Documentation
anything written or printed which is relied on as proof of all patient care activities
Documentation must be
Accurate Comprehensive and flexible Maintain continuity of care Track patient outcomes Reflect current standards of nursing practice
When a plan is not communicated to all members of the health care team
care becomes fragmented, tasks are repeated, and often delays or omissions in therapy occur.
When documenting, nurses must keep in mind:
- Quality of care
- The standards of regulatory agencies and nursing practice
- The reimbursement structure in the health care system
- The legal guidelines
- Principles to maintain confidentiality of information
Institutional standards or policies often
dictate the frequency of documentation.
What is generally the first reference used when it is suspected that standards were not met?
nurses notes
Institutional accreditation
Standards set by The Joint Commission (TJC) and/or Center for Medicare and Medicaid services (CMS) must be met to receive accreditation.
Reports may be
oral, written or audiotaped (not as common a way of shift change report)
Common types of reports given by nurses
Change of Shift Reports
Telephone Reports
Hand-off Reports
Incident Reports
Nurses also engage in
consultations and referrals
Purposes of Medical Records include
Communication Legal Documentation Reimbursement Education Research Auditing/Monitoring
Purposes of Record: Communication
Document information as you provide care.
Do not “save all of your charting for later” to do at one time… you will forget and omit important details.
Communication includes
Patient Needs and Progress Individual Therapies Content of Consultations Patient Education Discharge Planning
Purposes of Records: Legal Documentation (Table 26-1, p. 351)
The best defense for legal claims.
If you don’t document it, you didn’t do it.
Care must be
goal oriented, individualized and based on the nursing assessment.
Common Charting Mistakes
- Failing to record pertinent health or drug information
- Failing to record nursing actions
- Failing to record that medications have been given
- Failing to record drug reactions
- Failing to record changes in patient’s condition
- Writing illegible or incomplete records
- Failing to document discontinued medications
Purposes of Records: Reimbursement
DRG’s are the basis for establishing reimbursement: Classification based on diagnosis
Hospitals are reimbursed based off
DRG (Diagnosis Related Groups)
Purposes of Records: Education
Reading the patient care record helps to learn the nature of an illness and the patient’s response:
Identify patterns of information from patient to patient.
Learn to anticipate the care required for a patient.
Purposes of Records: Research
Charts are reviewed by nurse researchers for example, to gather statistical data, review complications, review therapies.
Purposes of Records: Auditing/Monitoring
Accrediting agencies (TJC) require quality improvement programs: Data must be shared A plan must be in place for remediation/correction of deficiencies
Auditing/Monitoring includes
Patient teaching Discharge planning Performance of individualized care Proof standards of care have been met
Goal for 2014 that all medical records will be kept electronically which will enhance
- communication among health care providers
- patient safety by providing clear, legible, standardized documentation and including physician order entry
- accessibility to health care records for continuity of care
Confidentiality
It is an ethical obligation to keep and maintain confidentiality concerning patient information.
Who can have legitimate access to the patient’s records?
only staff directly involved in the patient’s care
What organization governs all areas of patient information and management of that information?
HIPAA
As student nurses, you insure confidentiality by
not including any patient identifiers in your clinical care plans
EHR has inherent risks:
anyone with access to an agency computer station can access any patient information.
Security mechanisms in place include
Auto shut off
Firewalls
Antivirus/spyware-detection
Handling of Patient Information
- Should not be left out for view by unauthorized people
- Do not remove printed patient info from the agency
- On fax machines, use programmed speed dial
- Place computer/fax machines in protected areas
Disposing of Patient Information
Destroy (shred) any printed information containing PHI.
Know and follow disposal policies at the institution where you work.
Standards: Record Keeping Forms
Usually derived from institutional standards of practice or guidelines established from accrediting agencies.
Record Keeping Forms include
- Admission History
- Flow Sheets and Graphic Records
- Patient Care Summary or Kardex
- Standardized Care Plans
- Discharge Summary Forms
- Acuity records
Guidelines for Quality Documentation and Reporting have five important characteristics: (T. 26-1 p. 358)
- Factual
- Accurate
- Complete
- Current
- Organized
Factual
descriptive, objective information about what the nurse sees, hears, feels, and smells.
Guidelines for Quality Documentation and Reporting: Factual
Avoid vague terms such as “apparently”, “seems” as they suggest opinion.
Record subjective data from the patient with quotation marks.
Guidelines for Quality Documentation and Reporting: Accuracy
- Use approved abbreviations only.
- Use correct spelling and grammar.
- Use units of measurement such as cm, inches, ml, etc.
- Sign and date all entries
- Avoid the use of unnecessary words and irrelevant detail.
Guidelines for Quality Documentation and Reporting: Complete
The entries in the medical record document the care you gave your patient and the patient response to treatment.
Guidelines for Quality Documentation and Reporting: Current
Make entries timely: Document activities or finding at the time of the occurrence.
What activities should you document at the time of occurrence?
- Vital signs
- Pain assessment
- Administration of medications and treatments/Patient response to the treatment
- Preparation for diagnostics/surgery
- Change in patient condition, who was notified
- Admission, transfer, discharge
Guidelines for Quality Documentation and Reporting: Organized
Make your notes concise, clear, and to the point.
Apply critical thinking and the nursing process to give logic and organization to your documentation.
Narrative Notes (B. 26-1 p. 363) include
SOAP
PIE
DAR
*Becoming obsolete with advent of the EHR
SOAP
Subjective
Objective
Assessment
Plan
PIE
Problem
Intervention
Evaluation
DAR
Data
Action
Response
Problem-Oriented Medical Record
A system of organizing documentation to place the primary focus on patients’ individual problems.
Problem-Oriented Medical Record includes
Data Base
Problem List
Care Plan
Progress Notes
Data Base
contains all available assessment data
Problem List
Identified problems including physiological, psychological, social, cultural, spiritual, developmental, and environmental needs
Care Plan
care plan for each problem
Progress notes
from all health care team members
Data is considered normal unless
otherwise noted
Charting by Exception
- Charting according to deviations from what is considered normal.
- There is an assumption that all standards are met unless otherwise noted.
Case Management: Interprofessional approach. Manages patient care for:
Cost effectiveness
Evaluation of care plan goals/outcomes
Mutual needs of patient and family
Timely discharge planning
Critical Pathways
display goals for patients and provide the corresponding ideal sequence and timing of staff actions for achieving those goals with optimal efficiency. B. 26-2 p. 365
Common Record Keeping Forms
Admission Nursing History
Flow sheets/graphic records
Patient care summary
Standardized care plans (individualized)
Discharge summary forms B. 26-3 p. 366
Patient Care Summary
Document automatically updates to include, for example:
Basic demographic data
Diagnosis/history/orders/family contact info, code status, allergies
Acuity Rating System
How much nursing care is involved in a particular patient based on diagnosis, patient condition, needed interventions, and patient participation in their care (full care vs. ambulatory) over a 24/hr period
Staffing is many times based on
acuity
Nurse to Patient Ratios
How many patients can 1 nurse safely care for in a 24 hour period? (dynamic process)
Purpose of reporting
Standardized communication helps ensure patient safety.
A nurse should avoid using
Derogatory or inappropriate comments about a patient or family member.
May lead to legal charges.
Hand-Off Report
SBAR (Situation, Background, Assessment, Recommendation)
Telephone Report
Read back report
Telephone and Verbal Orders
RBO (B, 26-4 p. 367)
*Limit verbal orders to emergency situations.
Incident/Occurrence Report:
Any event not consistent with standards of care or routine care of the patient. For example: falls, injuries, near-misses, issues with family members medication issues.
Incident reports are important for
of all Quality Improvement and Risk management programs.
Health Informatics
Management and processing of information, mainly by computer, to facilitate:
Acquisition, processing and interpretation of health-related data, and communication.
Goal of Health Informatics
to enhance the quality and efficiency of care
Nurses are tasked in acquiring
awareness and competence in informatics and use of IT in BSN, MSN and doctoral nursing programs.
Nursing Informatics
a specialty that integrates nursing science, computer science, and information science to manage and communicate data, information, and knowledge in nursing practice (ANA, 2008).
