Test 1: Documentation content

Admission data forms

*used in all settings* -Record of baseline data from which to monitor change -Chief complaint -Helps forecast future needs -Informs about clients support system -Contains critical information (e.g., allergies, medications, adls, phys, assess data, and discharge planning info.) -Vital signs

Nurses can chart on...

- Admission data forms - Flow-sheets - MAR - Progress notes - Kardex - IPOC - Discharge summary - Occurrence report -Graphic records -Checklists -I&O

Flowsheets

- Record routine (frequently, routine schedule, or as a part of shift routines) aspects of care (hygiene, turning, weight, adls, meds) -Document assessments: usually organized according to body systems -Track client response to care (wound care, pain, IV fluids) -Graphic records: used to record vital signs - Intake and output record *Allows to see patterns of change in patients status eg bowel mvmts.

Occurrence report

-"Incidence report" -Formal record of unusual occurrence or accident -Not a part of the patients health record (never to be referenced in nursing notes or in other sections of health record) -Quality improvement -e.g., pt fall, med. error, injury of visitor... -You should report all errors, even if there was no adverse impact on the patient. -It is an organizational report used to analyze the event, identify areas for quality improvement, and formulate strategies to prevent future occurrences.

Telephone orders

-Appropriate in sudden change in patient condition and provider not is hospital or cant transmit prescriptions electronically -Life threatening emergency- safeguard must be applied "document and read back" -Recieved by phone and transcribed onto chart order sheet -Have an increased risk for errors (pronunciation, dialect, accent, poor communication...) -TO

Electronic entry format

-Change documentation formats from paper to electronic. -Documentation is done at the bedside instead of at the nurse's station. -Decision making processes change from gradual to immediate.

5 C's of documentation

-Clear -Complete -Concise -Comprehensive -Correct

Purpose of documenting

-Communication b/w providers -Legal documentation -Quality improvement -Legislative requirements/ legal -Professional standards of care -Reimbursement -Educational tool -Research

Discharge summary

-Discharge data are obtained with the admission assessment, but are often recorded on a separate form. 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. -The discharge summary may be a multidisciplinary document or each discipline may write a separate summary. -It is important to clearly document the client's condition on discharge because the discharge summary serves as baseline data for the healthcare professionals who provide follow-up care. *Time of departure and method of transportation *Name and relationship of persons accompanying client at discharge *Condition of client at discharge *Teaching conducted and handouts/informational matter provided to client *Discharge instructions (medications, treatments, activity) *Follow-up appointments or referrals given

Documenting client care

-Documenting should convey care provided to patient during shift -Be familiar with facility requirements and forms -Chart in the required format -Include all aspects of care -Be accurate, complete, and consistent *Refer to Doc. ABC's*

FACT documentation

-FACT documentation includes only exceptions to the norm or significant information about the patient. It eliminates the need to chart normal findings. -Noted for its individual elements, the FACT documentation model 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 -Incorporates many CBE principles and disadvantages

Transfer reports

-Given when patient is transferring from unit to unit (also transport paper chart, pt belongings), facility to facility... -Medication errors common in transfer of patients *Your contact information *Client demographics, diagnosis, reason for transfer *Family contact information *Summary of care *Current status, including medications, treatments, and tubes in the client *Presence of wounds or open areas of the skin *Special directives, code status, preferred intensity of care, or isolation required *Always ask if the receiver has any questions

SBAR (RQ)

-Identify yourself, the client, and the agency -Easy to remember, concrete acronym useful for framing any conversation. -Useful for inter-professional communication, esp. in critical situations. -Can be adapted for handoff reports S: Situation- "here's the situation" B: Background- "my supporting background information is..." A: Assessment- "My assessment of the situation is that..." R: Recommendation- "I recommend that you..." R: Read back- "To repeat the information and..." Q: Questions- Questions asked and aswered

Reporting

-Informing other caregivers about the client's condition -Maintain continuity -Passage of vital information related to the client's status/plan of care -Influences plan of shift at work -Done even if RN leaves unit for a few minutes

PACE

-Is an example of a specifically developed stand. approach to org. data for handoffs. P: Patient/problem- Include client's name, room number, diagnosis, reason for admission, and recent procedures. State the present problem. Briefly summarize medical history relevant to the current problem. A: Assessment/actions-Nursing assessments and interventions directed to the problem. C: Continuing/Changes-- *Continuing needs and potential changes include: *Client care and treatments that must be monitored on other shifts (e.g., dressing changes) *Changes in the client's condition or the care plan, recent or anticipated (e.g., new orders, changes in discharge date) E: Evaluation- Evaluation of responses to nursing and medical interventions, progress toward goals, and effectiveness of the plan

Hand-off report

-May be: verbal, through walking rounds, audio recorded report -No matter where or how, hand-off report should use a consistent, structured (stand.) process that contains critical items. -The nurse is alerted to the client's status, recent status changes, planned activities, diagnostic testing, or concerns that require follow-up. -A handoff report may be given at the bedside or in a conference room using paper notes or an EHR device. -As a student nurse, you will receive reports from either the off-going or on-coming shift nurse assigned to the client. -Report any changes to the nurse assigned to the client during your shift and always give a report before leaving the unit. *Client demographics and diagnosis *Relevant medical history *Sig. assessment findings *Treatments *Upcoming diagnostics or procedures *Restrictions *Plan of care for the client *Concerns

Source-oriented record

-Members of each discipline record findings in a separate section of the chart. -Includes: admission data, advance directive, history and physical, provider's orders, progress notes, diagnostic studies, lab data, nurse's notes, graphic data, rehab and therapy notes, discharge planning. -Advantages: Easily locate the care provided by each discipline and the results of lab and diagnostic tests. -Disadvantages: Data scattered; may lead to fragmentation e.g., long term care paper charting. Having to flip through pages of documentation.

Common Types of Charting

-Narrative -PIE -SOAPIER -Focus -Charting by exception (CBE) -FACT system -Electronic entry format

Problem oriented (POR's)

-Organized around the patient's problems Four Components: -Database-dem. data, history and phys... -Problem list- solved/not solved -Plan of care- includes the PCP's prescription and the nursing care plan to address the identifies problems. Other disc. may contribute to the plan. -Progress notes- org. according to problem list (problem #) Advantages: Allows for greater collaboration and is easy to monitor pt. progress *preferred over source oriented** Disadvantages: System requires a cooperative spirit among HCP as well as diligence in maintaining database and problem list.

Verbal orders

-Providers should never use verbal comm. as a routine method of giving prescriptions -Spoken to you; often during a client emergency -Should be made for critical change in patient condition -Gold standard with verbal orders: make sure to repeat what they say to you -VO

Bedside report

-Sometimes known as "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.

Medication Administration Record (MAR)

-Succinct way of looking at med times -Comprehensive list of all ordered medications -Provides information on clients allergies -Documents scheduled/ routine, PRN, STAT, or omitted doses *Additional explanation may be required for nonroutine or omitted medications. -Some allow HCP to look up info about med indications, contraind., adverse effects, and safe dosage ranges. Inpatient: Inpatient medication records not only contain a list of prescribed medications but also track medication administration and usage for the agency. Outpatient: Because patients do not stay at the facility, usually the MAR primarily contains information about how the patient is to use the medications prescribed. Patients retain responsibility for administering their own medications either independently or with the help of family or caregivers.

Problem-Intervention-Evaluation (PIE)

-Used only in problem-oriented charting -Establishes an ongoing plan of care -Organizes info according to clients problems -Requires daily assessment record and progress notes -Eliminates need for separate care plan- Nursing focused rather than medical-focused *Problem: Uses data from your assessment to identify appropriate diagnosis *Intervention: Document the nursing actions you take for each nursing diagnosis *Evaluation: Document the patient's response to interventions and treatments

Focus system

-Uses assessment data to evaluate (and highlight) patient care concerns, problems, or strengths. It also identifies necessary revisions to the care plan as you record each entry. -Contains three columns: 1. Time and Date 2. Focus or problem being addressed 3. Charting in a DAR format: Data- Subjective and objective data that support the focus. This section reflects the assessment phase of the nursing process. Action- Describes interventions performed, such as med admin or making calls to PCP. 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. **Works well in acute care settings, areas with same care, and where procedures repeated frequently.** Advantages: Addresses clients concerns directly Disadvantages: May lead to inconsistent labeling of focus of notes. Causing lack of problem list and difficulty is tracking client progress.

Narrative charting

-Written in source-oriented and problem-oriented charts -Tells the story of the client's experience in the order that it happens. -Tracks the clients changing status -Great way to document but have to keep things succinct. Advantages: -Useful when attempting to construct timeline of events Disadvantages: -Lack of standardization -Can be lengthy and disorganized -Difficult to retrieve relevant data timely

Charting by exception (CBE)

-a system of charting in which only significant findings or exceptions to standards and norms of care are documented. -To use CBE effectively, you must know and adhere to professional, legal, and organizational guidelines for nursing assessments and interventions. -CBE assumes that all standards have been met and the client has responded normally, unless a separate entry is made (an exception). -Each flow sheet has entries for expected aspects of care and thus can vary by specialty or diagnosis. Advantages: 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 Disadvantages: 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. CBE can lead to errors 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.

Do's and Dont's of documenting

-do not chart occurrence reports filled out -Chart any client refusal of treatment or medication -Doc. spiritual concerns expressed by the client and your interventions -Be accurate and nonjudgemental -Adhere to the requirements for reimbursement -Provide details about the client's condition, nursing interventions provided, and client response -Document legibly and ASAP -Record sig. events or changes in condition -Record attempts made to contact PCP -Chart teaching performed -Chart use of restraints, reason, type, and checks -Blue/ black ink for handwritten -Date, time, and sign all notes -use proper spelling and grammar -Use only authorized abbreviations -Document complete data about medications -If client refused meds- records on MAR in narrative form, chart reason given -Try to detect the reason for refusal -Quote patient exact language -Chart facts NOT inferences

Audio-recorded record

-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.

Documentation ABC's

A - Accurate B - Bias Free C - Complete D - Detailed E - Easy to read F - Factual G - Grammatically correct H - Harmless (legally)

Integrated Plans of Care (IPOCs)

A combined charting and care plan form Maps out on a daily basis, from admission to discharge -Client outcomes, interventions, and treatments for a specific diagnosis or condition - Laboratory work, diagnostic testing, medications, and therapies included in the pathway -Help admin. predict length of stay and monitor costs of care -Assist with staffing -Eliminate duplicate charting -Enhance nurse teachings and education to pts. -Multiple patient diagnosis captured easily

Electronic Health Record (EHR)

A computerized lifelong health care record for an individual that incorporates data from providers who treat the individual. An electronic record of health-related information on an individual that conforms to nationally recognized interoperability standards and that can be created, managed, and consulted by authorized clinicians and staff across more than one healthcare organization. -Advantages: *Enhanced communication and collaboration *Improved access to information *Time savings *Improved quality of care *Information that is private and safe -Disadvantages: *Expense *Downtime *Difficulties associated with change *lack of integration (e.g. integration across departments)

Documenting with the nursing process

A-Assessment: Chart signs and symptoms that may indicate actual or potential client problems. At an initial assessment, document comprehensive data about all client systems. D-Diagnosis/Analysis: After analyzing assessment data, document your clinical nursing judgment about the client's response to actual or potential health conditions or needs. P-Planning/outcomes: Document measurable and achievable short-term and long-term plans of care with goals directed at preventing, minimizing, or resolving identified client problems or issues. I-Implementation: After putting the plan of care into effect, record the specific interventions that were used. E-Evaluation: Document client responses to nursing care; chart whether the plan of care was effective in preventing, minimizing, or resolving the identified problems; and then modify the plan as needed.

Keep it CUBAN

Confidential Uninterrupted Brief Accurate Named nurse

Utilization Review (UR)

Determines whether medical treatments and interventions were necessary and appropriate.

Kardex

Is a special paper form or folding card that briefly summarizes a patients status and plan of care. -Typically pull patient data from multiple areas of the health record (medical and nursing diagnosis, prescriptions, treatments, results) -Usually kept together in a portable file in a central location in the nurses station to allow all team members access to patients summary information. -Not a permanent part of the patients health record.

MBAR

M: Medication B: Background A: Assessment R: Recommendation -Developed to provide a structured hand off that promotes medication reconciliation during hand-offs and transfers. -Decrease medication errors resulting in increased hospital readmission, injuries, or death.

Progress notes

Notes used in the patient chart to track the progress and condition of the patient.

SOAPIER

Subjective, Objective, Assessment, Plan, Intervention, Evaluation, Revision