NU 309: Documentation and Interdisciplinary Communication

Admission assessment

-Nurse conducts -Often referred to as nursing H & P -Within 24 hours to 3 days dependent on facility -Comprehensive information about the client's physical, psychological, functional, social, and spiritual abilities -Care providers can refer to this initial assessment to obtain important baseline info -When pt. is admitted you begin building a plan of care. A thorough assessment is necessary to accomplish this. -In the hospital setting, you typically see the admission assessment completed immediately or shortly after arrival.

Home care

-Outcome and Assessment Information Set (OASIS) -used by home care agencies -They are assessing to see if interventions are helping pt. to meet outcome they are looking at sociodemographic data, environmental information, support systems, health status, and functional status of pt. -This documentation is also linked to reimbursement.

Long-term care

-Resident Assessment Instrument (RAI) -used to optimize residents quality of care and quality of life

Point of care

-documenting information as you gather it -Most facilities have computers on wheels, or some have computers in pt. rooms to facilitate this -Frequently, charting is performed at bedside during admission

Reporting

-done during handoff, pt. rounds, during pt. and family care conferences, and when calling a provider to report a change -determine what assessment data to include in verbal report, how quickly to report assessment, proper team member to receive info, and what method of reporting to use and when nurse decides to notify provider

Individualize; SBAR; record; exact patient; point of care

1.Assessment data is used to develop the plan of care and helps health care professionals to _________ and coordinate care until the patient is discharged. 2.Effective verbal communication among the health care team may be organized using the ___________ framework. 3.The Health Insurance Portability and Accountability Act (HIPAA) requires the health care professional to legally and ethically protect the confidentiality of the patient medical _______. 4.When documenting subjective data, use ______ words whenever possible. 5.Document the assessment via a portable computer as it is gathered using _________________ documentation.

True; true; false; true; true

1.Sentinel events often occur from failure to communicate. 2.Internal audits are used to continuously improve the care delivered. 3.A handoff assessment after a patient is transferred from the perioperative area to the nursing unit can be delegated to unlicensed assistive personnel. 4.The role of the nurse is to help set goals and plan care during the interdisciplinary rounds. 5.Critical thinking is used to determine what assessment data to report to whom and how quickly and by what method.

Important

client medical record is _________: -Legal document (may be used in civil or criminal courts to provide evidence of wrongdoing) -Communication and care planning -Quality assurance -Financial reimbursement -Education -Research

Medical record

components in _______ ______: -Nursing admission assessment -History and physical examination (H & P) by primary health care provider -Primary care providers orders -Plan of care (POC) or clinical pathway -Flow sheets documenting vital signs, intake/output (I & O), and routine assessments -Focused assessment sheets (neurological/postoperative reassessment) -Medication administration record (MAR) -Laboratory and diagnostic test results -Progress notes by different members of health care team -Consultations -Discharge or transfer summary

Errors

high-risk ______ in documentation: -Falsifying client records -Failing to record changes in a client condition -Failing to document the notification of the primary care provider when client condition changes -Performing an inadequate admission assessment -Failing to document completely -Failing to follow the agency's standards or policies on documentation -Charting in advance

Communication

includes verbal and nonverbal

Plan of care

individualizes goals, outcomes, interventions

Documentation

involves entering client information into written or computerized client record

Flow sheet

used to document routine, scheduled assessments

Electronic

_________ medical record: -Computerized part or all of clients medical record -Increases client safety -Allows nurses to enter assessments quickly -Electronic Medication Administration Record (eMAR) -Computerized Provider Order Entry (CPOE) -Advantages (Graph trends in vital signs, Team members view records simultaneously, Legible, Time dated, Ensures complete assessments, and Create plan of care) -ALWAYS LOG OUT OF SYSTEM AFTER MAKING AN ENTRY TO ENSURE CLIENT CONFIDENTIALITY

Documentation

_____________ must be: -accurate and complete -logically organized -timely -concise

Critical thinking and clinical judgement

all nurses use this to determine if abnormal assessment data is significant

Discharge note

-Discharge teaching, medications, when to contact provider, condition at discharge, time of discharge -always get a set of vitals before discharging a pt. Give client a copy of discharge teaching and summary.

Telephone communication

-have record available and recent assessment findings -Document the call-time, who was called, information given and orders received -Some facilities have electronic resources and the provider can enter orders after a call -If you take a phone order, write order, then DO A READ BACK to provider to ensure accuracy

Confidentiality

-keeping information private -HIPAA -what happens at clinical, stays at clinical -NEVER take personal information away from clinical site -DO NOT look at charts of a pt. you are not directly caring for -No discussion of pt. in hall, elevator, cafeteria, etc.

SBAR model

-situation, background, assessment, and recommendation -why are you communicating, describe circumstances leading to current situation, give objective and subjective data pertinent to situation, and make suggestions for what needs to be done to manage the difficulty

Handoff

-transfer of care for a patient from one health care provider to another -verbal report is given along with written pt. information -Shift change, from recovery to med-surg, from med-surg to ICU are just a few examples

SOAPIE notes

-type of progress notes -Focuses on a single problem -similar to nursing process -easy to track progress for identified problems -lengthy and time consuming -(S) Subjective (O) Objective (A) Analysis (P) plan (I) Intervention (E) Evaluation

Charting by exception

-type of progress notes -Predetermined standards and norms to record only significant assessment data -unexpected findings require additional documentation

Narrative notes

-type of progress notes -Unstructured paragraph, relevant assessment and nursing activities during shift or visit

DAR notes

-type of progress notes -broad view -works well for long-term care -may be difficult to identify chronological order and may not relate to point of care -(D) Data (A) Action (Response)

PIE or APIE notes

-type of progress notes -goal is to incorporate the POC into the progress note -less redundancy -includes outcomes -(A) Assessment (P) Problem (I) Intervention (E) Evaluation

Batch charting

-waiting until end of shift or until all pt. have been assessed -Lots of room for error -Electronic charting will always show current time when you chart, but the time may be changed in the system to the time the assessment was actually performed

Chart; do

If you didn't _____ it, you didn't __ it.

Clinical pathway

Multidisciplinary tool that identifies a standard plan for a specific client population

Sentinel events

life threatening errors in health care

Never events

preventable through the use of evidence-based guidelines and should never occur