Nurse Documentation PPT PDF

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DocumentationbytheNurse TexasHealthandHumanServices QualityMonitoringProgram

“Ifitwasn’tdocumenteditwasn’t done”

DocumentationBasics  Documentationisfactualinformationabouttheresident  Itcontainsinformationregarding:  Theneedsandconditionsoftheresident  Careprovidedtotheresidentbythecarestaff

 Itoccursonanon‐goingbasis  Firsthandrecordofobservationsmadebycarestaff

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Whatisdocumentation?  Documentingthebasicsincludesthefollowing:       

Chronology:DateandTime ClientHistory Interventions:Medical,Social,etc. Observations:ObjectiveandSubjective ClientOutcomes ClientandFamilyResponse Authorship:YourfullName,Credentials,andSignature

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TheBasicsof Documentation Practicingthe4C’swhendocumentingwill ensurethatyouaredocumentingwell. Clear Concise Correct Complete

TheBasicsof Documentation Agoodtesttoevaluatewhetheryour documentationissatisfactoryistoaskthe followingquestion:“Ifanothernursehadto stepinandtakeovercareforthisresident, doesthechartprovidesufficientinformation fortheseamlessdeliveryofsafe,competent andethicalcare?”

Whydocument?  Documentationisdoneforthefollowingreasons:  Toensurethatservicesthatwerepaidfor,forthatresident,are delivered  Provideapictureoftheresident’scondition  Detailhowaresidentisrespondingtotreatment  DeterminetheamountofMedicare/Medicaidreimbursment a facilityreceivesforthecareofindividualresidents  Itisalegalrecordofcarethatcanbeusedinacourtoflaw  Documentationinfluencesthedecisionssubsequentcaregiverswill makeregardingaclient’scondition.

Purposeofdocumenting  Clear,complete,andaccuratehealthrecordsservemany purposesforresidents,families,nurses,andotherhealth careproviders.  Thedatafromdocumentationallowsfor:       

CommunicationandContinuityofCare CoordinationofServices QualityImprovement/AssuranceandRiskManagement EstablishesProfessionalAccountability LegalReasons FundingandResourceManagement ExpandingtheScienceofNursing

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DocumentationandState Law  TexasAdministrativeCode(TAC)Title22,Part11,Chapter217,§ 217.11:StandardsofNursingPractice  (1)StandardsApplicabletoAllNurses.Allvocationalnurses, registerednursesandregisterednurseswithadvancedpractice authorizationshall: • (D)Accuratelyandcompletelyreportanddocument: – – – – – –

(i)theclient'sstatusincludingsignsandsymptoms; (ii)nursingcarerendered; (iii)physician,dentistorpodiatristorders; (iv)administrationofmedicationsandtreatments; (v)clientresponse(s);and (vi)contactswithotherhealthcareteammembersconcerningsignificant eventsregardingclient'sstatus;

DocumentationandState Law  TACTitle22,Part11,Chapter217,§217.12:UnprofessionalConduct  Theunprofessionalconductrulesareintendedtoprotectclientsandthe publicfromincompetent,unethical,orillegalconductoflicensees.The purposeoftheserulesistoidentifyunprofessionalordishonorable behaviorsofanursewhichtheboardbelievesarelikelytodeceive,defraud, orinjureclientsorthepublic.Actualinjurytoaclientneednotbe established.Thesebehaviorsincludebutarenotlimitedto: • (1)UnsafePractice‐‐actionsorconductincluding,butnotlimitedto: – (C)Impropermanagementofclientrecords;

• (6)Misconduct‐‐actionsorconductthatinclude,butarenotlimitedto: – (A)Falsifyingreports,clientdocumentation,agencyrecordsorotherdocuments;

Documentationand FederalLaw  CentersforMedicareandMedicaidStateOperationsManualAppendix PP.F514,§483.70:MedicalRecords  (l)Medicalrecords. • (1)Inaccordancewithacceptedprofessionalstandardsandpractices,the facilitymustmaintainmedicalrecordsoneachresidentthatare— – – – –

(i)Complete; (ii)Accuratelydocumented; (iii)Readilyaccessible;and (iv)Systematicallyorganized.

• (5)Themedicalrecordmustcontain— – – – –

(i)Sufficientinformationtoidentifytheresident; (ii)Arecordoftheresident'sassessments; (iii)Thecomprehensiveplanofcareandservicesprovided; (iv)Theresultsofanypreadmissionscreeningandresidentreviewevaluationsand determinationsconductedbytheState;and – (v)Physician’s,nurse’s,andotherlicensedprofessional’sprogressnotes;and – (vi)Laboratory;radiologyandotherdiagnosticservicesreportsasrequiredunder §483.50

Whatshouldbeinyour documentation?  Nursingdocumentationshouldcontainthefollowing:      

Allaspectsofthenursingprocess Planofcare Admission,Transfer,Transport,andDischargeInformation ResidentEducation MedicationAdministration CollaborationwithotherHealthCareProviders

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Standardsfor Documenting  Sincethecareprovidedtotheresidentisviewedinthemedical recordbyallofthecareteamtodetermineappropriatenext stepsofcare,itisessentialthattherecordbe:       

Clear Accurate Legible Timely Factual Documentedbythestaffwhoperformsthecare Organized

Rulesfordocumenting  Eachfacilitywillhavetheirownpoliciesandprocedures(PP)centered arounddocumentation.Thebelowaregeneralacceptedrulesfor documenting:  Documentusingblackorbluepen(thismayalsobefacilitydriven)  Ensurethattherearenoskippedlinesinbetweensentences,asthisallows forthepossibilityofadditionstobemadetothechartatalatertime  Documentonlyforwhatyouhavedonetocareforortreattheresident. Youshouldneverdocumentataskortreatmentthatyoudidnotperform orcomplete  Donotmakechangestothechartunlessyouarecorrectingyourownwork  Whenmakingcorrections,besuretolinethroughthewordwithoneline andinitial.Donotusewhiteoutorcorrectivetape  Useonlyfacilityapproved abbreviationsandterminology  Linesthroughanyunusedlinestodecreasethechancesofadditional informationbeingaddedatalaterdateortime.

Lateentriesin Documentation  Thedefinitionofalateentryshouldbedeterminedbyfacility policy.Documentationshouldoccurassoonaspossibleafterthe eventoccurred.  Lateentriesorcorrectionsincorporatingomittedinformationina healthrecordshouldbemade,onavoluntarybasis,onlywhena nursecanaccuratelyrecalltheeventorcareprovided  Lateentriesmustbeclearlyidentifiedandshouldbeindividually dated.Theyshouldreferencetheactualtimerecordedaswellas thetimewhenthecare/eventoccurredandmustbesignedby thenurseinvolved  Lateentriesmustbeenteredonachartonthesameshiftthat thecarewasprovidedand/ortheeventoccurred,evenifthe informationisn’tinchronologicalorder

Gooddocumentationvs. Poordocumentation Gooddocumentationisaclear,concise, andaccuratedescriptionofthecare thatyouhavegiven. Poordocumentationleavestherecord opentoquestions,withnoclear directiontofollow.

Commonmistakesto avoid Failingtorecordresidenthealthordruginformation Failingtorecordsnursingactions Failingtorecordmedicationshavebeengiven Recordingonthewrongchart Failingtodocumentadiscontinuedmedication Failingtorecorddrugreactionsorchangesintheresident’s condition  Transcribingordersimproperlyortranscribingimproperorders  Writingillegibleorincompleterecords

     

Waystoimprove documentation  Whetheryouareaseasonednurseoranewgrad,documentingcanbe anissueforanyone.Herearesometipsthatwillassistwithimproving thedocumentation:  Beextracarefulwhenyouthinkyouare“toobusy”  CriticalvaluesshouldbereportedtotheMDwithin30minutesof verification  Ifyouchartbyexception,knowwhatthedefinedlimitsare,aschartingin thisinstanceisreporting“abnormal”findings.  Allergiesshouldbehighlighted  Chartingpatternsincludingflowsheetswillbereviewed.  Consultthepolicyandprocedureforacceptedabbreviations  Evaluateanynewonsetofpain

SampleNursesNotes Thesesamplesareonlyexamplesandareusedforeducational purposes.Thesesamplesarenottobeusedinactualresident charting

ProperDocumentation Example#1:03/21/140800 Mrs.GHalert,awake,andorientedtopersonandsituationbutisconfusedastotimeand place.Sheisabletostatehernameandthatsheisinthenursinghomebutstatesthatit isafternoonandthatitis1990.Sheasksyouifhersongottoschoolontimebecausehe usuallymissesthebusinthemorning.Wasreorientedtotimeandplace.Skinwarm,dry, palebutwithoutpallororcyanosis.Bilateralarmshavepurpurabutskinremainsintact andwithoutskintears.Nonoteddecubitusulcersoncoccyx,hips,orheels.Respirations regularandnon‐labored.Lungsoundsclearexceptforcracklesnotedinleftlowerlobe butimprovedwhencomparedtoearlierassessmentdone03/20/2014.Encouragedto coughanddeepbreathe(CDB);crackleslessenedafterCDBexercise.Pulseoxonright indexfingershowingsaturationof96%on2litersO2bynasalcannula.Earsandnares checkedandareclearofirritation.Peripheralpulsesare+2atradiusand+1atdorsalis pedispulses.Equalhandgrips;leftpedalpushisweakerbutunchangedsinceadmission. Perflowsheet,voidedclearamberurineat0715.C/Oabdominalpainof7on0‐10pain scale.Abdomenfirm,distended,andtendertoslighttouch.Bowelsoundshyperactivein RUQandabsentinremainingquadrants.Statesshedoesnotknowwhenshelasthada bowelmovement.NoindicationofBMonflowsheetsinceadmission.Refusesbreakfast statingsheisnauseous.VS148/92,100.6F(oral),114,24.‐‐‐‐‐‐‐‐E.Doe,LVN

ProperDocumentation Example#1:03/21/140815 Dr.JSmithnotifiedofchangeofstatusr/tabdominalpain,absentbowelsounds.STAT Abdomenseriesx‐raysorderedandresidentplacedNPO,.‐‐‐‐‐‐‐E.DoeLVN

Example#1:03/21/140900 Portablex‐rayarrivedatfacilitytoperformSTATabdominalseries‐‐‐‐‐‐‐‐‐‐‐‐‐E.DoeLVN

Example#1:03/21/141000 X‐rayresultscalledtoDr.Smith.MDordersforresidenttobetransferredtohospital.‐‐‐‐E. DoeLVN

Example#1:03/21/141010 CallplacedtoMetroAmbulancetotransportresidenttoNorthHillsHospitalASAP.‐‐‐‐‐‐‐E. DoeLVN

Example#1:03/21/141020 Ambulancearrivestotransportresidenttohospital.Copiesofallrecordsprovidedto transportteam.VS takenpriortoreleasefromfacility:144/94,124,24,101.4F‐‐‐‐‐‐‐E.Doe, LVN

ProperDocumentation Example#204/18/2014 0645:Receivedreportfromthenightnurseandassumedcare. Assessmentcompleted.VSS.Residentawake,alertand oriented.Complainsofpainasan8onascaleof0‐10infractured righthip.MedicatedwithtwoVicodinperMDorders.Will continuetomonitor.Discussedplanofcarewithresident.Goals aretohavepainlevelatorbelow5forthedurationoftheday andforresidenttowalkaroundnurse’sstationatleastonceby theendoftheshift.Residentverbalizedunderstanding.Call lightwithinreach.‐‐‐‐‐‐‐A.Dunn,LVN

ProperDocumentation Example#3:11/15/130815 Assessmentperformed,residentwithC/OSOB,states“Ijust can’tseemtocatchmybreathandIamcoughingupgreen phlegm”.Onauscultation,breathsoundsdecreasedinbases bilaterally,coarserhonchibilaterallyinupperlobes,accessory muscleusenotedbilaterally,breathingisshallowandlipsare cyanotic.Vitalsignsassessed;temp:100.5,BP:110/76,HR:108, RR:32,SpO2:95%onroomair.‐‐‐‐‐‐J.Smith,RN Example#3:0820 AssessmentfindingsreportedtoDr.Halifax‐‐‐‐J.Smith,RN Example#3:0825 ResidentassessedbyDr.Halifax‐‐‐‐‐‐J.Smith,RN

PoorDocumentation Example#1 6thOct09:Daveappearsupsetthismorningandwasreluctant tohavehisdressingchanged.Davecomplainingofatemperature andadvisedtotake2acetaminophen(500mgs)every4hours. Woundswabtaken.Nextvisitfor7thOctober2009at10.00 Example#2 “unresponsiveandinnodistress” Example#3 “Theneedtomaintaindialoguewiththefamilyregardingthe appropriatenessoflimitingfutilecaretotheresidentisnoted”

PoorDocumentation Example#4 “Shediuresedprettywell.Igaveher40ofLasixandsheputout 2000liters Example#5 “Pleasantmanlyingcomfortablyinbed.Appearstobe somewhatuncomfortable” Example#6 “Theresidentisdifficulthistorian.Thequestionisastowhatis goingonwiththepatient”

SamplesofNursingflowsheets Theflowsheetsshownbelowarejustexamplesofsomeofthe differenttypesofflowsheetsonthemarket.Theseexamplesshould notbeusedforthepurposesofchartingonyourresidents.Theseare onlyexamples

26

NursingAssessmentFlow Sheet

DailyNursingNoteFlow Sheet

NursingSkinAssessment FlowSheet

VitalSignsFlowSheet

WoundAssessmentFlow Sheet

NeurologicalAssessment FlowSheet

MedicalRecordReview

References  AdvantageConsultants,Inc.DocumentationMini‐Toolkit:Those EssentialBasics. http://www.glatfelterhealthcarepractice.com/documents/HCCISToolkit. pdf.  CollegeofNursesofNovaScotia.DocumentationGuidelinesfor RegisteredNurses. http://www.crnns.ca/documents/DocumentationGuidelines.pdf.  KeenanGM,YakelE,TschannenD,etal.DocumentationandtheNurse CarePlanningProcess.Chapter49:PatientSafetyandQuality:An Evidence‐BasedHandbookforNurses.AgencyforHealthcareResearch andQualityhttp://www.ncbi.nlm.nih.gov/books/NBK2674/  Med‐passdocumentationforms.http://www.med‐pass.com/

References  TexasAdministrativeCode(TAC):Title22,Part11,Chapter217,§217.12 UnprofessionalConduct. http://info.sos.state.tx.us/pls/pub/readtac$ext.TacPage?sl=R&app=9&p_ dir=&p_rloc=&p_tloc=&p_ploc=&pg=1&p_tac=&ti=22&pt=11&ch=217&rl= 12  TexasAdministrativeCode(TAC):Title22,Part11,Chapter217,§217.11 StandardsofNursingPractice. http://info.sos.state.tx.us/pls/pub/readtac$ext.TacPage?sl=R&app=9&p_ dir=&p_rloc=&p_tloc=&p_ploc=&pg=1&p_tac=&ti=22&pt=11&ch=217&rl= 11  CentersforMedicareandMedicaid(CMS)StateOperationsManual (SOM).F514§483.75(l)ClinicalRecords. http://www.cms.gov/Medicare/Provider‐Enrollment‐and‐ Certification/SurveyCertificationGenInfo/Downloads/Survey‐and‐Cert‐ Letter‐14‐37.pdf...