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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?


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