Chapter 18 Documentation

What forms do nurses use to document nursing care?

nursing admission data forms discharge summary flowsheets and graphic records checklists medication administration Records Integrated plan of care

What are Occurrence Reports?

Formal record of unusual occurrence or accident Not a part of patient's health record Quality improvement (helps others learn from other peoples mistakes) Never put incident report on chart because a pts chart can be used as evidence in legal case! Call the doctor and let them know about the accident

Documentation DOs and DOnts

Be accurate and nonjudgmental Adhere to the requirements for reimbursement Provide details about the client's condition, nursing interventions provided, and client response Document legibly and as soon as possible Record significant events or changes in condition Record any attempts you have made to contact the primary care provider Chart teaching performed Chart use of restraints, including reason for use, type of restraints, and frequent checks of the client Do not chart that you have filled out an occurrence report Chart any client refusal of treatment or medication Document any spiritual concerns expressed by the client and your interventions Use only authorized abbreviations Avoid subjective terms If a client refuses medication Record on the medication administration record in narrative form; chart the reason given Do not leave blank lines If you make a mistake, draw a single line through the entry and place your initials next to the change Sign all your charting entries

What types of orders are there? and when are they used?

Verbal orders Spoken to you; often during a client emergency Should be made for critical change in patient condition They have to sign that order within 24 hours Telephone orders ( done rarely) Received by phone and transcribed onto chart order sheet Have an increased risk for errors Write the order only if you heard it yourself Make sure the verbal orders make sense with the client's status Repeat back the order to confirm accuracy Spell unfamiliar names; pronounce digits of numbers separately As a student you cant take any orders!! If doc tells you something then you will have to go and get an RN.

Integrated plan of care

combined charting and care plan form) day by day pt goals, outcomes, interventions and treatments for a specific diagnosis or condition from admission to discharge everyone can look at

medication administration Records

comprehensive list of everything patient has been on since they have been admitted, even discontinued meds, schedule meds, IV fluids, and prn meds) any allergies that the pt has, safe dosage ranges. Some specialty areas will have different things on MAR

What is SOAP/SOAPIE/ SOAP (IER) charting?

subjective data: what they tell you objective data: what you observe, measurable, factual assessment: concussions drawn from the data collected plan: short and long term goals for pt problem Intervention: action taken by health care team to help pt meet goals Evaluation: is intervention effective? Revisions: if goal not met change it

What is focus charting?

uses assessment to evaluate client care concerns, problems, or strengths. also identifies necessary revision for care plan. ( uses abbreviations DAR for DATA, ACTION, RESPONSE.

Admission Data forms..

Admission Data forms: pts chief complaint, vital signs, head to toe assessment, info about support system, contact information, used to monitor change in pt, allergies, current meds, adls

What is Narrative Charting?

tells Story of the patient's experience in chronological order

Why do we do Hand- off Reports also called change of shift reports?

to promote continuity in care

checklists

comprehensive charting documents includes alot

What is PIE charting?

PIE (problem, intervention, evaluation) problem:identify approbate nursing diagnosis from assessment intervention: record nursing actions taken to fix problem evaluation: document patient's response ( like goal met or not)

What is reporting?

Passage of vital information related to the client's status/plan of care Informing other caregivers about the client condition be careful where you are exchanging information don't do it around patient unless you want to involve patient)

In a hand off report what is included?

Client demographics and diagnoses Relevant medical history Significant assessment findings Treatments (e.g., wound care, breathing treatments) Upcoming diagnostics or procedures Restrictions (e.g., diet, activity, isolation) Plan of care for the client Concerns Use a standardized format

What is the Purpose of the Written Record?

Communication between providers Continuity of care ( other nurses can pick off where you left off like when you switch) Quality improvement: (MANUAL CHART AUDITS, safety of patients, tracking defaultly things in hospital) Planning and Evaluating patient outcomes Legal documentation of care (health record is legal evidence, and experts critique the chart) Professional standards of care ( ANA competencies) Reimbursement (utilization review, getting the funds for the patients stay from the insurance company) Education and Research (as a student the chart helps so we know what is going on, and for clinical research purposes information is gathered)

What has to be documented in a telephone order?

Directly transcribe the order on the chart Date/time Text "TO" followed by provider's name Your signature Physicians must countersign within 24 hours

What are some Common Types of Charting?

Narrative, PIE, SOAPIER, Electronic entry format, FOCUS AND CBE ( charting by exception)

The nurse documents the following: "Patient able to administer own insulin per subcutaneous injection using correct technique." In Focus Charting, this statement would be preceded by the letter

R for response

What are Common Documentation Systems?

Source-oriented: Separate sections for each discipline like one for pt one for nurses etc. ( a disadvantage is data could be scattered in several different places) more on pg 373 Problem- oriented: no serrate sections it is all together organized around patients problem ( everyone is doing one care plan and working for the same goals for the patient, everyone collaborates with this system). This is a lot better than the source- oriented.

What is documentation?

The act of recording client assessments and care in written or electronic form Remember when you document it is permeant!! Always document what time the patient leaves the floor if they are going for a test or going anywhere in general. Cover your behind.

What is a transfer report?

Transfer Reports (pt transferred unit to unit in the same hospital, transferring to another facility)

flowsheets and graphic records

allows you to see patterns of change in patient status. can track such as vital signs, intake, output, hygiene etc.

What kind of Hand- off Reports( also called change of shift report) are there?

bed side report ( nurse introduces you to your pt) FACE TO FACE ORAL (Verbal): may be done nurse to nurse or include entire shift Through walking rounds Audio-recorded report (not the preferred method) Similar report giving like when people switch shifts, or if pt is comingback from OR ( operating room)

What is charting by exception ( CBE)?

charting only significant findings or exceptions to standards and norms of care are charted. preprinted flowsheets that records aspects of care, Disadvantages omissions can occur, or just clicking something to have something advantages : reduces time spent on documentation

What is Electronic entry format charting?

just doing the charting on a comp or iPad instead of writing it all out

Discharge Summary forms..

last entry made, any d/c needs/ d/c meds