tips-to-improve-nursing-documentation, charting, to cover all the. bases PDF

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cheatsheet for nursing documentation and assessment...

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Tips to Improve Nursing Documentation Cheat Sheet by [deleted] via cheatography.com/2754/cs/8662/

Introduction 

Tips (cont)

Documentation is critical for determining  if the standard of care was

A better option is “MD paged, assessment findings discussed, and

rendered to a patient to defend prior nursing actions. Failure to chart,

no additional orders at this time.”**

omissions, and poor communication  are hard to defend.

5. Some facilities use nursing charts by exception. They indicate

The statute of limitation is typically 2 years. Medical malpractice

findings are “within defined limits” (WDL) unless otherwise noted.

cases may be filed up to the end of these 2 years. It may take several

Know these defined limits. Charting by exception requires selecting

more years before a potential case goes to trial. Hence, a nurse may

“abnormal” and writing applicable text. In such cases, text will be

still be testifying long after the events

carefully scrutinized.

Here are 17 tips worth reviewing:

6. Regardless of the charting method used, nursing docume‐ ntation must be:

Credit: By Katie Morales

 Accurate  Legible

Tips

 Objective

1. Be extra careful when you think you are "too busy." It is ironic that it is at your busiest hour(s) that the importance of documenting  is the most crucial. Be aware of critical times such as:  abnormal vital signs

 Free of grammatical/spe   lling errors 7. Late entries and any corrections  entered should be per policy and procedure. 8. Allergies should be highlighted  and flow sheets filled out

 codes

completely. 

 transfers  change of nursing shift or patient hand offs

Nursing Documetation

 taking verbal orders  noting physician’s  orders  verifying medication orders 2. Remember that critical values should be reported to a nurse within 15 minutes of lab verification.  3. The nurse must report critical values to the physician within 30 minutes. If the physician can’t be reached, follow the facility’s fail safe plan. 4. Avoid general statements. Beware of general statements that can be misconstrued.  For example, you wrote “Dr. Smith called.” Did you mean:  you called and are waiting for a return phone call?  the physician called the nurse?  the nurse called and spoke to physician?

By [deleted]

Published 28th June, 2017.

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Last updated 28th June, 2017.

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Tips to Improve Nursing Documentation Cheat Sheet by [deleted] via cheatography.com/2754/cs/8662/

Tips continue 9. No charting should be done in advance. 10. Charting patterns including flow sheets will be reviewed. “Too perfect” charting may raise doubts. Patient assessment such as fall risk or skin assessments  must be carefully performed and documented. Failing to do so is a common error. 11. Documentation  should include staff notified and steps taken. Careful nursing assessment makes spotting changes in the patient’s condition easier. One recommendation is the DARE approach: document Data, Action, Response, and Evaluation.  The RN is responsible  for analyzing data. 12. Consult the nursing policy and procedure for accepted abbreviat  i ons. Sign each entry correctly, including date and time. An illegible signature may lead to all nurses on duty being named in order to “cast a wide net.” Date and time are crucial when creating a chronology of events. 13, Take caution with frequent flyers. It is easy to spot staff’s judgment.  The nurse applied oxygen on one patient complaining  of an impending sense of doom and documented,  “Patient recovered from her previous little episode.” It was the last entry before the patient died. 14. Evaluate any new onset of pain. One patient suddenly complained of a new onset of debilitating  headache after he fell and hit his head in the hospital. This is documented as a “migraine” although there is no previous history of migraines. 12 hours later, a CT scan revealed brain stem herniation. 15. Hospital bills will be audited for items such as tubing charges, etc. to determine if policy & procedure was followed to prevent infections. 16. Always use a disclaimer. Privacy issues include retaining backup records for prescribed time and avoiding fax and e-mail when possible.

By [deleted]

Published 28th June, 2017.

cheatography.com/deleted-

Last updated 28th June, 2017.

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2754/

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