Documention of Nursing Care

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Documention

provides a written record of the history, treatment, care and response of the patient while under the care of a health care provider. Shows progress toward the expected outcomes listed on the nursing care plan.

medical record(chart)

contains all orders, test, treatments, and care that occurred during the time the person ws under the care of the health care provider.

charting

is used to track the application of the nursing process

written/interdisciplinary care plan

provides the framework for the nurse's documentation.

implementation of each intervention is documented on

flow sheet or within the nursing notes

6 main methods of charting

source-oriented, problem oriented medical record (POMR), focus, charting by exception, computer-assisted and case management system

source-oriented/narrative

required documentation of patient cae in chronologic order. Organized to the source of information.

advantages of source/narrative

gives information on the patients condition and care in chronologic order, indicated the patients baseline condition for each shift, and includes aspects of all steps of the nursing process

disadvantages of source/narrative

encourages documentation of both normal and abnormal findings, making it difficult to separate pertinent from irrelevant information. It requires extensive charting time by the staff, discourages physicians and other health team members from reading all parts of the chart.

POMR

contains the database, problem list, plan, progress notes, and the discharge summary. Developed by Dr. Lawrence Weed (1960)

SOAP

subjective information, objective date, assessment data and plan

advantages of POMR

provides documentaion of comprehensive care by focusing on patients and their problems, promotes the problem-solving approach to care, improves continuity of care and communication by keeping relevant data related to a problem, allows easy auditing of patient records in evaluating staff performance or quality of patient care, requires continual evaluation and revision of the plan, and reinforces application of the nursing process

disadvantages of POMR

results in loss of chronologic charting, is more difficult to track trends in patient status, fragments data b/c of the increased number of flow sheets required.

PIE charting

problem identification, interventions, evaluation. This type of charting follows the nursing process and uses nursing diagnoses while placing the pan of care w/in the nurses' progress notes

Focus

data, action, response (DAR) data, action evaluation (DAE). Is directed at nursing diagnosis, a patient problem, a concern, a sign, a symptom, or an event.

advantages fo focus charting

is compatible w/ the use of the nursing process, shortens charting time by using many flow sheets and cheaklist, isnot limited to patient problems or nursing diagnoses

disadvantages of focus charting

database is not sufficient, patient problems may be missed, does not adhere to charting w/ the focus on nursing diagnoses and expected outcomes.

charting by exception

is based on the assumption that all standards of practive are carried out and met w/ a normal expected response unless otherwise documented.

protocols

standard procedures

advantages of charting by exception

highlights abnormal data and patient trends, decreases narrative charting time, eliminates duplication of charting

disadvantages of charting by exception

required development of detailed protocols and standards, required retraining staff to us unfamiliar methods of record keeping and recording, nurses become so used to not charting that improtant data are sometimes omitted

electronic health record (EHR)

computerized comprehensive record of a patient's history and care across all facilities and admissions

computerized provider order entry (CPOE)

provieds for efficiency of work flow because when orders are entered into the computer, there is automatice routing to the appropriate clincal areas for action.

advantages of computer-assisted documentation

date and time of the notation are automatically recorded, notes are always legible and easy to read, qucik communication between departments, allows multiple health care providers to access, reduce documentaion time,can be retrieved quickly, provided longitudinal record of the patients history, positive impact on patient safety.

Disadvantages of computer-assisted documention

very sophisticated security system is necessary to prevent unauthorized personnel from accessing patient records, costs are considerable, implementation of a full system can take a considerable lenght of time, cost and time involved in training, computer downtime can create problems

Case management

a method of organized patient care through an episode of illness so the clinical outcome are achieved w/in an expected time frame and at a predictable cost.

Kardex

quick reference for current information about the patient and ordered treatments. Usually consists of a folded card for each patient in a holder that can be quicly flipped from one patient to another.

Kardex includes

room number, patient name, age, sex, admitting diagnosis, and physicians name. Date of surgery, type of diet, scheduled tests, level of activity permitted, notations regarding tubes, machines and other equipt. Nursing orders for assistive or comfor measures, list of medication perscribed, IV fluids ordered.

American Nurses Association

Developed standards for nursing practice. They are developed for every state by the Nurse Practice Act

Which of the following are considered essential information to be included in documention?

change in blood pressue, physicians visits, and a new sigh or symptom

Rules to follow when documenting are

use only accepted abreviations, spell all words correctly, note changes in condition

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