Documentation Chapter 7

Case management system charting

-a method of organizing patient care through an episode of illness so clinical outcomes are achieved within an expected time frame and at a predictable cost -a clinical pathway or interdisciplinary care plan takes the place of the nursing care plan

Three purposes of documentation are

-provide a written record of the history, treatment, care, and response of the patient while under care. -serve as evidence in a court of law -provide data for quality assurance studies -guide reimbursement of costs of care

The medical record is a legal document and for that reason nurses adhere to the following guidelines

-verify you are the correct patient's computer screen before beginning to document in the medical record -documentation is done only by the person who made the observation or performed the intervention and who is legally responsible for the accuracy and quality of care. -spell medical record entries correctly. Use a dictionary or spell check to check words you are unsure how to spell -when a patient refuses a medication, record an explanation for the refusal in the medical record. Document the exact words the patient used when refusing to adhere to the treatment regimen. Document any instruction given to the patient and any patient behaviors that are against the instructions -follow hospital policy for amending the record -document objective data after completing a task; never document before doing the task -note late entries correctly -clearly identifying care given to the patient

Projection

A coping mechanism during which individuals attribute their own weaknesses to others

Rationalization

A logical but untrue reason is offered as an excuse for the behavior

An advantage of the charting by exception method of documentation is that it highlights ______________________________ ad patient __________________

Abnormal data; trends

Three major principles that should be followed to produce good documentation are

Accuracy of what is documented Brevity using abbreviations a and symbols as accepted Legibility and completeness of assessments, actions, and results

Focus charting 2

Advantages -compatible with the use of the nursing process -shortens charting time: many flow sheets, checklists Disadvantage -if database insufficient, patient problems missed -doesn't adhere to charting with the focus on nursing diagnosis and expected outcomes

Problem-oriented medical record charting (POMR) 2

Advantages -documents came by focusing on patients' problems -promotes problem-solving approach to care -improves continuity of care and communication by keeping relevant data all in one place -allows easy auditing of patient records in evaluating staff performance or quality of patient care Disadvantages -results in loss of chronological charting -more difficult to track trends in patient status -fragments data because more flow sheets required

Source-oriented or Narrative charting 2

Advantages -information in chronological order -documents patients baseline condition for each shift -indicates aspects of all steps of the nursing process Disadvantage -documents all finding: makes it difficult to separate pertinent from irrelevant information -requires extensive charting time by the staff -discourages physicians and other health team members from reading all parts of the chart

Charting by exception 2

Advantages -highlights abnormal data and patient trends -decrease narrative charting time -eliminates duplication of charting Disadvantage -requires detailed protocols and standards -requires staff to use unfamiliar methods of record keeping and recording -nurses so used to not charting that important data is something omitted

Five steps RN nursing process

Assessment Nursing diagnosis planning implementation Evaluation

Four steps LPV/LVN nursing process

Assessment Planning Implementation Evaluation

Aggressive behavior

Automatic response not based on choice Emotional behavior (based in anger) Violates the rights of others Attacks person instead of behavior Overall message: "You do not count. I count." Consequence: distances aggressor from staff and patients

An advantage of source oriented or narrative documentation is that it indicated the patient's ________________________________ for each shift

Baseline condition

Accuracy in documentation

Be specific and definite in using words or phrases that convey the meaning you wish expressed Words that have ambiguous meanings and slang should not be used in charting

Data collection (phase 1)

Begins on admission and continues with each patient encounter Verify the information Communicate information to appropriate health care team members Continuing data collection Accuracy in data collection Courtesy during data collection Explain the need to ask certain questions

When documenting, the patient's needs, problems, and activities should be presented in terms of _______________________________________

Behaviors

Only health care professionals _______________________ for the patient, or those involved in legitimate research or education, should have ____________________ to the medical record

Caring directly; access

Narrative charting requires the documentation of care in ____________________________ order.

Chronological

What to document

Completeness is more important than brevity

To protect patient confidentiality when using computer assisted documentation, each nurse should guard against leaving the _____________________

Computer screen visible

Electronic Health Record (EHR)

Computerized record of patient's history and care across all facilities and admissions

The medical record

Contains data about patient's stay in a facility Only health care professionals directly caring for the patient, or those involved in research or teaching, should have access to the chart Patient information should not be discussed with anyone not directly involved in the patient's care

Productive cough

Coughing up material

Focus charting

Directed at nursing diagnosis, patient problem, concern, sign, symptom, or event Three components: Data, action, response Or Data, action, evaluation

Computer-assisted charting

Documentation done as interventions are performed using bedside computers Variations depending on the system Some produce flow sheets with nursing interventions and expected outcomes Others use a POMR format to produce a prioritized problem list

Briefly correlate the nursing process to the process of documentation

Documentation is organized by nursing diagnosis. Assessment data are document. Implementation of the interventions noted on the nursing care plan is documents along with the patient response. Evaluation of patient progress toward expected outcomes is placed in the nurse's notes. Evaluation data are documented that indicate expected outcomes have been met

nonassertive (passive) behavior

Every automatic response not based on choice Emotional response (based on fear) Dishonest, self-defeating Overall message: "I do not count. You count." Consequence: nurse unable to recognize and meet patient needs

Documentation should show progress toward _____________________ listed on the nursing care plan

Expected outcomes

An advantage of the focus charting method is that it shortens documentation time by using many ________________________________ and _____________________

Flow sheet; checklists

Exudate

Fluid with cellular debris

Problem-oriented medical record charting (POMR)

Focuses on patient status rather than on medical or nursing care Five basic parts: -database -problem list -plan -progress notes -discharge summary

Assesrtive: expected in nursing

Helps nurse advocate for the patient Promotes honest, open communication and behavior Considers others' feelings and needs Benefits nurse, patient, and staff

Legibility and completeness in documentation

If writing not legible, misperceptions can occur Be sure to include as much information as needed

Barriers in Data Collection

Insufficient time Poor skills in data collection Communication failure

An advantage of some computer assisted documentation is that documentation is done as ___________________________ are performed

Intervention

List five advantages of POMR method of documentation

It provides documentation of comprehensive care by focusing on patients and their problems It promotes the problem solving approach to care It improves continuity of care and communication by keeping data relevant to a problem all in one place so that it is more available to all who are providing care It allows easy auditing of patient medical records in evaluating staff performance or quality of patient care It requires continual evaluation and revision of the care plan It reinforces application of the nursing process

The medical record in a(n) __________________________ and what is documented can be used in ________________________

Legal record; a court of law

A major advantage of computer documentation is that notes are always _______________________________________

Legible

Spasm

Localized muscle contraction

_______________________________ must display data that support the medical and nursing diagnosis

Medical records

Three communicating styles

Nonassertive (passive) Assertive Aggresive

Paresthesia

Numbness and tingling

A computer printed daily care sheet is a quick reference for current information about the patient and _______________________________

Ordered treatments

Source-oriented or Narrative charting

Organized according to source of information Separate forms for nurses, physicians, dietitians, and other health care professionals to document assessment findings and plan the patient's care Narrative charting requires documentation of patient care in chronological order

Charting by exception is based on the assumption that all standards of practice are carried out and result in a normal or expected response unless _____________________________________

Otherwise documented

Assertiveness keypoints

Own your own feelings Don't blame others Be direct (Use "I" statements) to make your feelings known Make sure verbal and nonverbal messages are consistent

PIE charting

P - problem identification I - intervention E - evaluation Follow the nursing process and uses nursing diagnoses. While placing the plan of care within the nurses progress notes

Developing your plan of care for assigned patinets

Patient care is a learning experience Plan for patient care assignments Internalize your role in four phases of the nursing process Improve your ability to think critically

APIE

Plan, implementation, evaluation

Focus charting is directed at a nursing diagnosis, a patient _______________________________, a concern, a sign, a symptom, or a(n) ________________________

Problem; event

The heart of the charting by exception method is unit-specific _________________________ and standards of nursing care

Protocols

Purpose of documentation

Provides a written record of the history, treatment, care, and response of the patient while under the care of a health care provider Is a guide for reimbursement of costs of care May serve as evidence of care in a court of law Shows the use of the nursing process Provides data for quality assurance studies Is a legal record that can be used as evidence of events that occurred or treatments given Contains observations by the nurses about the patient's condition, care, and treatment delivered Shows progress toward expected outcomes

Computerized provider order entry (CPOE)

Provides efficient work flow Automatically routes orders to appropriate clinical areas

Role differences between RN's and LPN/LVN

RN -nursing diagnosis -independent role in all five steps of the nursing process -uses an established list of current nursing diagnoses LPN/LVN -no nursing diagnosis Dependent role in the planning and evaluation phases Independent role in the data collection and implementation phase

POMR methods of documentation are said to improve continuity of care and communication by keeping ________________________________ related to a problem all in one place

Relevant data

Home care documentation must particularly note ______________________________________ in place and the need for ________________________________

Safety factors; continued care

Brevity in documentation

Sentences not necessary -articles may be omitted -the word "patient" omitted when subject of sentence -abbreviations, acronyms, symbols acceptable to the agency used to save time and space -choose which behaviors and observations are noteworthy

Approximated

Situated close together

Methods of documentation (charting)

Source-orienting (narrative) charting Problem-oriented medical record (POMR) Focus charting Charting by exception Computer-assisted charting Case management system charting

Radiates

Spreads to other areas

Paroxysmal

Sudden attacks

___________________ sets the standards for documentation

The joint commission

Dienal

The nurse refuses to recognize the existence and significance of the patient's personal concerns .

Problem solving: what the nurse can do

Use assertive behavior and communication Manage own verbal, nonverbal, and effective behaviors Identifying appropriate role at each step of the problem-solving process Consider criteria for positive patient outcome

When a case management system is used, documentation ________________________________________ of placed on the back of the care path sheets

Varience

Documentation and the Nursing Process

Written nursing care plan or interdisciplinary care plan is framework for documentation Charting organized by nursing diagnosis or problem Implementation of each intervention documented on flow sheet or in nursing notes Evaluation statements placed in nurse's notes and indicate progress toward the stated expected outcomes and goals

Charting by exception

based on the assumption that all standards of practice are carried out and met with a normal or expected response unless otherwise documented; a longhand note is written only when the standardized statement on the form is not met A longhand note is written only when the standardized statement on the form is not met

CPOE

computerized physician order entry

Assertive behavior

current name for (honesty) Proactive, not emotional response Positive, confident, open stand Overall message: "I count. You count." Consequence: Nurse feels in control of emotions and responses, and can be more effective patient advocate.

MAR

medication administration record

POMR

problem-oriented medical record

coping mechanisms

projection, rationalization, denial, compensation

SOAP

subjective data, objective data, assessment, plan

SOAPIE

subjective data, objective data, assessment, plan, intervention, evaluation