Documentation

List the uses and basic purposes of documentation/patient written record, be able to give examples

(1) documented communication; like given the past vitial through the other shift (2) permanent record for accountability; pt information is there to be found when ever it is need so that way if something goes wrong you will be able to find info (3) legal record of care; (4) teaching; and (5) research and data collection.

Know the list of unapproved abbreviations according to TJC (JCAHO)

AD - right ear AS -left ear AU -each ear cc - ml DPT- DTaP IU- international units OD - right eye os -po OS- Left eye OU - each eye QD- daily QOD- every other day sc or sq - syb Q or subcytaneous u- units ug-mcg MS or MSo4 0 morphine or morphine sulfate MgSO4 -magnesium sulfate

Discuss problems of computer documentation, associated with electronic documentation.

Promblem are Confidentiality, access to information, and inappropriate alterations in patient records are areas of concern.

Who is responsible for the initial admission assessment,obtaining pt. history, and development of the patient care plan?

rn

Who owns the original health record?

the institution of the care

How would the nurse document what is said by the patient, but not witnessed by the nurse?

with "" and stating that the pt has said it was what happened

what is APIE

• A - assessment • P- problem, • I - intervention, • E - evaluation

Identify "jello" words, unclear, judgmental documentation

• Avoid using generalized, empty phrases, such as "status unchanged" or "had good day."

How does the nurse begin each entry?

• Begin each entry with time of entry,

How does the nurse document a late entry?

• Chart a late entry by stating Late Entry with the time your putting it in and then the time it happen

What is a critical pathway?

• Clinical (critical) pathways allow staff from all disciplines to develop standardized, integrated care plans for a projected length of stay for patients of a specific case type.

what is DARE

• D- data, subjective/objective info • A- action (planning and implementation) • R- response • E- education/patient teaching

Identify examples of "red flags" in documentation that may lead or support a malpractice claim.

• Don't chart excuses • Don't chart YOUR OPINION • Don't chart anything that suggests a negative attitude (stubborn, loony, weird) • Don't use vague terms (appears to be, apparently) • Don't chart ahead of time • Don't chart staffing problems/conflicts • Don't erase or use white out ( correct mistakes by drawing a single line through the entry and write mistaken entry) • Don't leave empty spaces or lines • Don't write in the margins • Don't mention incident reports in the chart • Don't use words like mistakenly, accidentally, unintentionally, etc. • Don't use empty "jello" words such as "had a good day", or "normal vital signs" • Don't chart for someone else

Medical records should provide information for all medical providers, to include

• Information about care given to the patient • Care planned for the patient • Patient's nursing problems • Patient's medical problems • Responses to treatments

what is Focus

• Initial assessment done at beginning of shift • Only additional treatments done or withheld charted • Changes is patient condition charted • New concerns are charted

What phase of the nursing process is documentation a part of? Diagnosis

• Nursing dx

What phase of the nursing process is documentation a part of? Assessment

• Patient and family interview History and physical examination Laboratory and radiology results Medication records Environment

What phase of the nursing process is documentation a part of? Evaluation

• Patient and family interview Physical assessment Staff reports Progress notes Diagnostic test results Flow sheets

What phase of the nursing process is documentation a part of?planning

• Patient care plan Critical pathways • Projected length of stay Standards of care Admission assessment data Staff reports

What phase of the nursing process is documentation a part of?Implementation

• Progress notes Patient rounds Direct patient care

what is SOAP (IER)

• S- subjective info • O- objective info • A- analysis/assessment • P- plan • I- implementation • E- evaluation • R- revisions (what needs to be updated or changed to improve care)

how does the nurse document exact patient statements?

• Use direct quotes. " "

When an entry does not fill the entire line, how does the nurse fill the unused space?

• With a line throw it and your name KVJ spn

What type of ink does the nurse use when documenting?

• black

How does documentation help with QA (quality assurance)?

• legible records are the only means institutions have to prove that they are providing care to meet patient needs and established standards.

HIPPA Rules

• may not read a record, or allow others to do so, without a clinical reason, and personnel must hold the information regarding the patient in confidence.

What is the LPN role in documentation?

• must ensure the information recorded in the chart is clear, concise, complete, and accurate.

What is the proper way to correct a charting error?

• put a line though the mistake and put your initials and CE

Discuss the rules related to "incident reports", when should an incident report be utilized?

• should give only objective, observed information. The nurse should not admit liability or give unnecessary details. Care given to the patient in response to the incident and the name of the health care provider notified • (form used to document any event not consistent with the routine operation of a health care unit or the routine care of a patient)

rules for documentation p1

•All documents should have the correct patient name, identification number, date of birth, date, and time if appropriate. •Use only approved abbreviations and medical terms. •Be timely, specific, accurate, and complete. •Write legibly (for written documentation). • Follow rules of grammar and punctuation. •Fill all spaces; leave no empty lines. •Chart consecutively. Go line by line. • Do not indent left margin. • Chart after care is provided, not before. •Chart as soon and as often as necessary. •Chart only your own care, observations, and teaching; never chart for anyone else. •Use direct quotes when appropriate.

rules for documentation p2

•Be objective in charting: only what you hear, see, feel, smell. •Describe each item as you see it: for example, "white metal ring with clear stone" (rather than "diamond ring"). Do not speculate, guess, or assume. • Chart facts; avoid judgmental terms and placing blame. •Document only what you observe, not opinions. Never use charting to accuse someone else. •Sign each block of charting or entry as directed by the agency policy. •When a patient leaves a unit (e.g., to go to x-ray, laboratory, or office), chart the time and the method of transportation on departure and return.

rules for documentation p3

•Chart all ordered care as given or explain the deviation (nothing by mouth [NPO] for laboratory, off unit, refused, etc). •Note patient response to treatments and response to analgesics or other special medications. •Use only hard-pointed, permanent black ink pens; no erasures or correcting fluids are allowed on charts for written patient records. •If a charting error is made, identify the error according to facility policy and make the correct entry. • When making a late entry, note it as a late entry and then proceed with your notation: for example, "Late entry _______________," or as dictated by the facility policy. •Follow each institution's policies and procedures for charting. • Avoid use of generalized empty phrases such as "status unchanged" or "had good day." •If you question an order, record that clarification was sought. For example, do not record "physician made error," but chart "Dr. Bradley was called to clarify order for __________."

Discuss rules of computer documentation associated with electronic documentation.

•Do not share with another caregiver the password that you use to enter and sign off computer files. •Follow the correct protocol for correcting errors. • Make sure that stored records have backup files, an important safety check. • •Do not leave information about a patient displayed on a monitor where others have the opportunity to see it • . • Follow the agency's confidentiality procedures for documentation. • Printouts of computerized records also have to be protected.

when is Military time is used

•at all times in hospital