NUR 121 Test 2-Ch 18: Documenting & Reporting

Problem-Intervention-Evaluation (PIE)

Problem-Intervention-Evaluation (PIE) system organizes information according to the client's problems; it requires keeping a daily assessment record and progress notes. PIE eliminates the need for a separate care plan and provides a nursing-focused rather than medical-focused record.

POR

Problem-oriented records are organized around the patient's problems Has five components: database, problem list, initial plan, progress notes, and a discharge summary

Problem-Oriented Record Systems

Problem-oriented records (PORs) are organized around the patient's problems. There are no separate sections for each discipline. The POR consists of four parts: database, problem list, plan of care, and progress notes. The database consists of many parts: demographic data, the history and physical, nursing assessment data, and family and social history. As the patient's condition changes, the database is updated to reflect his current status. The problem list is a concise listing of problems identified from the database. Once a problem is resolved, it is noted on the problem list. If a problem changes or is redefined, the problem list is updated to reflect the change. See Figure 18-1 for an example of a problem list. The plan of care includes the PCP's prescription and the nursing care plan to address the identified problems. Other disciplines may also contribute to the plan. Progress notes are organized according to the problem list. Each discipline charts on shared notes. Charting is labeled according to problem number. Note also that the list contains both medical and nursing diagnoses.

STAT

STAT medication is given immediately, only once, and documented immediately.

Verbal and Telephone Orders

Taking a telephone or verbal prescription may be acceptable in the following situations: When there has been a sudden change in your client's condition and the provider is not in the hospital or cannot transmit prescriptions electronically. In a life-threatening emergency—but you must apply the "document and read-back" safeguard.

DO NOT USE THESE ABBREVIATIONS!

"U" or "u" "IU" Q.D., QD, q.d., qd Q.O.D., QOD, q.o.d., qod MS, MSO4, and MgSO4 The trailing zero for medications (X.0 mg) Lack of leading zero (.X mg)

prn

"as needed." given only when the patient meets certain conditions that were established in the medication prescription. administer a prn medication when requested or your assessment of need is validated by the patient.

What Are Some Common Formats for Nursing Progress Notes?

paper charts, computerized electronic documents, audio or video files, e-mails, faxes, scanned paper documents, electronically stored photographs, x-ray findings, and other images.

A bedside report

"walking rounds," allows you to observe important aspects of client care, such as appearance, IV pumps, and wounds. With a bedside report, the outgoing nurse introduces you to the client. If the client is alert, give her the opportunity to participate in the report and ask questions. Although this type of report is time consuming, it encourages continuity of care, team collaboration, and client/family communication. KEY POINT: Ensure that the patient's privacy rights are protected when using bedside reports.

How much time do nurses spend during shift on documenting the care they provided?

15% to 25% of their workday

Long-Term Care

A nurse must record a weekly summary that includes the following: A summary of the client's condition An evaluation of the client's ability to perform ADLs The client's level of consciousness and mood Hydration and nutrition status Response to medications Any treatments provided Safety measures (e.g., bed rails, bed alarm, wander guard) Long-term care facilities also provide intermediate-care services for clients who need assistance with medications, nutrition, and ADLs. These clients require a nursing care summary every 2 weeks.

Source-Oriented Record Systems

A typical source-oriented record includes the following sections: Admission data—demographic information, insurance data, contact information Advance directive—information on client's wishes for the extent of care and medical support that should be given in the event of a life-threatening event History and physical—a detailed summary of the current health problem; past medical, surgical, and social history; medications taken; allergies; review of systems; and physical examination data Provider's orders—prescriptions for medications, treatments, and activities Progress notes—chronological charting by healthcare team members including client exams, problem identification, and response to therapy Diagnostic studies—reports detailing the findings of tests that have been performed, such as x-ray exam and ultrasound, or pulmonary function tests, such as complete blood count Laboratory data—results from diagnostic test results Nurses' notes—documentation of client care and response to treatment recorded by nurses (usually chronological) Graphic data—numerical data collected over time and displayed visually to allow analysis of trends. Examples include intake and output records; vital sign flow sheets; rating scales; and checklists regarding client activity, dietary intake, and activities of daily living (ADLs) Rehabilitation and therapy notes—chronological charting by therapists (e.g., physical, occupational, respiratory) about assessments, the treatment plan, and client response to therapy Discharge planning—includes data from utilization review, case managers, or discharge planners on anticipated client needs after discharge

Disadvantages of a Paper Health Record

Access may be delayed. Only one care provider can access the record at a time; the provider must be in the same location as the chart. Retrieving information may be slow. Healthcare providers may need to search through multiple pages to find needed information. Specific documentation is difficult to retrieve when needed, especially when files are archived in another part of the building. Documentation is time consuming. Documentation may take more time because writing by hand is slower than computer entry. Documentation is often redundant and repetitive. Paper records require manual audit of many charts to create reports and collect client data. This is time and resource intensive. There is a relatively high risk for patient care error. Narrative documents are hard to read if the handwriting is illegible or messy. This means nurses have to take time from patient care to contact providers to clarify handwritten prescriptions. Papers can be lost from the chart or damaged, leading to duplicate assessments or medication errors. Paper records are often inconsistent in how the same client information is documented, even within the same organization. Often standardized terminology is not used. Storage of paper records is expensive. Confidentiality is difficult to protect. There is no way to know who may have access to the paper health record without proper authorization.

Documentation ABCs

Accurate Bias Free Complete Detailed Easy to Read Factual Grammatical Harmless (legally)

Electronic Health Record (EHR) Systems Advantages

Advantages Enhanced communication and collaboration. Communication is improved among healthcare providers. Improved access to information. Multiple healthcare providers can access the same information at the same time. Authorized persons can access information remotely (e.g., from a client's home). EHRs integrate client information between multiple departments so that new information is immediately available to users in all areas. For example, when the laboratory enters a critical result, such as a clotting time, you do not need to wait for the lab to phone or e-mail to the nursing unit. Time savings Nurses spend up to 25% less time documenting. Stored information is quickly and easily retrieved. Reports can be created quickly because of the computer's ability to aggregate data (e.g., a 24-hr graph of the client's vital signs). Repetition and duplication are reduced. Improved quality of care The system can use protocols to automatically enter prescriptions based on the client's condition. For example, some EHR systems will automatically enter a prescription to observe and document risk of falls when a client's "falls score" exceeds a certain level. Embedded protocols enhance caregiver knowledge and the ability to follow clinical practice guidelines. For example, suppose there is a medical prescription to administer insulin based on a patient's blood glucose results. In some EHR systems, the nurse can activate an immediate link to the tables of information needed to decide how much insulin to administer to the client. Medical errors are minimized by programmed alerts that are automatically displayed when a provider takes an action that could be harmful (e.g., when a provider prescribes a drug to which a patient is allergic). Data can be analyzed at the time of collection, making immediate nursing decisions possible. EHRs facilitate evidence-based practice by analyzing thousands of records in ways that cannot be done with paper forms. With aggregated data, nursing practice can be compared across populations and geographic locations to support nursing decisions and guide professional and organization quality improvement. Information that is private and safe Information is permanently stored and not likely to be lost. Confidentiality of client information is enhanced by restricting access, tracking everyone who accesses the healthcare record, and using proper security clearances, unique passwords, and front view screen protectors.

Problem-Oriented Record Systems Advantages and Disadvantages

Advantages A common problem list allows for input from all disciplines, making it easy to monitor the patient's progress. Because each problem is readily identified in the notes, the findings of each discipline can easily be reviewed, which promotes greater collaboration. Disadvantages To work well, the POR system requires a cooperative spirit among health providers as well as diligence in maintaining a current database and problem list.

Focus Charting: Advantages & Disadvantages

Advantages Focus Charting® is attractive because it addresses the client's concerns holistically. Disadvantages The lack of a common problem list may lead to inconsistent labeling of the focus of notes, thus causing difficulty in tracking client progress.

Source-Oriented Record Systems Advantages and Disadvantages

Advantages In source-oriented records, you can easily locate the care provided by each discipline and the results of laboratory and diagnostic tests. Disadvantages Data may be fragmented and scattered throughout the chart. That means you need to review all sections of the medical record to fully understand the client's condition and care. It is especially difficult with source-oriented records to track the treatments and client outcomes associated with a particular problem. For example, suppose a client with congestive heart failure is retaining fluids, causing her to be short of breath on exertion. To find the interventions that have been done for this problem, you would need to look in the: Primary care providers' (PCP) prescriptions to see which drugs (e.g., cardiac or diuretics) were prescribed to help with the fluid retention Respiratory therapist's notes for the client's response to breathing treatments Nursing notes to determine positioning (head of the bed elevated to facilitate breathing) Graphic section to evaluate urinary output in response to the medication

Documentation in Home Healthcare

Among the requirements for care are the following: Certification of homebound status A plan of care Ongoing assessment of the need for skilled care Home health documentation includes the following: Your assessment highlighting changes in the client's condition Interventions performed (e.g., wound care, dressing changes, teaching) The client's response to interventions Interaction or teaching that you conducted with caregivers Interaction with the client's primary care provider If you would like to see an OASIS form,

Documentation and the Nursing Process

Assessment Diagnosis Planning Implementation Evaluation

Maintain confidentiality

Do not provide written or verbal information to anyone not involved in the direct care of the client without his consent.

What are some advantages of paper health records?

Care providers are comfortable with it because it is familiar. There is little "learning curve." Paper records do not require large databases and secure networks to function. There is no downtime for system changes, weather, and so on. It is relatively inexpensive to create new forms and update old ones.

In a handoff report:

Client's name, age, and room number Client's admitting diagnosis—one or several may exist. Status of identified outcomes. Client's relevant past medical history Treatments the client has received during this admission, such as surgery, line placements, breathing treatments. Include consultations completed with other disciplines. Upcoming consultations, diagnostic tests, surgeries, or treatments Client restrictions, such as diet, bedrest, isolation, activity limits Plan of care, such as IV therapy, pain management, current medications, wound care, client or family concerns, discharge planning Significant assessment findings from the previous shifts Teaching conducted

Maintain Confidentiality and Data Security

Close the screen, lock the computer, or permanently log off of the EHR system when moving away from an open EHR privacy filters to prevent unauthorized viewers from seeing the information. Do not share your personal username or password with anyone Do not leave the computer unattended after you have logged on Never access client health records that you have no professional reason to view

How Do Healthcare Providers Use Documentation?

Communication Communication enables healthcare professionals to plan and evaluate treatment and monitor health status over time. Continuity of Care Communication promotes continuity of care. For example, if you are concerned that the client is at high risk for infection, you can include nursing diagnosis of Risk for Infection on the written or electronic plan of care. You would then initiate nursing prescriptions for other nurses to regularly observe for and document signs of infection. Quality Improvement healthcare agencies must identify ways to decrease length of stay, control costs, and identify knowledge and practice gaps that can be addressed through inservice and continuing education. Planning and Evaluation of Client Outcomes Documentation enables providers, nurses, and other healthcare professionals to plan and evaluate treatment and monitor health status over time. Legal Record In court, the health record is legal evidence of the care given to a client and is used to judge whether the interventions were timely and appropriate. Professional Standards The American Nurses Association's (ANA) Nursing: Scope and Standards of Practice (2015) includes documentation in many of its standards. Reimbursement and Utilization Review Insurance companies, government and third-party payers, budget managers, and organization billing staff use client health records to determine the cost of care. They also use the health record for utilization review to determine whether the medical treatments and interventions were necessary and appropriate.

Documentation

Documentation is the act of making a written record. The terms documenting, recording, and charting are often used to mean the same thing.

Electronic Entry of medical information

Electronic clinical information systems streamline electronic processes make them more accurate and efficient reduce the risk of human error. include the information that your organization has decided is important to document. EHR software is user friendly The extensive use of clearly named data entry fields, drop-down menus, check boxes, and specially created templates allows you to enter your nursing documentation quickly and efficiently, usually with minimal keyboard typing.

STAT, prn, unscheduled, and single-order medications.

Enter on the MAR the time the medication is given. narrative note of your assessment findings and the patient's response to the medication

Electronic Health Record (EHR) Systems Disadvantages

Expense. Electronic documentation systems are expensive. Downtime. Downtime processes must be in place for times when parts of the EHR are not available (e.g., because of power outages and system upgrades). Difficulties associated with change. Learning to use some documentation systems can be challenging and time consuming. Some healthcare providers resist the change to EHRs. It is not easy to capture narrative nursing content from paper documentation into an electronic format. Some EHRs are not user friendly (e.g., difficult to quickly find information needed to make care decisions). Some systems do not control redundancy well, requiring caregivers to continuously ask the client for the same information. Lack of integration. Most EHRs are not integrated across the different departments: This means that sometimes a person with a legitimate reason to enter the record cannot see entries made by other departments and must then request verbal, e-mail, or paper reports (e.g., lab reports).

Learning Outcomes

Explain the purposes of documentation. Compare and contrast electronic and written documentation. Identify a variety of charting formats and their purposes. Follow documentation guidelines to accurately record client health status, nursing interventions, and client outcomes in written and electronic formats. Identify approved abbreviations to use in documenting in clinical environments. Discuss the key elements of giving an oral client report. Explain the process for verifying or questioning a medical prescription.

Dosage range orders.

For example, "Titrate morphine 2-3 mg IV every 1-2 hours to achieve pain control." The Joint Commission and most agency protocols no longer allow dosage range orders.

Comparison of Content of MARs for Inpatient and Outpatient Facilities

INPATIENT MARS Drug name Dosage Route of administration Frequency Duration Scheduled times of administration Charting of medication administration Signatures (written or electronic) of nurses administering medication OUTPATIENT MARS Drug name Dosage Route of administration Number of pills, patches, and so on to be dispensed at each prescription refill Number of refills ordered Directions for using the medication, including frequency and duration Historical information about prescriptions,

Patient refusal.

If the patient refuses a medication, note the refusal on the MAR. electronically, you can click on an option offered in the MAR, such as Not Given drop-down field listing multiple reasons that a medication is not given.

When should care be documented?

Immediately after care is given

Focus Charting-meaning of DAR:

In focused charting, the first column contains the time and date, the second column identifies the focus or problem addressed in the note, and the third column contains charting in a DAR format. DAR is an acronym for data, action, and response. Data. Subjective and objective data (e.g., laboratory and diagnostic test results) that support the focus. This section reflects the assessment phase of the nursing process. Action. Describes interventions performed, such as administering medications or making calls to the primary provider. This section reflects the planning and implementation phases of the nursing process. Response. The client's response to your interventions. This section reflects the evaluation phase of the nursing process.

What should you document after administering a prn medication?

Make a narrative note of your assessment findings and the patient's response to the medication in the appropriate location on the MAR. pain score before administration of an analgesic and pain score after

Why Are Standardized Nursing Languages Important?

Make nursing visible Standardized nursing terminology helps do that by making nursing care and its effect on patient outcomes more visible in patient records. Support nursing research. ANA recognized terminology allows researchers to retrieve nursing data for aggregation and analysis and establish standards for the delivery of evidence-based nursing care. Provide standardized terminology for use in EHR systems.This is important in EHR systems because computers require standardized information that can be converted to numerical codes.

Can I Delegate Charting?

No! You are responsible for documenting the nursing care you provide. Never chart the actions of others as though you performed them.

What Forms Do Nurses Use to Document Nursing Care?

Nursing Admission Data Forms information about the client's support system and helps forecast future needs presenting illness or reason for admission, vital signs, allergy information, current medications, activities of daily living [ADL] status, physical assessment data, and discharge planning information Discharge Summary: discharge planning begins on admission. Therefore, discharge needs should be evaluated when the patient first enters a healthcare facility, especially in acute care facilities. Flow Sheets and Graphic Records I&O, weight, hygiene measures, ADLs, and medications, vital signs, Checklists nursing actions, such as wound care, treatments, or IV fluid administration, Client care activities, responses, and exceptions, treatments, IV fluid administration, and other parameters Medication Administration Records Medication administration records (MARs) contain information about the medications that have been prescribed for the client. Kardex® or Patient Care Summary the Kardex is a special paper form or folding card that briefly summarizes a patient's status and plan of care. Paper Kardex and electronic patient care summaries typically pull patient data from multiple areas of the health record (medical and nursing diagnoses, prescriptions, treatments, results). Integrated Plan of Care (IPOC) a combined charting and care plan form An IPOC maps out, day by day, the patient goals, outcomes, interventions, and treatments for a specific diagnosis or condition from admission to discharge. laboratory and diagnostic testing, medications, standardized interventions, therapies Occurrence Reports or incident report, is a formal record of an unusual occurrence or accident. used to analyze the event, identify areas for quality improvement, and formulate strategies to prevent future occurrences. KEY POINT: An occurrence report is not part of the client's health record and thus should never be referenced in the nurses' notes or in other sections of the health record.

reporting

Oral communication about a patient's status

OASIS

Outcome and Assessment Information Set. The most commonly used paper home health documentation form is known as OASIS Home health is moving toward electronic documentation. Home health nurses use electronic devices (e.g., tablets, laptop computers) to retrieve client data, record progress notes in the home, order supplies, and coordinate scheduling of follow-up visits.

Identify four events in which you will need to complete an occurrence report.

Patient fall or other injury Medication error Incorrect implementation of a prescribed treatment Needlestick injury or other injury to staff Loss of patient belongings Injury of a visitor Unsafe staffing situation Lack of availability of essential patient care supplies Inadequate response to emergency situation

PACE format

Patient/Problem, Assessment/Actions, Continuing/Changes, and Evaluation

Date and time all your documentation.

The day begins at 0001 (1 minute past midnight) and ends at 2400 (12 midnight). Morning hours—Most people have little difficulty with early morning hours.Example: 9:00 a.m. is 0900. Hours after 12 noon—To convert to military time after 12 noon, simply add 12 to the clock time. Example: 7:30 p.m. + 12 = 1930 in military time.

Injections.

You must chart the type and site of the injection. This documentation protects the patient from repeated injections in the same location.

In a transfer report:

Your name, facility, and phone number Client's name, age, gender, and admitting and current diagnoses Client's providers(s), if still following client Procedures or surgeries performed Current medications and last date/time each was taken/time next dose is due Client status at present as well as progression since admission Last set of vital signs, plus any pertinent trends since admission Tubes in place, such as IVs, catheters, drainage tubes, along with the intake and output of each tube or drain Presence of wounds or open areas of the skin plus current interventions for each Names and contact numbers for family and significant others Special directives, such as code status, presence of advance directives, preferred intensity of care, or isolation required Reason the client is being transferred Location of above information (on transfer form, in medical records, etc.)

Drug allergies.

always noted on the MAR If the patient has an allergic reaction to a medicine, you must report this to the prescriber and record this response on the MAR and in the nurses' notes.

SBAR (Situation—Background—Assessment—Recommendation)

an easy-to-remember, concrete acronym useful for framing any conversation. Because nurses and providers communicate in very different ways, SBAR is useful for interprofessional communication, especially in critical situations requiring a clinician's immediate attention and action allows for an easy and focused way to set expectations for how and what will be communicated among team members

Continuous infusions

are IV fluids that are infusing consistently unless stopped to administer an incompatible medication or blood transfusion.

Transfer reports

are given when a patient is transferred from unit to unit or from facility to facility. if the client is being transported to another unit in the same facility, you will need to transport a paper chart, unless the receiving organization can electronically access the client record. review your facility's policy on what can be copied or electronically transmitted during client transfers.

Verbal Orders/Prescriptions

are spoken directions for patient care given to you in person, usually during an emergency Providers should never use verbal communications as a routine method of giving prescriptions.

Always use _____ ink for handwritten notes

black

Soap/soapier disadvantages

can be inefficient and ineffective You may find the same interventions and responses repeated in more than one section for patients with overlapping problems. nurses write a complete narrative rather than a single problem entry use of SOAP has also been shown to shift the focus from the patient to the disease, thus promoting a medical model instead of the nursing process

Electronic Health Record (EHR) Systems

consists of records that are entered via computer combine source-oriented and problem-oriented record styles contains prescriptions, clinical documentation, and results of laboratory and other tests and procedures, as well as an integrated plan of care (IPOC), a problem and diagnosis list, and progress notes entered by providers, nurses, therapists, and other healthcare providers.

If a prescription is written illegibly on paper or is entered into the EHR missing certain details or components:

contact the provider directly for clarification. Generally, you should contact the provider who wrote the prescription.

health record

documents: Care, in chronological order, provided by all healthcare providers The patient's responses to interventions and treatments Important facts about the patient's health history, including past and present illnesses, examinations, tests, treatments, and outcomes

Omitted medication or delayed administration.

patient is not available or is experiencing health changes that require immediate interventions code to indicate why the medication was withheld or given at a different time. document the omission or delay in your nurses' notes often it is possible to reschedule administration times for a single dose or permanently going forward.

What are some advantages of EHR's?

enhanced communication improved access to information time savings improved quality of care information that is private and safe

Charting By Exception can lead to ____________because nurses may conclude that care has been completed when in fact it was not done. This system requires you to carefully assess and validate care provided.

errors

NOC

patient outcomes

FACT documentation model for charting

incorporates many charting-by-exceptions (CBE) principles and disadvantages. It includes four key elements: Flow sheets individualized to specific services Assessment features standardized with baseline parameters Concise, integrated progress notes and flow sheets documenting the client's condition and responses Timely entries documented when care is given includes only exceptions to the norm or significant information about the patient.

IPOC

integrated plan of care

NIC

interventions

face-to-face oral report

is a convenient but sometimes time-consuming way to transmit information. The outgoing nurse audio-records a report on her clients. This method does not allow you to ask questions about the client; occasionally the audio quality is poor and the report is not clear. However, an advantage of this method is that the outgoing nurse continues to provide patient care while the incoming nurse receives report. To minimize communication errors, the outgoing and incoming nurses should speak directly to each other to update information or answer any questions about the client care.

Charting By Exception

is a system of charting in which only significant findings or exceptions to standards and norms of care are documented. you must know and adhere to professional, legal, and organizational guidelines for nursing assessments and interventions. KEY POINT: CBE assumes that all standards have been met and the client has responded normally, unless a separate entry is made (an exception). Advantages CBE reduces the amount of time spent on documentation, reduces repetitive charting of routine care, provides a record that is easily read and understood, and clearly highlights any variations from the expected plan of care. EHRs can standardize common processes and list abnormal findings from the menu bar (Duffy, 2015). Disadvantages The main problem associated with CBE is omissions of pertinent information. Omissions may result from disagreement over what constitutes a significant variation. Some define deviations based on the client's baseline while others use normal physiological parameters (Kerr, 2013). Critics of CBE believe it: Requires nurses to be overly familiar with the organization's documentation standards and policies Makes it difficult to capture the skilled judgment of nurses Reduces care to such rote repetitions that the nurse may forget to chart an exception to the established standards

SOAP,SOAPIE, and SOAP(IER) format for charting

is often used to write nursing and other progress notes. It can be used in source-oriented, problem-oriented, and electronic health records. Subjective data—What the client or family members tell you about the client's signs and symptoms and the reason they are seeking healthcare. Typically, this is documented by quoting the actual words said. Objective data—Factual, measurable clinical findings such as vital signs, test results, and quality of breath sounds. Refer to Chapter 3 to review subjective and objective data. Assessment—Conclusions drawn from the subjective and objective data, usually client problems or nursing diagnoses. Plan—Short-term and long-term goals and strategies that will be used to relieve the client's problems. Interventions—Actions of the healthcare team that are performed to achieve expected outcomes. Evaluation—An analysis of the effectiveness of interventions. Revision—Changes made to the original care plan.

discharge summary

is the last entry made in the paper chart. In the electronic chart, the discharge summary can begin any time after admission and revised throughout the hospitalization. A summary is completed when the client is transferred within the same organization, to another facility, or discharged to home.

Narrative Format

is written in source-oriented and problem-oriented charts The narrative chart entry tells the story of the client's experience in the order that it happens. details of the client's care—status, activities, nursing interventions, psychosocial context, and response to treatment. useful when attempting to construct a time line of events, such as a cardiac arrest or other emergency situations. lack of standardization can result in lengthy notes, making it difficult to retrieve relevant data in a timely manner

Assessment required before administration.

make a specific assessment before giving the drug to ensure that it is safe to administer. document that assessment data on the MAR along with the time of administration and other required information For example, you should not give digoxin (a cardiac medication) if the apical heart rate is below 60 beats/min, so you must auscultate the rate before giving the drug. Blood pressure, insulin, and anticoagulants medications also require assessments before administration.

single-order

medication is given once at a prescribed time but not necessarily immediately.

Scheduled medications

medications that are to be given on a regularly scheduled basis.

Unscheduled medications

medications that are to be given on call at the appropriate time. An example of an unscheduled medication is a preoperative medication to be administered immediately before the patient goes to the operating room.

NANDA-I

nursing diagnoses

Your documentation should convey:

the care that you provided to the patient during your shift.

health records system

the overall process by which all client records are created, stored, and retrieved in an organization. In a sense, it consists of all the EHRs in an organization.

Focus Charting®

uses assessment data to evaluate patient care concerns, problems, or strengths. It also identifies necessary revisions to the care plan as you record each entry. The focus is often: A nursing diagnosis (e.g., Ineffective Breathing Pattern) A sign or symptom (e.g., shortness of breath) Client behavior (e.g., inability to follow inhaler instructions) A special need (e.g., non-English-speaking) An acute change in condition (e.g., sudden appearance of chest pain) A significant event (e.g., surgery). works well in acute care settings, in areas with the same care, and where procedures are repeated frequently.

MBAR (Medication—Background—Assessment—Recommendation)

was developed to provide a structured handoff that promotes medication reconciliation during handoffs and transfers

Documentation can be in Documentation can be in _________or _______form or in a combination of the two forms.

written or electronic

If you don't feel comfortable about a prescription,

you may refuse to implement it. Inform the chain of command at your organization about your refusal. Usually you will speak with the charge nurse, who may then contact the nurse manager or nursing supervisor. The nature of the prescription will determine how this situation is handled. If you do refuse to follow a prescription, you must document your refusal and the actions you took to clarify the prescription. KEY POINT: If you believe an order is inappropriate or unsafe, you are legally and ethically required to question the order.