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nursing documentation (NCI)

Terms in this set (51)

Why do we document?
provides written record of history treatment care response of patient while under care of healthcare provider. Permanent record of accountability purposes
Why do we document?
Serve as evidence in court of law (legal record of care- may protect or hurt you)
Why do we document?
Teaching purpose (how to document appropriately) research and data collection( research project assurance)
Why do we document?
Used in licensing and accreditation
Justifies reimbursment
Demonstrates compliance with Nurse Practice Act
How DOES documentation correlate to nursing process? framework organization
Written care plan provides the framework
Charting is organized by nursing diagnosis or problem; Initial assessment (data collection) is completed and charted each shift; Standard areas of assessment (data collection) are noted on flow sheets; Written notes are completed for abnormalities; Nursing diagnoses (problems) are entered on plan of care which is created soon after admission; Plan reviewed and updated at least every 24 hours; implementation of interventions documented on flow sheet or written note- Specifics of what was done, how it was done, patient response are entered on chart; Evaluation statement placed in notes to indicate progress toward goals-If goal met, diagnoses (problem) is marked "resolved" and removed from plan, if not being, goal is altered (revised)
Legal Guidelines for Documentation (Charting)
Brief
Concise
Accurate
No open lines
Facts only
Legible
Complete
Timely
Correct patient name, date, time
Sign each entry
Legal Guidelines for Documentation (Charting)
Chart after care is given, not before
Chart as soon as and as often as possible
Chart only your own care, not someone else's
Use direct quotes when appropriate describe each item as seen
Objective only, no opinions
Facts only-nonjudgemental
A nurse cannot effectively and efficiently use health record until some understanding and knowledge of common abbreviations and medical terms have been developed
Most facilities have a published list of generally accepted medical abbreviation and terms approved for use in charting
Joint Commission for Accreditation of Hospitals Organization (JCAHO), or The Joint Commission as it is now known, has published a list of "Do Not Use" abbreviations because these have been know to cause confusion
PIE
Problem, Implementation, Evaluation
FOCUS
Data, Action, Response and evaluation, Education and patient teaching (DARE)
SOAP/SOAPIER
Subjective, Objective, Assessment, Plan, Intervention/Implementation, Evaluation, Revision
Problem Oriented according to problem
problem is numbered and charting is according to numbered problem
Charting by Exception
only chart what is out of ordinary
Computer-Assisted (Electronic)
on electronic system
Traditional/narrative/Block
"story" of what happened-written note of what occurred through all systems
Forms: Traditional Chart cont,
Chart is divided into specific sections or blocks. Emphasis is placed on specific sheets of information; typical sections are admission sheet, physician's orders, progress notes, history and physical examination data, nurse's admission information, care plan and nurse's notes, graphics, and laboratory and x-ray reports;
Forms: Traditional Chart cont,
Nursing care Plan-Preprinted guidelines used to care for patients with similar health problem. Developted to meet the nursing needs of patient/ Based on nursing assessment and nursing diagnosis;
Forms: Traditional Chart cont,
Clinical-Critical-Pathways-Managed care isa systematic approach that provides a framework to target the coordination of medical and nursing interventions. Allows staff from all disciplines to develop integrated care plans for a projected length of stay for a specific case type;
Forms: Traditional Chart cont,
The nurse and other team members use the pathways to monitor a patient's progress and as a documentation tool Kardex/Rand-Card system used to consolidate patient orders and care needs in a centralized, concise way Kept at the nursing station for quick references-24hour Patience Care Records and Acuity Charting Forms: Consolidation of the nursing records into a system that accommodates a 24-hour period is often done-aids in the elimination of unnecessary record-keeping forms; Accurate assessment information and documentation of activities of daily living are more easily obtained with 24-hour notations
Legal Guidelines for Documentation-Charting
Using the facility format
Facility forms
Carting format-Narrative, PIE, FOCUS, SOAP/SOAPIER, Problem-Oriented, Charting by Exception, Computer-Assisted (Electronic), Traditional(narrative/block), Approved method to correct entries in record
Charting Don'ts
Dont's: Include staffing problems, conflicts, conversations
Mention incident reports
Use words associated with errors
Name a second patient
Use unapproved abbreviation
Document information obtained in shift report
Chart opinions or assumptions
Chart what someone else did
Scribble or write over errors
Use correction fluid
Double document
Use colored ink-Black only
Most commonly used forms of documentation:
Charting by Exception using Flow Charting, Narrative Note, Order of Documentation, words to avoid, Basic Rules
Narrative Note
Opening note Date&Time, report received, Initial Head to Toe; Done within first 60-90 minutes
At least every 2 hours documentation; Always note pain and safety; Never leave blank lines; Don't indent on nurses notes; Closing note, Repot given(to whom); Signature (credentials)
Order of documentation
Vital Signs; LOC; ABC's, "the star" Head to Toe (visually place star on patients' forehead)-Note everyting not mentioned on flow sheet; Pacemaker, Surfical scars, wound, Tubes (foley, GT, NG tube, etc)
words to avoid
Normal; good/bad/big; tolerated well; sleeping; comfortable; appears; seems; and; the; his; her; that; is (at times); Pt.(repeatedly) Always document: pain, safety
When do you fill out an incident report
if not consistent with routine of health care unit; used when patient care was not consistent with facility of national standards of expected care
What do you include in an incident report
objective, observed information; do not admit liability or give unnecessary details
What do you NEVER chart in a patient's records about an incident report?
Neer record in a patient's chart that an incident report was completed (in other words, do not mention the incident report in the nurse's notes)
Common reactions to admission
fear on unknown, loss of identity, disorientation, separation anxiety, loneliness
Admission process
meet with admission clerk/secretary-obtains infor, places ID band on pt and allergy band, provide consent for treatment and Pt bill of right and responsibilities to patient or legal guardian, address Patient Self-Deterination Act and HIPPA(telephone versus ER admission)
prepare room, admission to room
admission to clean, organized room, address pt by surname, explain hospital routine, assess immediate needs, have pt give valuables to family to take home, have pt change into pj's or hospital gown, assess further needs, provide pt teaching and orientation to surroundings, obtain health history and prioritize needs, make comfortable, notify physician of admission, obtain orders in none have been received before this time.
When pt is being transferred to another facility
write a paragraph when, why, patient is being transferred and were they are being transferred
What is a transfer?
moving pt from one unit to another or one health care facility to another
What does documentation and communication do for the nursing staff?
ensures continuity of care (Continuing of established pt care from one setting to another) and legal protection for transferring facility and staff
What begins the transfer process?
Physician's order begins the transfer process
What is discharge planning?
the systematic process of planning for pts care after discharge from the hospital/facility
When does discharge planning begin?
when the pt is admitten
What is the purpose of discharge planning?
teach the pt and family about pt illness and effect of illness on pt lifestyle, provide instructions for home care, communicate dietary or activity instructions, explain purpose/adverse effects/scheduling of medication treatments, arranging for transportation, arranging follow-up care if required, coordination outpatient or home health care services
Who is involved in discharge planning?
pt, family, all healthcare workers-nurse, physician, therapy, social services, dietary; uses the strengths of the patient in planning; provides resources to meet pt limitations; is focussed on improving pt long-term outcomes
What is the ultimate, desired outcome?
the ultimate desired outcome is to limit the number of return visits of the pt to the healthcare system if possible
List the Joint Commission requires instruction for discharged
safe and effective use of meds/medical equipment;nutrition and modified diets; rehabilitation techniques to support adaptation to or functional independence in environment; access to community resources as needed; when/how to obtain further treatment; patient/family responsibilities in ongoing health care needs and knowledge/skills to carry out responsibilities; maintenance of standards of good grooming and hygiene
Which risk factors need to be considered for discharge planning?
age group(especially order adults; multi system disease processes; major surgical procedures; chronic/terminal illnesses
What is the discharge process?
physicians' order obtained; contact business office to make sure there is no billing arrangements to keep pt in facility- make arrangements for pt/or fam to visit office for bill arrangements; if not physicians' order, obtain against medical advice paperwork and notify appropriate ind.. about pt's decision to leave w/o drs approval; notify fam or appropriate person to transprot pt to home or location; gather equip, supplies, pt belongings in prep for discharge; review discharge office release; check that personal belongings in preparation for discharge; review discharge inst. w/pt/fam/significant other/guardian; check for business office release; check that personal belongings list corresponds with belongings releases @ time of discharge; have pt dam/significant other sign discharge inst's and belongings list; trans pt and belongings, equip &supplies to transport vehicle; assist pt to vehicle; which pt and fam/representative well as they leave facility; return to unit; document discharge process
Discharge summary form
alternative form to discharge narrative not- information is provided that pertains to the pt continued health after discharge; discharge summary forms make the summary concise and interactive.
Home health care agencies have specific guidelines regarding doc to ensure reimbursement
examples of doc's that would meet requirements and thus result in denied reimbursements. Medicare has specific guidelines for establishing eligibility for home health care reimbursement.
largest problem for nurses in home health
50% of nurse time is spent in documentation
What is the purpose of documentation in home health care?
quality control, justification for reimbursement form medicare, medicaid, or private insurance. Have unique problems from different health providers to access the medical records.
Long term health care documentation
*Omnibus Budget Reconciliation Act (OBRA) of 1987(reg long-term care facilities regarding standards for pt care)
* Frequent written nursing records
*Documentation Minimum Data Set (MDS)
Who owns the patient record?
facility, not the patient
Who can access the patient record?
Record Ownership and Access, patients written permission
What law protects the pt regarding their patient regarding their patient record?
Patient Bill of Rights
What issues can potentially lead to a violation of this law and how can the nurse protect him/her and the patient?
sharring passwords to owns computer with pt records,do not leave pt info display on monitor, follow agency's confidentiality procedures
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