Chapter 26 PDF

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Chapter 26- Documentation study notes...

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CHAPTER 26: DOCUMENTATION Documentation of nursing care  Documentation is any written or electronically generated info that provides a written account of pt data, clinical decisions and interventions, and the pt’s response to that care  It is an integral part of nursing practice  The quality of your documentation is a reflection of your professional practice Purposes of the Medical Record  Communication  Legal documentation  Reimbursement  Education  Research  Auditing/ monitoring The shift to electronic documentation  Experts believe that implementing EHRs across the health care delivery system will decrease costs and improve the quality of pt care  Difference between EHR and EMR o EHR (Electrical Health Record): is the longitudinal (lifetime) record of all health care encounters for an individual pt o EMR (Electrical Medical Record): describes a single encounter or visit created in hospitals and outpatient healthcare setting that is the source of data for the EHR

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Advantage of EHR: a means for nurses to compare current clinical data about a pt with data from previous health care encounters and to maintain an ongoing record of health education provided to a patient and the patient’s response to that info

Interprofessional Communication within the medical record  The quality of pt care depends on your ability to communicate with other members of the health care team  When a plan is not communicated to all members of the health care team, care becomes fragmented, tasks are repeated, and delays or on missions in care often occur Confidentiality  Nurses are legally and ethically obligated to keep all pt info confidential  Nurses are responsible for protecting records from all unauthorized readers  HIPAA requires that disclosure or requests regarding health info be limited to the minimum necessary Privacy, Confidentiality, and Security Mechanisms  Electronic documentation has legal risks  There are many security mechanisms for computerized info systems  Physical security measures include placing computers or file servers in restricted areas or using privacy filters for computer screen visible to visitors or others without access Handling and Disposing of Info  You must safeguard any info that is printed from the record or extracted for report purposes  You need to de-identify all pt data when you write it onto forms or include it in papers written for nursing courses  Shred everything that is printed when the info is no longer needed.

Standards of Documentation  Know standards of your organization  Documentation must conform to standards of the NCQA and TJC to maintain institutional accreditation and minimize liability.  Components of the medical record. Guidelines for Quality Documentation  Factual  Accurate  Complete  Current  Organized Methods of Documentation  Narrative: o Traditional Method o Storylike Format o Many Disadvantages  Repeatitious  Time consuming  Lengthy  Disorganized  Problem-Oriented Medical Record

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Emphasizes the Pt’s problems o Database o Problem List o Nursing Care Plan o Progess Note ( SOAP, PIE, DAR ) Source Records Charting by Exception o Document normal findings and routine care on clearly defined standards o Document only deviations from the established norm o Advantages:  Reduce charting time/ multiple entries  Use of flow sheets, protocols and standards o Disadvantages:  Can pose legal threat if not documenting exceptions Case Management/ Critical Pathways. o A critical pathway eliminates nurses’ notes, flow sheets, and nursing care plans because the document integrates all relevant information. Unexpected outcomes, unmet goals, and interventions not specified within the critical pathway are called variances.  A variance occurs when the activities on the critical pathway are not completed as predicted or a patient does not meet the expected outcomes.  A positive variance occurs when a patient progresses more rapidly than expected. o Once a variance is identified, modify the patient’s care to meet the needs associated with the variance.

Common Record-Keeping Forms  Admission nursing history form o Guides the nurse through a complete assessment to identify relevant nursing diagnoses or problems  Flow sheets and graphic records o Help team members quickly see pt trends over time and decrease time spent on writing narrative notes  Pt care summary  Standardized care plans or clinical care guidelines (CPGs) o Preprinted, established guidelines used to care for pt who have similar health problems  Discharge summary forms Documentation DO’s and DO NOT’s DO

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Sign name and follow with title SN for student nurse Use black ink for all entries Assure all forms have pt’s label Use only hospital approved abbreviations Record when physicians are notified and their recommendation Write neatly Use military time Document in a timely manner Note “Late Entry” if out of sequence Draw a single line through a mistake and document “error” above with your initials and date Include factual info Include all pt education

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Chart your personal opinion Falsify a record Chart in advance Leave blanks Erase or use white out Use general words like “appears” Make assumptions about an accident Put an incident report on the chart

Documenting Communication with providers and events  Telephone calls made to a provider o Document every call  Telephone and verbal orders o Telephone orders (TOs)

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o Verbal orders (VOs) Incident or occurrence reports o Used to document any event that is not consistent with the routine operation of health care unit or the routine care of a pt o Follow agency policy

Nursing Infomatics  The use of info and computer technology to support all aspects of nursing practice, including direct delivery of care, administration, education, and research  Nursing infomatics is also recognized as a specialty area of nursing practice  Advantages of Nursing Information Systems include o Increased time to spend with clients o Better access to info o Enhanced quality of documentation o Reduced errors of omission o Reduced hospital costs o Increased nurse job satisfaction o Compliance with TJC o Development of a common clinical database Clinical Info Systems  Computerized provider order entry (CPOE)  Clinical decision support systems (CDSSs)

o Used to support decision making Reporting Pt Info  Verbal Info transmitted between healthcare team o Timely o Accurate o Relevant o Organized  SBAR o Situation: Admitting Dx and current problem o Background: Pertinent History, Lab Fata, Code status, .. o Assessment: Significant assessment info, vital signs.. o Recommendation: your suggestion of what needs to be done Types of Pt reports:  Change of Shift Report: o Nurse to Nurse when one nurse is ending their shift and another nurse is starting their shift.  Transfer Report o Nurse to Nurse when pt is being transferred to a different area  Report to the Provider o Nurse to Physician, Nurse Practitioner, or Physician’s Assistant when the pt’s condition has changed and the Provider needs to be notified. Often result in new orders from the provider....