Documentation

Plan and evaluate

Documentation enables providers, nurses, and other healthcare professionals to ____ ___ ________ treatment and monitor health status over time.

The correct option is A. True. Rationale: The Centers for Medicare and Medicaid Services (CMS) requires that documentation include an ongoing assessment of the need for skilled care.

Documentation of nursing care for home health clients requires ongoing assessment of need for skilled nursing care. A.True B.False

Purpose of the Written Record

Communication Continuity of care Quality improvement Planning and evaluation of client outcomes Legal record Professional standards Reimbursement and utilization review Education and research

continuity of care

Communication promotes __________ __ ____.

DAR format

Data: Subjective and objective information that supports the focus. This aspect reflects the assessment phase of the nursing process and includes other data, such as laboratory results or other diagnostic testing. Action: Describes interventions performed, such as administering medications or making calls to the provider. This aspect reflects the planning and implementation phases of the nursing process. Response: Describes the client's response to your interventions. This aspect reflects the evaluation phase of the nursing process.

Professional standards

The American Nurses Association's (ANA's) Nursing: Scope and Standards of Practice (2015) includes documentation in many of its ____________ _________.

Documentation

The act of recording client assessments and care in written or electronic form

Electronic clinical information systems

streamline electronic processes, make them more accurate and efficient, and reduce the risk of human error. This frees you to do the expert work that only nurses can do. Electronic documentation requires changes in how you document your work: •EHRs change documentation formats from paper to electronic. •Documentation is done at the bedside instead of at the nurse's station.

Transfer Reports

•Your contact information •Client demographics, diagnoses, reason for transfer •Family contact information •Summary of care •Current status, including medications, treatments, and tubes in the client; when the next medication is due •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.

Handoff Report

(sometimes called a change-of-shift report or handover report) is to alert the next caregiver about the client's status or recent changes in the client's condition and to discuss planned activities, tests, procedures, or concerns that require follow-up. may be given at the bedside or in a conference room using paper notes or a mobile or desktop EHR device. May be Verbal Walking rounds Audio-recorded report (not the preferred method) •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 such as SBAR or PACE. •Keep it CUBAN

Importance of Standardized Language

Make nursing visible Support nursing research Provide standardized terminology to use in electronic health record (EHR) systems.

Nursing admission assessment

Creating a baseline _______ _________ __________ is essential because it 1) may be used as a benchmark to monitor change; 2) provides information about the client's support system and helps forecast future needs; 3) contains critical information such as presenting illness or reason for admission, vital signs, allergy information, current medications, activities of daily living (ADLs) status, physical assessment data, and discharge planning information.

Client refusal

If ______ _______ a medication, note on the paper or electronic MAR. Your organization's policy will determine how this is recorded.

Omitted medication or delayed administration

If the client is not available or is experiencing health changes that require immediate interventions, it may be necessary to ____ _________ __ _____ _____________. Use the guidance on the paper MAR to indicate why the medication was withheld or given at a different time. Circle the scheduled time and fill in the symbol. You will also have to document the ________ or _____ in your nurses' notes. However, in the electronic MAR, often it is possible to reschedule administration times for a single dose or permanently going forward, or to document that a medication could not be given at the scheduled time and will be skipped.

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, also known as _____________. They also use the health record for ___________ ______ to determine whether the medical treatments and interventions were necessary and appropriate.

Communication

Members of the multidisciplinary team use the health record to/for ___________ about the client's status and care. _____________ promotes continuity of care.

Long-Term Care Documentation

Minimum data set (MDS) for resident assessment and care screening must be completed within 14 days of admission and updated every 3 months. Legal requirements to protect older adults mandate that you report changes in a client's condition to the primary care provider as well as the client's family. Document your reports in narrative notes on paper or in the appropriate areas of electronic forms. If you are caring for a client receiving Medicare-reimbursed services, such as IV therapy, wound care, or rehabilitation services, documentation is required with each shift. In addition, a summary written by a nurse must be recorded weekly.

PACE

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

Quality improvement

Results are used to formulate strategies to improve care, decrease length of stay, control costs, and pinpoint knowledge and practice gaps, otherwise known as _______ ___________, that can be addressed through continuing professional education and in-service education. Accrediting agencies, such as The Joint Commission, review written and electronic records to ensure delivery of quality care and public safety.

NANDA-I, NIC, and NOC

Several standardized nursing language models have been created and are used in nursing documentation, such as _____-_ (for nursing diagnoses), ___ (for interventions), and ___ (for patient outcomes).

SBAR

Situation Background Assessment Recommendation

•The charge nurse should immediately clarify the order, even though she can interpret the prescription as morphine sulfate 2 mg every 2-3 hour prn pain, as a verbal order taken by the RN. However, there are several violations with the prescription as written. To ensure client safety, the charge nurse must identify the prescribing provider, since she is not identified, clarify the prescription, and then transcribe it correctly. MSO4 is on The Joint Commission's list of "Do Not Use Abbreviations" based on previous misinterpretations and medical errors. They recommend that MSO4 is written out as Morphine Sulfate. The dosage 2.0 mg contains a trailing zero, which is also not recommended because of the risk of omitting the decimal point and 2.0 can be miswritten as 20. Thus, the correct way to write the dosage is 2 mg. The prescription does not contain a route of administration (more on this in the medication chapter). Finally, the nurse did not identify the prescribing provider, nor the date and time of the prescription. The charge nurse should review the prescription with the new nurse and the preceptor to immediately identify the errors, review previous prescriptions taken, and collaborate with the nurse educator to provide additional learning activities in this area. The charge nurse and nurse educator should collaborate to ensure that new nurses and new nurse employees are provided an orientation and learning module that covers acceptable abbreviations, taking verbal and telephone orders/prescriptions, and other safeguards to prevent medication errors. In addition, a refresher discussion with preceptors should be given to ensure they are current with the most recent recommendation on medication administration and preventing medical errors.

Socratic Reasoning The charge nurse notes the following provider prescription taken by a new nurse who has been orienting with a preceptor for 2 months: Administer MSO4 2.0 mg q2-3hrs prn pain. VO-Jo King, RN •What should be the charge nurse's initial response? •What is the basis of the response? •Identify long-term preventive strategies to correct this situation.

SOAP Charting

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. 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. Intervention: 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.

SOAP/SOAPIE/SOAPIER

Subjective, Objective, Assessment, Planning Subjective, Objective, Assessment, Planning, Implementation, Evaluation Subjective, Objective, Assessment, Planning, Implementation, Evaluation, Revision/Re-Assessing

The correct answer is B. A = Charting by exception. B = Focused charting identifies the client problem as a "focus" and presents it using the DAR format. The D presents the objective and subjective data to support the problem or diagnosis. The A is the action or interventions performed based on the data (D), and R is the client's response to the actions/interventions. Providers and team members can readily identify the problem and the current status. C = The Problem-Intervention-Evaluation (PIE) is a documentation format that organizes information according the client's problems. It has a nursing focus and is built on keeping daily assessment records and progress notes. D = Narrative charting. The narrative chart entry has the benefit of providing a chronological record of the client's progress. However, it does not clearly identify problems and may require providers to go through numerous records to find information on a particular problem.

The documentation task force recommended Focused charting with flowsheets for the electronic documentation system for a high acuity postoperative surgical unit. The goal is to have a system that promotes interprofessional collaboration. What is the primary reason to accept this recommendation? A. Only abnormal findings will be documented for ease of use and review. B. Client problems are readily identified and use the DAR format. C. Client problems are numbered, easily followed, and use a PIE format. D. A narrative chronological accounting of the client's experiences are recorded to identify progress toward goals.

Legal record

The health record will be scrutinized by legal experts if a dispute about a client's care arises. Expert reviewers look at the health record as a _____ ______ for documentation of the client's baseline status, changes in status, interpretation of the changes, interventions implemented, and the client's responses to those interventions.

The correct option is 4. Progress notes and MAR. Rationale: The nurse would document the administration of the medication itself on the MAR. Additional information includes the intervention and the client's response to the intervention in the progress notes.

The nurse has just medicated a client for pain. Documentation of this intervention would be found on the: A. Kardex and graphic sheet B. IPOC and discharge summary C. Flow sheet and assessment checklist D. Progress notes and MAR

The correct option is B. R Rationale: In Focus charting, the acronym used is DAR: data, action, response. This statement describes how the client responded to the nursing intervention of teaching, so it is "R" for "Response."

The nurse documents the following: "Client able to administer own insulin per subcutaneous injection using correct technique." In Focus charting, this statement would be followed by which letter? A. D B. R C. P D. E

Education and research

The record provides a snapshot of what is going on with the client so you are able to do _________ ___ ________ unfamiliar diagnoses, prescriptions, and treatments before direct care begins. The health record is also used to gather data for clinical research.

Discharge Summary

Time of departure and method of transportation Name and relationship of person(s) accompanying client at discharge Condition of client at discharge Teaching conducted and handouts/informational matter provided to client Discharge instructions (including medications, treatments, or activity) Follow-up appointments or referrals given •A general principle in nursing is that discharge planning begins on admission. Therefore, discharge needs should be evaluated when the patient first enters a healthcare facility, especially in acute care facilities. •A summary is completed when the client is transferred within the same organization, transferred to another facility, or discharged to home. •The _________ _______ may be a multidisciplinary document or each discipline may write a separate summary. •The forms are different in each organization, but they contain similar data.

Drug allergies

always noted on the MAR, whether paper or electronic. This makes them easily visible for caregivers who are prescribing and administering medication.

Organization of Documentation Systems: Electronic health record (EHR) systems

consists of records that are entered via computer. typically combine source-oriented and problem-oriented record styles, although the source-oriented system is most common. •Advantages Enhanced communication and collaboration, Improved access to information, Time savings, Improved quality of care, Information that is private and safe. •Disadvantages Expense: Electronic documentation systems are expensive. Downtime: Downtime processes must be in place for times when parts 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. It is not easy to capture narrative nursing content from paper documentation into an electronic format. Some 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 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).

CUBAN

•Confidential •Uninterrupted •Brief •Accurate •Named nurse

Creating a record of client assessments and care: A client's health record permanently documents

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

Source-oriented system

• Disciplines document in separate sections of the chart • Contains a variety of sections (e.g. admission, H&P, diagnostic, graphic, nurses' notes, progress notes, lab, rehab, DC plan, etc.) • Data scattered; may lead to fragmentation Advantage: You can easily find the care provided by each discipline. Disadvantage: Data may be fragmented and scattered throughout the client's record. You need to review all sections of the chart to fully understand the client's condition and care. • It is especially difficult to track the treatments and client outcomes associated with a particular problem.

Charting by exception

• Only significant findings are documented • Uses preprinted flow sheets • Reduces the amount of time spent on documentation • Can lead to omission of information and errors in care Assumes that all standards have been met and the client has responded normally, unless a separate entry is made. 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 (Duffy, 2015). Disadvantages: The main problem is omissions of pertinent information. Omissions may result from disagreement over what constitutes a significant variation.

Problem-oriented system

• Organized around client problems • Four components: database, problem list, plan of care, and progress notes • Promotes greater collaboration Advantages: a common problem list that includes input from all disciplines, easy to monitor the client's progress because each problem is readily identified in the notes, & each discipline has ready access to the findings of the other members of the health team. Requires a cooperative spirit among health providers as well as diligence in maintaining a current database and problem list.

Integrated Plans of Care

•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 administrators predict length of stay, monitor costs of care, and can assist with staffing. •Other advantages: They eliminate duplicate charting, increase team effort, and enhance the nurse's teaching about what the client can expect during the hospital stay.

Long-Term Care: Weekly Summary

•A summary of the client's condition •An evaluation of the client's ability to perform ADLs •The client's level of orientation and mood •Hydration and nutrition status •Response to medications •Any treatments provided •Safety measures used (e.g., bed rails)

Guidelines for Electronic Health Records

•Be able to use computer equipment. •Frequently save entered information. •Follow organization procedures if the computer is "down." •Maintain confidentiality. •Ensure the data is secure.

Documenting Client Care

•Be familiar with facility forms. •Chart in the required format. •Include all aspects of care. •Be accurate, complete, and consistent. •Document immediately: Document as soon as possible after making an observation or providing care. The longer you wait, the less you will recall. •Chart chronologically to communicate the changing status of the client: If you forget to make an important entry while charting, you will need to add to or modify your documentation. Record the time and date you are charting, but clearly designate this is a late entry. •Date and time all your documentation.

Narrative Charting

•Can use with source- or problem-oriented system •"Story" of care in chronological format •Tracks the client's changing status •Can be lengthy and disorganized Disadvantages: • Requires a great deal of time for writing all the details of the client's care. • Requires you to read the entire note or multiple notes to find client responses and outcomes to interventions. • Promotes disorganized, repetitive documentation, resulting in a lengthy record with important facts randomly buried in the text. • Is inconsistent among healthcare providers. (Some believe "if it's not charted, then it's not done." Others document only abnormalities that are relevant to the client's care or change in health status.) • Makes it difficult to track problems from day to day and identify trends.

Medication Administration Records (MAR)

•Comprehensive list of all prescribed medications •Provides information on client's medication allergies •Documents scheduled/routine, prn, STAT, or omitted doses •Additional explanation may be required for nonroutine or omitted medications.

Kardex or Client Care Summary

•Demographic data •Medical diagnoses •Allergies •Diet/activity prescriptions •Safety precautions •IV therapy prescriptions •Prescribed treatments (wound care, physical therapy), surgery, laboratory, and tests •A summary of medications prescribed •Special instructions, such as preferred intensity of care or isolation prescriptions Paper ________ are usually kept together in a portable file in a central location in the nurses' station to allow all team members access to clients' summary information. Each client has a separate electronic summary screen. All authorized members of the care team can access the electronic ____ _______ at the same time, whether they are away from the client or even outside the organization in a remote location, depending on the institution's permission for access. The paper ______ and the electronic ____ _______ are not a permanent part of the client's health record.

FACT Documentation

•Flow sheets individualize specific services •Assessment with baseline data •Concise progress notes •Timely entries includes only exceptions to the norm or significant information about the client. It eliminates the need to chart normal findings.

Occurrence Reports

•Formal record of unusual occurrence or accident •Not a part of client's health record •Quality improvement or incident report, an organizational report and is not part of the client's health record. •You should report all errors, even if there was no adverse impact on the client. This is important from a safety standpoint and for improving your institution's quality of care. When completing an __________ form, be sure to clearly identify the client, date, time, and location. Briefly describe the incident in objective terms. Quote the client or persons involved if possible. Avoid drawing conclusions or placing blame. Identify any witnesses to the event and any equipment involved.

Focus Charting

•Highlights the client's concerns, problems, or strengths in three columns •Column 1: Time and date •Column 2: Focus or problem being addressed •Column 3: Charting in a DAR format: Data, action, response •_____ ________ is attractive because it addresses the client's concerns holistically. Critics claim, however, that lack of a common problem list leads to inconsistency in labeling the focus of notes and may cause difficulty in tracking client progress.

Home Healthcare Documentation

•Homebound status •Assessment highlighting changes in the client's condition •Interventions performed (wound care, teaching, etc.) •Client's response to interventions •Any interaction or teaching that you conducted with caregivers •Any interaction with the client's provider

Guidelines for Paper Health Records

•Maintain confidentiality. •Use the correct form. •Ensure forms are marked with the client's name and ID number. •Write legibly, neatly, and in an organized manner. •Use use black ink for handwritten notes. •Do not leave leave blank lines in the narrative notes. •Draw a line through the incorrect documentation and initial it. •Use •Never use a correction fluid, "ink over," or cover up written notes. •Sign all paper charting entries with first name, last name, and professional credentials. •Use approved abbreviations.

Reporting

•Method to inform other caregivers about the client condition •Nurse to nurse; nurse to provider •Communication of vital information related to the client's status/plan of care a communication pathway from one nurse to the next or from a nurse to provider. allows nurses to prioritize the client's vital information.

Common Formats for Nurses' Notes

•Narrative •PIE •SOAP/SOAPIE/SOAPIER •Focus •FACT system •Electronic entry

PIE Charting

•Problem •Interventions •Evaluation •Used only in problem-oriented charting •Establishes an ongoing plan of care The primary disadvantage of ___ charting is that it does not document the planning portion of the nursing process. There is no seamless flow of client data, nursing diagnosis, and interventions such as can be seen in a nursing care plan.

Telephone orders (T.O.)

•Received by phone and transcribed onto the provider order sheet •Have an increased risk for errors •may be acceptable when there has been a sudden change for the worse in your client's condition and the client's primary care provider is not in the hospital, or the provider does not have access to placing prescriptions electronically outside the hospital. •Write the prescription only if you heard it yourself. •Make sure the verbal prescriptions make sense with the client's status. •Repeat the prescription to confirm accuracy. •Spell unfamiliar names; pronounce digits of numbers separately. •Directly transcribe the prescription on the chart. •Date/time •Text •To be followed by provider's name •Your signature •Providers must countersign within 24 hr. Verbal and _________ prescriptions are also acceptable in a life-threatening emergency, but you must apply the "read-back" safeguard. Faxes and e-mail have reduced the need for telephone prescriptions; however, the need for them may never disappear entirely.

Flow Sheets and Graphic Records

•Record routine aspects of care (hygiene, turning). •Document assessments, usually organized according to body systems. •Track client response to care (wound care, pain, IV fluids). •Use _______ _______ to record vital signs. •Record intake and output. •____ ______ ___ _______ _______ allow you to see patterns of change in client status. •Other types of information recorded on ____ ______ include intake and output (I&O), weight, hygiene measures, ADLs, and medications administered.

Verbal orders (V.O.)

•Spoken to you; often during a client emergency •Should be made for critical change in client condition Always Verify and Repeat When recording, include the date, time, and the written text of the prescription or the electronic entry of the prescription. If you are writing the prescription on an order sheet, an indicator "V.O." designating ______ ______ is then followed by the provider's name and your name. • If you are entering the prescription electronically, then the prescription will be designated as a ______ _____ and be routed to the selected provider for co-signature.

Electronic Entry

•Streamlines processes •Moves documentation to the bedside •Decision-making processes are immediate

Questioning an Order/Prescription

•Written illegibly- Contact the provider •Uncomfortable following a prescription- Follow the chain of command