Chapter 15- Documenting Fundies LO PDF

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Chapter 15: Documentation

1 Learning Objectives

1. List the measures used to maintain confidentiality and security of computerized client records. ● Ensure the private information is protected against unapproved users. Do not open emails on the computer from unknown senders or from personal contacts to avoid unknown download of a computer virus. Protect your computer login information (i.e.- do not tell or share) 2. Discuss purposes for client records. ● Ensures quality care. Allows physicians to have health history records from other physicians and other diagnostic centers. Allows for a hospital or HCP visit to be shortened and able to focus on the illness occurring at the exact moment. 3. Compare and contrast different documentation methods: PIE, focus charting, charting by exception, computerized records, and the case management model. ● Source-Oriented Record - Each person or department makes notations in a separate section(s) of the patient’s chart. Source-Oriented records give information about a particular problem that is distributed throughout the record. Source-Oriented Records include narrative charting which consists of written notes that include routine care, normal findings, and patient problems. ● Problem-Oriented Medical Records (POMR)/Problem-Oriented Record (POR) - Data that is arranged according to the problems the patient has rather than the source of information. POMR/POR consists of progress notes which is a chart entry made by all health professionals involved in the patients care; which they all use the same type of sheet for notes. A type of progress note used in POMR/POR is SOAP. a) S - Subjective data: information obtained from what the patient says b) O - Objective data: information that is measured or observed by use of the senses c) A - Assessment: interpretation or conclusions drawn about the subjective and objective data

d) P - Plan: the plan of care designed to resolve the stated problem ● Over the years the “SOAP” format has been modified and some acronyms have been added to it; SOAPIE and SOAPIER a) I - Interventions: specific interventions that have actually been performed by the caregiver b) E - Evaluation: patient responses to nursing interventions and medical treatments c) R - Revision: care plan modifications suggested by the evaluation ● PIE - PIE documentation model groups information into three categories; Problems, Interventions, and Evaluation. The PIE system consists of a client care assessment flow sheet, and progress notes. A flow sheet uses specific assessment criteria in a particular format, such as human needs or functional health patterns. After the assessment, the nurse establishes and records specific problems on the progress notes. The PIE system eliminates the traditional care plan and incorporates an ongoing care plan into progress notes. ● Focus Charting - Is intended to make the patient and patient concerns and strengths the focus of care. Three columns for recording are usually used: date and time, focus, and progress notes. The focus may be a condition, a nursing diagnosis, a behavior, a sign or symptom, and acute change in the patient’s condition, or a patient’s strength. The progress notes are organized into DAR, which stands for: D - data, A - action, R - response. The data category reflects the assessment phase of the nursing progress and consists of observation of patient status and behaviors, including data from flow sheets. The nurse records both subjective and objective data in the data section. The Action category reflects planning and implementation and includes immediate and future nursing actions. It may also include any changes to the plan of care. The Response category reflects the evaluation phase of the nursing process and describes the patient's response to any nursing and medical care. ● Charting by Exception (CBE) - A documentation system in which only abnormal or significant findings or exceptions to norms are recorded. CBE consists of three key elements: Flow Sheets:

Graph records of a vital sign sheet, a head and face assessment in a daily nursing assessment record, and a Braden assessment of the skin. Standards of Nursing Care: Documentation by reference to the agency’s printed standards of nursing practice eliminates much of the repetitive charting of routine care. Bedside Access to Chart Forms: All flow sheets are kept at the patient’s bedside to allow immediate recording and to eliminate the need to transcribe data from the nurses worksheet to the permanent record. ● Computerized Documentation - Electronic Health Records (EHR) are used to manage the huge volume of information required in contemporary health care. The EHR can integrate all pertinent patient information into one record. Nurses use computers to store the patient’s database, add new data, create and revise care plans, and document patient progress. Multiple flow sheets are not needed in computerized record systems because information can be easily retrieved in a variety of formats. ● Case Management - This model emphasizes quality, cost-effective care delivered within an established length of stay. Case management uses a multidisciplinary approach to planning and documenting patient care, using critical pathways. These forms identify the outcomes that certain groups of patients are expected to achieve on each day of care, along with interventions necessary for each day. 4) Explain how various forms in the client record are used to document steps of the nursing process (assessing, diagnosing, planning, implementing, and evaluating). ● Assessment: Initial assessment form, various flow sheets ● Nursing Diagnosis: Nursing care plan, critical pathway, progress notes, problem list ● Planning: Nursing care plan, critical pathway ● Implementing: Progress notes, flow sheets ● Evaluating: Progress notes 5) Compare and contrast the documentation needed for clients in acute care, long-term care, and home health care settings.

● Long-Term Care Documentation a) Complete the assessment and screening forms (MDS) and plan of care within the time period specified by regulatory bodies. b) Keep a record of any visits and of phone calls from family, friends, and others regarding the client. c) Write nursing summaries and progress notes that comply with the frequency and standards required by regulatory bodies. d) Review and revise the plan of care every 3 months or whenever the client’s health status changes. • Document and report any change in the client’s condition to the primary care provider and the client’s family within 24 hours. e) Document all measures implemented in response to a change in the client’s condition. f) Make sure that progress notes address the client’s progress in relation to the goals or outcomes defined in the plan of care. ● Home Health Care Documentation a) Complete a comprehensive nursing assessment and develop a plan of care to meet Medicare and other third-party payer requirements. Some agencies use the certification and plan of treatment form as the client’s official plan of care. b) Write a progress note at each client visit, noting any changes in the client’s condition, nursing interventions performed (including education and instructional brochures and materials provided to the client and home caregiver), client responses to nursing care, and vital signs as indicated. c) Provide a monthly progress nursing summary to the attending primary care provider and to the reimburser to confirm the need to continue services. d) Keep a copy of the care plan in the client’s home and update it as the client’s condition changes.

e) Report changes in the plan of care to the primary care provider and document that these were reported. Medicare and Medicaid will reimburse only for the skilled services provided that are reported to the primary care provider. f) Encourage the client or home caregiver to record data when appropriate. g) Write a discharge summary for the primary care provider to approve the discharge and to notify the reimbursers that services have been discontinued. Include all services provided, the client’s health status at discharge, outcomes achieved, and recommendations for further care. 6) Discuss guidelines for effective recording that meet legal and ethical standards. ● Date and Time - Document the date and time of each recording. ● Timing - Follow the agency’s policy about the frequency of documenting, and adjust the frequency as a client’s condition indicates. As a rule, documenting should be done as soon as possible after an assessment or intervention. No recording should be done before providing nursing care. ● Legibility - All entries must be legible and easy to read to prevent interpretation errors. ● Permanence - All entries on the client’s record are made in dark ink so that the record is permanent and changes can be identified. ● Accepted Terminology - Abbreviations are used because they are short, convenient, and easy to use but may also be ambiguous. Ambiguity places the client at risk for medical errors and significant harm, possibly even death. Therefore, it is important to use only commonly accepted abbreviations, symbols, and terms that are specified by the agency. ● Correct Spelling - Correct spelling is essential for accuracy in recording. ● Signature - Each recording on the nursing notes is signed by the nurse making it. The signature includes the name and title. ● Accuracy - The client’s name and identifying information should be stamped or written on each page of the clinical record. Before making an entry, check that the chart is the correct one. Do

not identify charts by room number only; check the client’s name. Special care is needed when caring for clients with the same last name. Notations on records must be accurate and correct. Accurate notations consist of facts or observations rather than opinions or interpretations. When a recording mistake is made, draw a single line through it to identify it as erroneous with your initials or name above or near the line. Write on every line but never between lines. If a blank appears in a notation, draw a line through the blank space so that no additional information can be recorded at any other time or by any other person, and sign the notation. ● Sequence - Document events in the order in which they occur. ● Appropriateness - Record only information that pertains to the client’s health problems and care. Any other personal information that the client conveys is inappropriate for the record. ● Completeness - Not all data that a nurse obtains about a client can be recorded. However, the information that is recorded needs to be complete and helpful to the client and health care professionals ● Conciseness - Recordings need to be brief as well as complete to save time in communication. The client’s name and the word client are omitted. ● Legal Prudence - Accurate, complete documentation should give legal protection to the nurse, the client’s other caregivers, the health care facility, and the client. 7) Identify prohibited abbreviations, acronyms, and symbols that cannot be used in any form of clinical documentation. ● U, u (unit) - Mistaken for “0” (zero), the number “4” (four), or cc ● IU (for International Unit) - Mistaken for IV (intravenous) or the number 10 (ten) ● Q.D. QD, q.d., qd (daily) Q.O.D., QOD, q.o.d., qod (every other day) - Mistaken for each other Period after the Q mistaken for “I” and “O” mistaken for “I” ● Trailing zero (X.0 mg) - Decimal point is missed. ● Lack of leading zero (.X mg) - Decimal point is missed. ● MS - Can mean morphine sulfate or magnesium sulfate.

● MSO4 and MGSO4 - Confused for one another 8) Identify essential guidelines for reporting client data. ● DO’s : a) Chart a change in a client’s condition and show that follow-up actions were taken. b) Read the nurses’ notes prior to care to determine if there has been a change in the client’s condition. c) Be timely. A late entry is better than no entry; however, the longer the period of time between actual care and charting, the greater the suspicion. d) Use objective, specific, and factual descriptions. e) Correct charting errors. f) Chart all teaching. g) Record the client’s actual words by putting quotes around the words. h) Chart the client’s response to interventions. i) Review your notes—are they clear and do they reflect what you want to say? ● DON’T: a) Leave a blank space for a colleague to chart later. b) Chart in advance of the event (e.g., procedure, medication). c) Use vague terms (e.g., “appears to be comfortable,” “had a good night”). d) Chart for someone else. e) Record “patient” or “client” because it is their chart. f) Alter a record even if requested by a superior or a primary care provider. g) Record assumptions or words reflecting bias (e.g., “complainer,” “disagreeable”)....