documentation in nursing

dr smith
documetation outline
the written, legal, record of all pertinent interaction with the client
only permenant legal document that details the healthcare providers interaction with the client
good documentation is the best legal defense
documentation guidelines
consistent with professional and agency standards
complete, accurate, concise, factual, organized, and timely
legally prudent
legally prudent
document what we expect to find when the average nurse documents
guidelines on content
record observations of behaviors (not interpetation)
avoid subjective terms ie good, normal, avearge, sufficient
note changes in orderly manner
document nursing resonse to questionalble orders: date/time, md/apn notified and response
don't use derogitory terms
documentation timing
timely manner: 30-1 hr; know institution policy
date and time
dont documetn interventions before you do them
late entry: note appropriatly
put current time/date and late entry
format guidelines
use proper forms
use dark ink and prink legible using correct grammer
standart terminology: approved abbreviations
dont skip lines
draw line through blank spaces
a nurses best defense it what
good documentation
pt demor was good upon 700 assessment. is this documentation legal and correct?
no b/c good is not defined
accountability guidelines
sign first initial, last name, and title
draw single line through errors and write error above and sign
each page should have clients name/id number
document in a legally prudent manner false documentation = termination of employment
medical orders
written by md, apn, dmd, psychologists, and podiatrists
must be signed by writer with name, title, pager # and if med student or not
nurses responsible for taking-off/signing off and implementing orders
telephone orders TO and verbal orders VO are to be read back
verbal order guidelines
verbal orders only in emergency situation when perscriber cannot write the order
telephone orders TO determined by the institution
only RNs or registered professional pharmacists can take VOs and TOs; not nursing students
who outlines guidelines
joint commission
VO/TO procedures
records order in record
reads order back to perscriber (accuracy)
date and time order
writes VO perscribers name and signs own name title
Perscriber then
reviews the order
signs with name, title, pager #
date/times when signed
a perscriber of a verbal order also signs the actual order, true or false
a nurse may take a verbal order from a physican assistant, true or false
methods of documentation
source orientated
problem orientated medical records (POMR/SOAP)
problem intervention evaluation (PIE) written from soap notes
focus charting (DAR)
flow sheets: check box for whatever care you provided
discharge/transfer summeries
source orientated documentation
each hc group has separate sections or forms
advantage: each discipline finds what they need fast and easily
disadvantage: fragmentation
nursing notes
types of source orientated records
admission sheet
admission nursing assessment
graphic sheet
flow sheet to record routine care
narrative nurses notes
medication sheet
medical history and examination sheet
physicians order sheet
physicians progress notes
miscellaneous forms
what are nursing notes
narrative notes that address routine care, normal findings and patient problems
admission sheet
name, id number, age, occupation, regilous perferance, date time admission, insurance, discharge data, next of kin, etc
admission nursing assessment
results of nursing history and physical assessment
graphic sheet
daily temp, pulse, vitals, special measurements ( I/Os )
flow sheet to record routine care
resp, cardiac, pain, nutrition, elimination, iv therapy, wound, tubes, hygiene, activity, sleep, safety, equipement, teaching, progress sheet
narrative nurses notes
descriptions of pertinent observations of pt
statements that specity th enrusing care, incluiding teaching
describe pt condition and progress
description of pts complaints and how pt is coping
med sheet
name, dosage, route, time, name or perscriber
med history and exam
results of physical exam by physicial
current med condition
health history
family medical history
confirmed or tentative condition
physicians order sheet
orders for medication
orders for treatment
other directives pertinent to a pat pt care
physicians progress notes
interpertations of patients pathology
responses of patient to med therapy
miscellaneous forms
lab reports
consultation reports
dietary requirements
results of social service consultation
types and results of physical, resp, and xray therapy
problem orientated medical records
organized around pt problems
advantages: all working on same page to identify and plan around specific problems
collaborative plan of care
parts of POMR:
summary data base
problem list
plan of care
progress notes
soap means
s: subjective
o: objective
a: assessment
p: plan
i: interventions
e: evaluation
r: response
PIE charting
Problem Intervention Evaluation Charting
plan of care incorporated inot progress notes that are numbered
complete assesment every shift: problems identified and numbered adn worked up using PIE format, evaluated each shift
advantages: promotes continuity of care; time saver
disadvantages: no formal care plan, nurses must read all notes to determine problems and plans
focus charting
brings focus of care back to the client
focus: clients strenght porblem or need: client concerns/behaviors, theapies and responses, changes in condition, significant events
written as:
D: data
A: action
R: response
advantage: holistic, easy
FLOW sheets
document routine nursing care throughout a given period of time
graphic record: VS
fluid balance: I/Os
medication records
special forms:
neuro checks
braden skin assessment
Discharge/transfer summeries
consice clinical report of what occured at discharging/transferring institution or unit
should include: reason for treatment, findings
procedures/treatment: clients condition at time of d/c transfer
special instructions (includes meds)
usually done by MD or APRN
do you add herbal/otc meds as well as perscriptions?