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Chapter 7 - Documentation from Nursing Fundamentals

Terms in this set (35)

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(p. 139).
Chart
Also called "Health Care Record", it is a legal record that is used to meet the many demands of the health, accreditation, medical insurance, and legal systems (p.138).
Charting
The process of adding written information to the chart. It is also called "RECORDING', 'DOCUMENTING'. It involves recording the interventions carried out to meet the patient's needs. It is essential when charting interventions to document the type of interventions, the time of care was rendered, and the signature of the person providing care (p. 138).
Charting by exception
It is when the notes you make will be for additional treatments done or planned treatments withheld, changes in patient condition, and new concerns (p. 145).
Database
Accumulated data from history, the physical assessment and the diagnostic tests that are used to identify and prioritize the health problems on the master medical and other problem list (p. 142)
Diagnosis-related groups (DRG)
The cost reimbursement rates by the government plans (Medicare, Medicaid) are based on this group. It is a system that classifies patients by:
a) age,
b) diagnosis, and
c) surgical procedure,
using 300 different categories to predict the use of hospital resources, including the length of stay (p. 139).
Documenting
The process of adding written information to the chart. It is also called "RECORDING', 'CHARTING'. It involves recording the interventions carried out to meet the patient's needs. It is essential when charting interventions to document the type of interventions, the time of care was rendered, and the signature of the person providing care (p. 138).
Kardex (or Rand)
A card system used to consolidate patient orders and care needs in a centralized, concise way. The cumulative care file or Rand is kept at the nursing station for quick reference (p. 145)
Narrative Charting
It is a recording of patient care in descriptive form to chart observations, care and responses. Nursing notes in this form are easier to complete when the steps of the nursing process are followed. They include the same information as the SOAPE notes. 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

Information is CLUSTERED and organized in a HEAD-TO-TOE manner (p. 142).
Nomenclature
A classified system composed of technical or scientific names or terminology used mainly for documentation by computer (p. 153).
Nursing Care Plan
Are normally preprinted guidelines used to care for patients with similar health problems, developed to meet the nursing care needs of a patient. Sometimes, a standardized nursing care plan is used for certain conditions like surgery; special needs or interventions are indicated so as to tailor care for the individual. This kind of plan, developed by nurses for nurses, is based on NURSING ASSESSMENT and NURSING DIAGNOSIS. Standardized nursing care plans include the pertinent nursing diagnoses, goals, and plans for care and specific actions for care implementation and evaluation (p. 145)
Nursing Notes
A form on the patient's chart on which nurse record their observations, the car given, and the patient's responses when deciding whether the necessary and ordered care is being given or was given (p. 139)
Peer Review
An appraisal by professional co-workers of equal status. It appraises the manner in which an individual nurse conducts practice, education or research (p. 139)
Problem List
It is a list of active, inactive, potential and resolved problems that serves as the index for chart documentation (p. 142)
Problem-Oriented Medical Record
Organized according to the scientific problem solving system or method. The principal sections in this record are DATABASE, PROBLEM LIST, CARE PLAN and PROGRESS NOTES (p. 142)
Quality Assurance, Assessment and Improvement
Specific procedures that institutions have which is an audit in health care that evaluates services provided and the results achieved compared with accepted standards. Accurate and legible records are the only means to prove that they are providing care that meets patient's needs and established standards (p.139)
Recording
The process of adding written information to the chart. It is also called "CHARTING', 'DOCUMENTING'. It involves recording the interventions carried out to meet the patient's needs. It is essential when charting interventions to document the type of interventions, the time of care was rendered, and the signature of the person providing care (p. 138).
SOAPE
It is the briefer adaptation of the charting format for the POMR. In this more compact form, the care given or action taken (intervention) is included in the notations under planning.
The needed plan revisions (R) are noted in the evaluation section after the evaluation of the response to treatment (p. 144)
S - subjective
O - objective
A - assessment
P - plan
E - evaluation
SOAPIER
S - Subjective information is what the patient states or feels; only the patient can provide this information.

O- Objective information is what the nurse can measure or factually describe.

A - Assessment refers to an analysis or potential diagnosis of the cause of the patient's problems or need.

P - Plan is the general statement of the plan of care to be given or action to be taken.

I - Intervention or implementation is the specific care given or action taken,

E - Evaluation is an appraisal of the response and effectiveness of the plan.

R - Revision includes the changes that may be made to the original plan of care. (p. 142)
Traditional (block) chart
Divided into sections or blocks. Emphasis is placed on specific sections or sheets of information. Typical sections are the following:
(1) Admission Sheet, (2) Physician's Orders, (3) Progress notes, (4) History and Physical Examination Data, (5) Nurse's admission information, (6) Care plan and nursing notes, (7) Graphics, (8) Laboratory and x-ray examination reports.
APIE
A variation of the PIE format: Assessment before PIE (Problem, Intervention, Evaluation)
FOCUS CHARTING FORMAT
Data Action 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
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
INCIDENT REPORT
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)
5) Incident reports are mainly used for risk management, are not part of a permanent patient documentation, and are oftentimes for internal use only.
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
Principal sections of POMR
1) Database (accumulated data) - history -physical examination -diagnostic test
2) Problem list - active and inactive potential -resolved problems
Procedures for giving an incident report
1) Give only objective, observed information. Opinions, judgments, and personal assessments are not necessary
2) Do not admit liability
3) Do not provide unnecessary details
4) List date, time, care given to patient and name of physician notified
5) Do not mention incident report in nursing notes
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
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".
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
4) Teaching
5) Research and Data Collection
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 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.
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
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 reimbursement for care provided
3) to establish or review accreditation
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