Week 5: Documentation 1 Flashcards
What are the 6 purposes of patient records?
- Communication and care planning
- Legal documentation
- Education
- Funding and resource management
- Research
- Quality review (auditing and monitoring)
What is documentation?
A nursing action that produces a written account of pertinent patient data, nursing clinical decisions, and interventions, and patient responses in a health record.
“Anything written or electronically generated that describes the status of a patient or the care or service given to the patient”
How do pt records serve the purpose of ‘communication & care planning’?
- all HCT members communicate its needs, progress, care, tx, and education (starts on admission and ends on discharge)
- this ensures
consistency and
continuity of care
- this ensures
- reflects the nursing process (ADPIE)
- provides baseline data
How do pt records serve the purpose of ‘legal documentation’?
- demonstrates accountability for practice
- best defense against legal claims
- need to document: assessments, care, pt. responses, instructions, referrals, etc.
- CARE NOT DOCUMENTED = CARE NOT GIVEN
How do pt records serve the purpose of ‘education’?
- provides uniqueness of each pt (for education for students, staff, etc)
- get to learn about illness and patterns of behavior
- enables students to see patterns & types of care provided/needed
How do pt records serve the purpose of ‘funding & resource management’?
- chart/record shows how health care resources have been used
- level of acuity of pt indicates the type and amount of resources required (eg. hours of nursing care, qualifications of HCP)
How do pt records serve the purpose of ‘research’?
- data for statistical purposes (e.g rate of infection post-C-section, rate of recovery post appendectomy)
- analysis of data for research purposes (e.g rates of depression in residential care)
How do pt records serve the purpose of ‘quality review (auditing)?
- evaluation of the quality and appropriateness of care
- audit charts (multidisciplinary)
- deficiencies are shared with the care team so new policies or practices can be introduced
What are the six guidelines for quality documentation?
- factual information
- accurate
- complete
- current
- organized
- complies with standards
‘Factual information’ is a guideline for quality documentation and entails:
- descriptive, objective data
- avoids: “appears, seems, apparently”
- notes subjective data as exact as possible (e.g pt states “I passed a clot the size of a toonie”)
‘Accuracy’ is a guideline for quality documentation and entails:
- accurate specific times, amounts, sizes, description & responses
- acceptable abbreviations & symbols (1st use always spelled out)
- clear & concise w/ accurate spelling
- initials and status after each timed charting entry
- knows how to chart and error & late entry
‘Complete charting’ is a guideline for quality documentation and entails:
- comprehensive
- paints a clear picture of pt status, care provided to pt or pt. response
‘Being current’ is a guideline for quality documentation and entails:
- timely entries (@ time of occurrence or asap)
- bedside computers for charting are a bonus (@ARH)
What things should be documented immediately (being current - part of quality documentation guidelines)?
- vital signs
- administration of meds
- treatments
- prep for tests/surgery
- change in staus & associated treatments
- admission, discharge, birth, death
‘Being organized’ is a guideline for quality documentation and entails:
- DARP (data, action, response, plan) focus charting
‘Complying with standards’ is a guideline for quality documentation and entails:
- pt name & ID number
- date on each page
- time with every new entry
- signature, initial, status with each timed entry
- proper use of abbreviations
- correction of errors (no white-out allowed)
- no blank spaces or lines
- black pen only
- no ditto marks
What is narrative charting?
- traditional method of charting
- story-life format
- time-consuming/difficult to find specific data
What is focus charting based on?
- current pt concern/behavior
- change in pt’s condition/behavior
- significant event in pt’s tx
- key words (nursing dx, flow sheet or compliance)
Focus charting follows DARP, which is?
Data
Action
Response
Plan
(do not have to be in sequence + not all need to be written with each timed entry)
‘Data’ during focus charting should be?
- subjective or objective
- supports stated focus or described pt’s status
Example:
Focus: skin integrity
Data: quarter-sized reddened area noted to coccyx when providing peri-care. Skin remains intact. Pt c/o 2/10 pain to site
When should ‘action’ be noted during focus data?
- not always but if there is an action then include after data.
ex. area cleansed with bath wipe, dried, and barrier cream applied. Pt positioned on right side
The ‘response’ in focus charting is the impact of what?
- response is the impact of “action(s)” on patient outcome
Example: Pt reported pain dissipated to 0/10 once repositioned
What is noted in the ‘plan’ section of focus charting?
- future actions/interventions
Example: turn pt and monitor coccyx Q2H
‘Expected outcomes’ are used alongside DARP by CGH, what does it entail?
- expected outcomes by the patient by a certain time
Example: pt will notify if coccyx feeling sore & will have no further impaired skin integrity
What category of DARP charting does this belong to?
The resident ate 100% of breakfast & returned to the recliner at the bedside.
Data
What category of DARP charting does this belong to?
A urine sample was collected and the resident encouraged to drink fluids
Action
What category of DARP charting does this belong to?
Pt. will perform DB & C with the incentive spirometer Q2H
Plan
What category of DARP charting does this belong to?
Pt. reports pain has decreased to 2/10
Response
