Documentation & Reporting Flashcards
1
Q
What is the purpose of documentation?
A
1) To communicate
- so everyone involved in the care of the patient knows what is going on
2) To be accountable
- to keep track of WHO is providing care, and WHAT has been done
3) To maintain legal records
- in case any event becomes legal matter
4) To support research
- sometimes documentation can be part of a research study
5) To uphold standards
- it may help support improvements in certain processes around the unit
2
Q
Importance of Documentation
A
- Communication about client‘s health status and needs to all members of the health care team
- Communication of a client centred plan of care to other nurses
- Communication of changes in a client’s condition or situation
- Communication of a client’s educational/information needs
3
Q
Documentation Standards and Legal Implications
A
- Communication: Nurses ensure that documentation presents an accurate, clear and comprehensive picture of the client’s needs, the nurse’s interventions and the client’s outcomes.
- Accountability:Nurses are accountable for ensuring their documentation of client care is accurate, timely and complete.
- Security:Nurses safeguard client health information by maintaining confidentiality and acting in accordance with information retention and destruction policies and procedures that are consistent with the standard(s) and legislation.
- Charting is a LEGAL document that can be used in court
- Documentation should include ALL the client care that is provided by the nurse in chronological order from admission until discharge
4
Q
Progress Notes
A
- are long-form notes that explain and describe events. - These notes go on the chart for everyone to read so that the whole team is updated on the client’s condition.
- This type of documentation (charting) requires your signature & designation).
- use a line at the end so others can not add to what you wrote
- if you forget to write something, add an addendum later
- if you ask another nurse to administer medication, but you did not administer it yourself, do not write it down
5
Q
Well-written notes are:
A
- written in black or blue pen (never pencil or other pen colours)
- focused
- clear
- concise
- professional
- informative
6
Q
Poorly written notes are:
A
- do not isolate the issue
- are disorganized, and hard to read
- are wayy too long
- are missing information
- do not tell you anything helpful
7
Q
Types of Documentation
A
The most common formats are
1. DAR (data, action, recommendation)
- SOAP (subjective, objective, assessment, plan)
8
Q
How to write the date & time on a progress note.
A
Date
- INTERNATIONAL STANDARD yyyy/mm/dd
Always check with your employing institution
Time
- use the 24 hour clock
- no am/pm
- no : (colon) between the numbers
- include the ‘0’ with morning times (0815)
- write 4 numbers only, at all times.
9
Q
Things NOT to do for progress notes
A
- never scribble
- add forgotten things in the margin
- never squeeze words in with a ^ above the space
- Don’t leave spaces to write in later, for others to add data, or because you like the way it looks.
10
Q
Professional & legal guidelines/responsibilities regarding documentation (applied to our BScN, year 1 program)
A
- DO NOT leave blank spaces in the note
- Write legibly & in ink
- Chart only for yourself
- Avoid using generalized phrases
- Begin each entry with date, time
○INTERNATIONAL STANDARDyyyy/mm/dd - End each entry with first initial,fulllast name & designation (WFN-1)
- The # changes as you advance through the program
- Be considerate of language used
- The nurse documents as soon as possibleafter the client interaction.
11
Q
Best Practices for Correcting an Error
A
- DO NOT erase or use white out
- If you make a mistake when hand-writing or typing a note, you need to fix it in a way that allows the first thing you wrote to be legible or retrievable.
Why?
- All documentation can be brought into court.
- Everything, even mistakes, should be accessible.
- Draw one single line through written mistakes, initial, and then keep writing.
- Follow your agency’s rules about fixing mistakes using their electronic documentation platform.
12
Q
Principles of Documentation
A
You documentation should BE:
- Factual
- Accurate
- Concise
- Complete
- Organized
- Specific
Your documentation
should INCLUDE:
- Proper grammar
- Spelling
- Punctuation
- Professional language/ terminology
13
Q
- Factual
A
- Avoids words such as “seems” or “appears” (it suggests an opinion, not a fact)
- Avoid vague words such as “good” or “normal”,(what is good to 1 practitioner may not be good to another)
- Avoid giving an opinion, such as “client progressing well” (this is an interpretation and “well” is vague)
- Objective data are the things you see and do. There is no interpretation required. Data are FACTS, and they inform your client assessment.
- 1 common mistake made is when documenting objective data is including language that implies subjective interpretation.
- Recording only the facts means careful and clear wording is used to communicate your findings.
- Certain words (ie. seems, appears, normal, anxious) are RED FLAGS in documentation and should not be used.
14
Q
- Accurate
A
- Be precise: describe in detail what was assessed, observed, measured
- Ensure proper terminology is used
- Ensure proper grammar and spelling are used to reflect nursing competency. (If something is poorly written, people make assumptions about the writer’s level of knowledge and skill)
- Document your own assessments, not the impressions or assessments of others. Your signature indicates that you assume responsibility for the information documented on the chart
- Do not include information given to you from someone on another shift, as the client’s condition may change, or the information may not be accurate at the time of your documentation
- Ensure documentation is done within a reasonable timeframe
15
Q
- Concise
A
- Focuson one note per issue
- Include only relevant information.
- Ask yourself “What is important to know?” and do not include extraneous details
- Use only approved abbreviations to avoid confusion and misinterpretation
16
Q
- Complete
A
- Ensure the date and time for every entry on flow sheets and notes is included
- Title every entry. Client charts contain many entries so a title will assist other health care providers to identify quickly those entries that pertain to their particular interest
- Try to give as much information as necessary to assist the reader to understand the client’s situation
- Include relevant lab values and/or vital signs
- Ensure the note (and flow sheet entries) is signed with your full signature and professional designation, not just initials (follow agency guidelines)
17
Q
- Organized
A
- Begin all documentation with subjective data, then present objective data
- Present all information in a logical order
- Only 1 “problem” per note
18
Q
- Specific
A
Vague
ex. “continue to monitor”
Specific
“reassess respiratory status Q2h and prn”
Q2h - every 2 hours
prn - as needed
RTC - return to clinic
19
Q
Subjective Info
A
- Information that comes directly from the client
- Extremely valuable
- Ensures client-centeredcare
- Reflects the feelings and experiences of the client, not the nurse’sinterpretation
- Use direct quotes of what the client has said
Ex. “I feel so sick… is it time for Gravol yet?”
Document as:
S:client states he feels “sick” and requests Gravol.
20
Q
Objective Info
A
- Reflects the nurse’s assessments andfindings
- Canincludesize, smell,colour, consistency, clarity, location, lab values, vitalsigns, and specific clientbehaviours
- Information obtained from your assessments is includedhere
Ex.
O:Client pale & diaphoretic. Vomited 250 ml bile-colored emesis at 1100 hrs.
21
Q
SOAP Note
A
- A format used for organizing information in your documentation.
- Depending on the organization, differentformats for charting are used
- A SOAP note is an example of a commonly used format.
S – SUBJECTIVE
O – OBJECTIVE
A – ASSESSMENT (Nursing Diagnosis from NANDA)
P – PLAN
22
Q
DAR Note
A
D = Data (subjective & objective)
A = Action or what nursing interventions were used
R = Response or how the client responded to your interventions
- In a DAR note, subjective and objective info are grouped together under “data”.
- Subjective info should still be presented before objective.
- DAR is increasingly used more than SOAP
23
Q
A progress note must include:
A
- Date
- Time
- Title
- Patient ID (stamped in upper right corner)
- Signature + designation
- always document according toyour specificorganization’s policies
- must log out (not only minimize screen) if leaving the workstation
24
Q
Electronic Health Records (EHR)
A
- A digital version of the client’s chart containing their health history
- The norm in an increasing number of healthcare facilities
- A tool for providing safe and quality client care
- Allows to find updated client information at the point-of-care
25
Interprofessional Communication
- Communication in the professional context among members of various professional groups (i.e. nurses, doctors, physiotherapists, pharmacists, etc.) that are a part of the client's care team
- Includes written communication (documentation), verbal (reporting), and non-verbal (body language)
Reporting: A verbal way of communicating patient health information within and across the interprofessional care team
26
End-of-Shift/ Beginning-of-Shift Hand-Off Report
- Providing “report” or “handover” or "end-of-shift or beginning-of-shift hand-off"— is a crucial component of the care transition process
- Care transitions happen often (ex. when a client changes locations or health care providers/nurses, when shifts end, or when nurses go on break)
- With any transfer of care, there is risk for miscommunication which could compromise client safety and their care
- For this reason, it is helpful to have a specific model for communication (SBAR)
- DO NOT discuss client info in public areas (hallways, elevators, cafeteria)
27
Reporting Standards
- Each time care is transferred, nurses must communicate client-specific information to a colleague that is:
1) Clear
2) Concise
3) Comprehensive
28
Why is reporting/SBAR important?
- Effective communication (such as SBAR) reduces errors and increases client safety
- SBAR provides a format that is easy to follow to healthcare professionals to voice their concerns
- Provides structure and clarity for conveying concise and relevant patient info
29
(I) SBAR – Communication Tool
- A standardized tool to facilitate interprofessional communication
- Commonly used communication tool
- Communication is a fundamental component of interprofessional collaboration
- Clear communication optimizes client outcomes
- SBAR is quick and efficient
- Enhances communication between professionals
- using this tool, decreases client safety risk
- Nursing SBAR communication is beneficial because it provides nurses with a framework to communicate with patients, nurses, and physicians quickly and efficiently.
(When the SBAR in nursing technique is used correctly, it enhances communication between health professionals)
- SBAR communication facilitates rapid response = the risk of jeopardizing client safety is reduced. (when there are treatment delays, client safety is at significant risk of being compromised)
- Nursing SBAR technique bridges the gap in differences between nurse and physician communication types, allowing them to understand one another and the client’s situation better.
30
Prior to SBAR
Use the following modalities according to physician preference, if known. Wait no longer than 5 minutes between attempts.
1. Direct page (if known)
2. Physician’s Call Service
3. During weekdays, the physician’s office directly
4. On weekends and after hours during the week, physician’s home phone
5. Cell phone
- Before assuming that the physician you are attempting to reach is not responding, utilize all modalities.
For emergent situations, use appropriate resident service as needed to ensure safe client care.
31
Prior to SBAR…
- Have I seen and assessed the client myself before calling?
- Has the situation been discussed with charge nurse or preceptor?
- Review the chart for appropriate physician to call.
- Know the admitting diagnosis and date of admission.
- Have I read the most recent MD progress notes and notes from the nurse who
worked the shift ahead of me?
- Have available the following when speaking with the physician:
○ Client’s chart
○ List of current medications, allergies, IV fluids, and labs
○ Most recent vital signs
○ Lab results: provide the date and time test was done and results of previous tests for comparison
○ Code status
32
SBAR
1. Situation
2. Background
3. Assessment
4. Recommendation
33
S- Situation
Situation: Clearly and briefly describe the current situation.
- What is the situation you are calling about?
- Identify self (full name and designation), unit, client, room number.
- Briefly state the problem, what is it, when it happened or started, and how severe.
34
B- Background
Backround: Provide clear, relevant background information on the client.
- Pertinent background information related to the situation could
include the following:
○ The admitting diagnosis and date of admission
○ List of current medications, allergies, IV fluids, and labs
○ Most recent vital signs
○ Lab results: provide the date and time test was done and results of previous tests for comparison
○ Other clinical information
○ Code status
35
A- Assessment
Assessment: State your professional conclusion, based on the situation and background.
- What is the nurse’s assessment of the situation?
36
R - Recommendation
Recommendation: Tell the person with whom you’re communicating what you need from them in a clear and relevant way.
- What is the nurse’s recommendation or what does he/she want?
Examples:
* Notification that client has been admitted
* Client needs to be seen immediately
* Order change (medication, test ordered)
*Document the change in the client’s condition and physician notification*
37
Summary
Documentation
- Important method of written communication to support client care
- Is a LEGAL document
- Most used formats are DAR and SOAP
- Documentation should be factual, accurate, concise, complete, organized, and specific
Reporting
- Verbal method of communicating cleint health information to other members of the care team
- Occurs whenever there is ANY transfer of care, or information needs to be communicated to another member of the care team
- SBAR format is commonly used
