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Essential to the coordination and continuity of care •Enables personnel to support and compliment one another's services •Avoid duplications and omissions of care •Nurses utilize: documenting, reporting , conferring these are the guidelines for effective communication Communication (other specialists use it to) •Planning client care •Quality assurance ( charts reviewed, positive or negative outcomes) •Research (records utilized for this) •Education •Reimbursement (insurance) •Legal documentation (charts and patients records are admissible in court) these are the purposes of documentation in nursing documentation this is written or typed. Its a legal record of all pertinent interactions with a patient ( nursing process) Assessing -Diagnosing -Planning -Implementing -Evaluating this is the nursing process assessment Initial assessment forms Flow sheets Progress notes (nurse's notes) Diagnoses Care plans Critical pathways Progress notes Problem lists Planning Care plans Critical pathways Kardex Implementation Progress notes Flow sheets Evaluation Progress notes -Complete, accurate, concise, current, factual -Reflects nursing process -Record observations, not interpretation ( note behavior of patient ) -Terminology ( accurate and spelled correctly ) -Sequencing (document in order of occurance) -Include safety precautions -Medical visits, consultations -Document nursing response to questionable medical orders -Avoid use of stereotypes or derogatory terms these are documentation guidelines for content -Timely ( increases accuracy) -Include date and time -24-hour clock (military time) -Do not document before carrying out (the patient may refuse medication...) these are documentation guidelines for timing -Correct chart -Appropriate form -Write legibly -Use standard terminology -Date and time each entry -Chart interventions chronologically -Use consecutive lines, do not skip lines -Draw a single line •For blank spaces •For corrections (initial) these are documentation guidelines for format -Sign first initial, last name, title to each entry -Do not use dittos, erasures correcting fluids, etc. •Correct by a single line through the word or statement, write error and initial. Ex.: sleepy (error) LY drowsy -Identify each page of record -Record is permanent these are documentation guidelines for accountability HIPAA this agency protects patients moral and legal rights of confidentiality. patient can object if don't want something ( medical record) reviewed in court. year 1996 •Admission notes (date, time, how they got to the hospital) •Change-of-shift notes ( note stating who nurse gave report to or received it from) •Assessment notes •Interval or progress notes ( occur any time) •Transfer and discharge notes ( if they are transferred to another unit) •Client teaching notes ( what you instructed someone to do) these are the different types of nursing documentation •Descriptions of observations •Symptoms and complaints •Dressings, tubes, or attached devices •Medications and treatments •Observations of psychosocial status •Activities of daily living •Valuable ( place in care of someone else and document) •Spiritual care •Safety concerns these consist of the things that should be documented •Narrative charting ( traditional written notes such as routine care, normal findings, client problems) •Focus charting ( three column date, time, DAR charting which is assessment data, action, and response of patient) •Charting by exception ( only chart what isn't normal, made for each person) •Problem Oriented Medical Record (POMR) •Flow sheets •Graphic records •Clinical pathways (care maps) these are the different types of documentation systems POMR - soap subjective objective assessment plan can add intervention subject Client states , "The pain in my hip is so bad." objective Pain is 9 on scale of 0 to 10, skin warm, moist, pale; lying stiffly in bed with fists clenched. assessment Acute pain, needs pain medication plan Check vital signs, administer dilaudid2 mgs IV as ordered. Evaluate in 30 minutes for response. _____ NAME telephone and verbal orders Write the order down or enter into a computer •Read the order back to the prescriber •Use words instead of abbreviations •Write the order on the physician's order sheet, record date, time, indicate it was a telephone order, and sign name with credentials date time write out info doctor Care plans •Access to knowledge •Continuity of care Nursing informatics is evolving from storage of data to being clinically useful for: not done if something is not documented it is considered this documentation written or typed legal record of all pertinent interactions with patient. It includes all patients health information JCAHO Joint Commission on Accreditation of Health-care Organizations. Inspect and accredit hopsitals make sure they are functioning at national standards. They specify nursing care data related to assessment nursing diagnoses patient needs nursing interactions and patient outcomes. Become a permanent part of the patients records. 24 to 72 hours this is when you should change an IV Ink records should be written in this so you cant go back and change them instead of saying they are angry which is an interpretation you should say they are frowning, they speak loudly .... this is an example of how you document an observation someone can write in the spot.you should draw a line you do not skip lines when documenting because put one line through it so you can still read the mistake. initial EKU BSN nursing student. when you make a mistake this is what you do conclusion your assessment is your ___ 24 hours this is the amount of time you have to sign a telephone (TO) or verbal order (VO)