request copies of MR
request copies of standard of care policy
some states require a sworn affidavit
witness to support that the standard of care was breached
differnent forms
They will differ from facility to facility
Some are standardized – purchased from a
company
Some are State forms
Some are created by the facility for specific
reasons
Others are generated because of Joint
Commission requirements
types of charting
Narrative free flow
Focus Charting PIe and SOAP
Charting by Exception something that is out of the norm
Computerized Charting hospital docucare
advantages of narrative charting
Oldest style and most familiar Flexible Can be used in many clinical settings
disadvantages of narrative charting
Subjective and lack structure Task oriented and little or no evaluation Following progress is difficult Double charting Time consuming
advantages of focus charting
Consistent with JCAHO Promotes nursing process AIR or PIE format Encourages critical thinking Easily understood and adapted
disadvantages of focus charting
May turn into
narrative notes
lacking patient
responses
advantages of charting by exception
Highlights abnormal Trends in patient status are easy to follow Norms are clearly defined Eliminates double charting
disadvantages of charting by exception
Developed for an all RN staff Legal system is suspect Every section must have a documented response
advantages of computerized nursing documentation
Easy to access demographics and reports Printouts are legible Reduces med errors Improves productivity and quality of care Decreases ability to tamper with documentation
disadvantages of computerized nursing documentation
Possible loss of confidentiality Need sophisticated security Downtime may disrupt work Inadequate amount of terminals Cost
rules for good charting
Be factual Document what you saw, heard or did Avoid making generalizations Avoid using ‘appears’ or ‘seems’ Never sign off a med that another nurse gave Never chart procedures you did not do Watch your timing Guard your name Use proper abbreviations Don’t omit anything Maintain nursing care plans Chart in the ‘positive’ Create a picture
words to avoid
Complainer Abusive Drunk Lazy Spoiled Problem patient Difficul Hostile Rude Demanding Aggressive Crazy Obnoxious Nasty Disagreeable Bad Failed Excessive Sufficient Prolonged Tolerated well” Within normal limits – “normal” Poorly Appears Appears in pain Appears restless Appears disinterested “Seems to have” “Improved”
