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Review - Ch 7: (Nursing) Documentation
Notes from Foundations of Nursing by Kockrow and Christensen 6th Edition for Practical Nursing
Terms in this set (26)
What is a Chart ?
Also called a health record, they are Legal Records used to meet demands of health, accreditation, medical and insurance systems
What does Charting, Recording or Documenting involve?
Involve interventions carried out to meet the patient's needs. Document the type of interventions, time rendered, and signature of health care provider
What does Good documentation reflect?
Reflects nursing process
What are the Five purposes for accurate and complete written patient records?
1) Written Communication
2) Permanent Record for Accountability
3) Legal Record of Care
5) Research and Data Collection
What does a patient chart provide?
Concise, accurate and permanent RECORDS of PAST and CURRENT medical and nursing problems, plan for care, care given, and patient's response to various treatments. It covers areas of PHYSICAL, EMOTIONAL, PSYCHOLOGICAL, SOCIAL and SPIRITUAL needs.
Who else uses the patient's permanent record and why?
The Government and other agencies like Insurance companies. They use it ..
1) to evaluate institution's patient care
2) to adjust cost reimbursment for care provided
3) to establish or review accreditation
Who are AUDITORS?
Appointed to examine patient charts and health records to
a) assess quality of care,
b) see whether ordered care was given and charted,
c) and whether responses to care plans and treatments are noted
What are PEER REVIEW Systems?
An appraisal by professional co-workers of equal status. They also provide quality assurance, assessment and improvement
What are DRG's (Diagnosis-related groups) ?
A system that classifies the charting system by
c) surgical procedure
using 300 different categories to predict the use of hospital resources including length of stay
What are the USES of patient chart or health record?
It is a legal document that can be used when appropriate in:
1) Court proceedings
2) Teaching students in the health care professions
3) Research and data collection in the health field
What are the BASIC RULES for DOCUMENTATION?
1) Should have correct name of patient, date and time if appropriate
2) Use only approved abbreviations and medical terms.
3) Be timely, specific, accurate and complete
4) Write legibly
5) Follow rules of grammar and composition
6) FILL ALL SPACES. LEAVE NO EMPTY LINES. CHART CONSECUTIVELY. GO LINE BY LINE. DO NOT INDENT LINE MARGIN.
7) Chart after care is provided, not before.
8) Chart as soon and as often
9) Chart your own, never chart for anyone else
10) Use DIRECT QUOTES when appropriate
11) Be Objective - hear, see, feel and smell
12) Describe items as you see it
13) Chart facts, avoid judgments
14) Write only what you observe - not opinions
15) Sign blocks of charting or entry with full legal name
16) When a patient leaves a unit, write time and means of transportation on departure and return
17) Chart all ordered care as given or explain why not
18) Note patient response to treatments and interventions
19) USE ONLY PENS WITH PERMANENT BLACK INK
20) When ERRORS are made, DRAW ONE LINE through faulty information, mark error, initial if required, and make correction entry.
21) When making a late entry, note it as a late entry and then proceed with notation.
22) Follow agency policies and procedures for charting
23) Avoid using generalized empty phrases such as "status unchanged" or "had a good day".
Four common errors of inadequate documentation
1) not charting the correct time when events occurred
2) failing to record verbal orders or failing to have them signed
3) charting actions in advance to save time
4) documenting incorrect data
Traditional Block Charting
Divided into sections or blocks. Emphasis is placed on specific sections, or sheets of information.
Typical Sections of Traditional Block Charting
1) admission sheet
2) physicians's orders
3) progress notes
4) history and physical examination data
5) nurse's admission
6) care plan and nursing notes
7) laboratory and x-ray reports
Recording of patient care in descriptive form. Written in abbreviated story form and includes:
a) subjective and objective data about patient need or problem
b) whether anyone has been contacted or consulted
c) care and treatments provided
d) patient response to treatment
e) information from head to toe assessment
Problem-Oriented Medical Record (POMR)
Organized according scientific problem-solving system or method
Principal sections of POMR
1) Database (accumulated data)
- physical examination
- diagnostic test
2) Problem list
- active and inactive potential
- resolved problems
Legal Guidelines for Documentation
1) Do not erase, apply correction fluid or scratch out errors made while recording
2) Do not write any subjective negative comments about patient or care about other health care professionals
3) Correct all errors promptly
4) Do not leave blank spaces in nurses notes
5) Record all entries in black ink
6) When an order is questioned, document clarification was sought
7) Chart only for yourself
8) Avoid empty, generalized phrases
9) Begin each entry with TIME and end with SIGNATURE
10) Keep DOCUMENT PASSWORD to yourself
S - subjective information is what patient feels
O -objective is measurable and factual
A -assessment refers to analysis or potential diagnosis
P -plan is generalized statement of the plan of care
I -intervention or implementation, specific care given
E -evaluation is an appraisal of the plan
R -revision includes changes that may be made
S - subjective
A - assessment
P - plan
E - evaluation
SOAPE is the briefer adaptation of the charting format for the POMR.
FOCUS CHARTING FORMAT
Response and evaluation
Education and patient teaching
1) Developed by nurses, it is a modified list of nursing diagnoses and is used as an index for nursing documentation instead of problem lists. Similar to the problem list of the POMR
2) Uses the nursing process and the more positive concept of the PATIENT'S NEEDS rather than MEDICAL DIAGNOSES AND PROBLEMS.
3) It is sometimes a patient's current concern or behavior, sometimes a significant change in patient status or behavior. or a significant event in patient therapy.
4) FOCUS IS NOT A MEDICAL DIAGNOSIS
Charting by exception (CBE)
At the BEGINNING of each SHIFT - chart complete physical assessments, observations, vital signs, IV site and rate
DURING THE SHIFT - the only notes are for additional treatments done or planned treatments withheld, changes in patient conditions and new concerns.
Notations should reflect PROGRESS or REVISIONS for all active nursing diagnoses on the care plan
A variation of the PIE format
Assessment before PIE (Problem, Intervention, Evaluation)
KARDEX OR RAND
card system used to consolidate patient orders and care needs in a centralized, concise way.
1) Any event not consistent with routine operation of a health care unit
2) Routine care of a patient or other hospital notification form when patient care delivered is not consistent with facility or national standards of expected care (e.g. medical errors)
3) Events that may cause injury or has caused injury to patient or staff
4) Reports about any unusual events in the facility (e.g. injured visitor, fights resulting in injury, criminal behavior)
Incident reports are mainly used for risk management, are not part of a permanent patient documentation, and are oftentimes for internal use only.
When giving out an incident report...
- give only objective, observed information. Opinions, judgments, and personal assessments are not necessary
- do not admit liability
- do not provide unnecessary details
- list date, time, care given to patient and name of physician notified
- do not mention incident report in nursing notes
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