Funda PP Documentation PDF

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1/22/18

DOCUMENTATION Tonya Mullen, MSN, RNC-OB, CNL, CNE Middle Georgia State University *

Why Document? * Means of communication * Chronological record of patient care * Planning patient care * Research * Education * Reimbursement * Legal documentation * Law suits can last 18 years * Health care analysis

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Legal Considerations * Medical record = legal document * May be used to provide evidence in court * Evidence of appropriate care given * Patient’s response to that care * “If it isn’t documented, it wasn’t done.” Maintaining Confidentiality of Records * Bound by strict ethical codes and legal responsibility * HIPAA • Privacy Rule • Protected Health Information (PHI) • Security Rule Security for Computerized Records * Passwords required and should not be shared (connected to your name and cannot be changed) * Never leave the computer terminal unattended after logging on (anyone can see that) * Do not leave patient information displayed * Shred all unneeded computer-generated worksheets Security for Computerized Records (cont'd) * Know the facility’s policy and procedure for correcting an entry error * Follow agency procedures for documenting sensitive material (time stamps…chart in real time not 6 hr later) General Principles * Date and time (time stamps, so be accurate) * Timing * Legibility * Permanence * Accepted terminology * Correct spelling * Signature

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* Accuracy * Sequence * Appropriateness * Completeness * Conciseness * Legal prudence Documentation Systems (most around here are meditech..so not much time learning this) * Source-oriented record * Problem-oriented medical record * PIE * Focus charting * Charting by exception * Computerized records * Case management model Source-Oriented Records * Traditional patient record * Each discipline makes notations in a separate section * Narrative charting used * Information about a particular problem distributed throughout the record Problem-Oriented Medical Records (POMR) * Data arranged according to patient problem * Health team contributes to the problem list, plan of care, and progress notes * Encourages collaboration * Easier to track status of problems * Vigilance required to maintain problem list Problem-Oriented Medical Records (POMR) * Four basic components * Database * Problem list * Plan of care * Progress notes * Uses SOAP, SOAPIE, SOAPIER documentation * Notes from providers : S O A P Intervention, evaluation, reassessment * PIE Documentation * Groups information into three categories: Problem, Interventions, Evaluation * Consists of a patient assessment flow sheet and progress notes Focus Charting * Focus on patient concerns and strengths * Progress notes organized into DAR format * Data  assessment phase * Action  planning and implementing phase * Response  evaluation phase Charting by Exception (CBE) (WRITING WHAT IS NOT WITHIN NORMAL LIMITS) * Only abnormal or significant findings or exceptions are recorded * Incorporates flow sheets, standards of nursing care, bedside chart forms * Agencies develop standards of nursing practice

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* Documentation according to those standards of nursing practice Computerized Documentation * Developed to manage volume of information * Use of computers to store the patient’s database, new data, create and revise care plans and document patient’s progress * Information easily retrieved and transmitted * EHR (Electronic Health Record) Case Management Model * Emphasizes quality, cost-effective care delivered within an established length of stay * Uses a multidisciplinary approach * Use of critical pathways * Documentation of variance include: * Actions taken to correct the situation (SO PROVIDERS DO THE RIGHT WAY TO SAVE MONEY) * Justify the actions taken Documenting Nursing Activities * Record should describe the patient’s ongoing status * Reflect the full range of the nursing process * Documented on a variety of forms Nursing Care Plans * Joint Commission requires clinical record to include: * Evidence of client assessment * Nursing diagnosis * Nursing interventions * Patient outcomes * Current nursing care plans Nursing Care Plans (cont'd) * Traditional care plans * Written for each patient * Standardized care plans * Based on institutions standards of practice Kardexes * Concise method of organizing & recording data * Information quickly accessible * Pertinent information about the client * Allergies * List of medications including IV fluids * List of daily treatments and procedures * List of diagnostic procedures * Physical needs that are to be met Flow Sheets * Graphic record * Intake and output * Medication administration record * Skin assessment record

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Progress Notes * Provide information about the progress is making toward achieving desired outcomes * Include information about patient problems and nursing interventions * All disciplines use progress notes Nursing Discharge/Referral Summaries * Completed when patient discharged * Written in terms that can be readily understood * Completed when patient transferred to another institution Nursing Discharge/Referral Summaries (cont'd) * All must include * Description of patient’s physical, mental, and emotional status * Resolved health problems * Treatments that need to be continued * Current medications Guidelines for Reporting * Should be concise, including pertinent information but no extraneous detail * Types of reporting: * Change-of-shift report * Telephone reports * Care plan conference * Nursing rounds Change-of-Shift Reports * Provides continuity of care & promote patient safety * Follow a particular order * Provide basic identifying information * For new patients provide the reason for admission or medical diagnosis/es, surgery, diagnostic tests and therapies in the past 24 hrs * Significant changes in patient’s condition Change-of-Shift Reports, cont’d * Provide exact information * Report patient’s need for emotional support * Include current nurse-prescribed and primary care provider-prescribed orders * Clearly state priorities of care and care due after the shift begins Change-of-Shift Report, cont'd * Be concise * Incorporate a verification process SBAR format (Situation, Background, Assessment, Recommendation) * * Very quick to the point/timely/precise to call Dr and get approval of recommendation for x y z * Receiving Telephone Report (always repeat back) * Document date and time * Record the name of person giving the information * Record the subject of the information received * Sign the notation Repeat information to ensure accuracy * Giving Telephone Report

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Be concise and accurate SBAR often used State name and relationship to patient State the patient’s name, medical diagnosis, changes in nursing assessment, vital signs related to baseline, significant laboratory data, related nursing interventions Giving Telephone Report, cont'd * Have chart ready to give any further information needed * Document the date, time, and content of the call Telephone Orders * Know the state nursing board’s position on who can give and accept * Know the agency policy Write the order down on physician’s order forms * * Read the order back to the primary care provider Telephone Orders (cont'd) * Question the primary care provider about any order that is ambiguous * Have the primary care provider verbally acknowledge the read-back order * Indicate telephone order (TO) * Must be countersigned by the primary care provider within a time described by agency policy...