Documentation and Communication in the Healthcare Team
What essential information should be charted?
-Assessments -Nursing interventions -Medications given -Physician's orders carried out -Physician notification of change in patient's status -Patient teaching -Patient responses -Any change in the plan of care
What are high risk errors in documentation?
-Falsifying patient records -Failure to record changes in patient's condition -Failure to document the physician was notified when patient's condition changed -Inadequate admission assessment -Failure to document completely -Failure to follow agency's standards or policies on documentation -Charting in advance
What are the advantages of CBE?
-It requires less nursing time -Guidelines about expected outcomes and normal assessment parameters are clear -Changes in patient status can readily be detected
What is included in the discharge summary?
-Medications -Diet -Activity -Follow-up care -Special instructions
What is commonly found on either the patient care summary or kardex?
-Pertinent demographic information such as name, medical record number, emergency contacts, physician, admission date, allergies, diagnosis, surgery, or diagnostic procedures -Code status -Safety precautions for infection, falls, or skin breakdown -Basic care needs such as activity status, diet, hygiene -Treatments and procedures (vital signs, dressings, catheters, respiratory therapy) -IV therapy and blood transfusions -Diagnostic and laboratory tests
What items are included in OASIS?
-Sociodemographic data -Environmental information -Support systems -Health status -Functional status of all adult home care patients
Why are nurses entries on the patient record important?
-They show medical and nursing orders carried out -Independent assessments and interventions performed -The exact dates and times of care delivered -Evaluation of care provided
No leading zero before decimal dose (e.g. .5mg)
0.5mg
Trailing zero after decimal point (e.g., 1.0 mg)*
1 mg
Audits of patient records serve a dual purpose. What are they?
1. Quality assurance 2. Reimbursement
TIW or tiw
3 times a week
The patient record serves as what?
A legal document of the patient's health status and care received
What charting is done for the ambulatory setting?
A single form of one or two pages that encompasses technical, educational, and psychosocial dimensions of care.
What APIE?
A-Abnormal assessments P- Problem I- Intervention E- Evaluation
What is computerized physician (provider) order entry (CPOE)?
Allows authorized providers to enter all orders directly into the computer, electronically communicating orders to the laboratory, pharmacy, and nursing personnel.
What is the vocera system?
Allows the nurse to verbally respond to call lights or answer a team member request without breaking sterile technique or interrupting direct patient care.
Nursing progress notes
Are recorded for all patients but vary in format depending on the agency and setting. They reflect a specific problem being addressed or the care provided over a specific period. Is an evaluating statement summarizing significant problems or improvements.
What are flow sheets?
Are tables that have vertical and horizontal columns that allow nurses to document routine assessments and procedures.
When is a nursing discharge plan started?
At the initiation of care, indicating potential discharge needs and patient teaching that will take place.
BT
Bedtime
Team leadership
Brief: Brief sessions prior to start to discuss expectations and expected outcomes Huddle: Ad hoc planning to reinforce plan in place and assess the need to readjust Debrief: Review and informal information exchange designed to improve team performance and effectivness
Per os
By mouth orally
Communication
Clearly documented information on the patient's record communicates the plan of care and the patient's progress to all members of the healthcare team. Helps ensure continuity of care and provides essential data for revision or continuation of care.
What is FOCUS?
D- data A- action R- response Advantage: Broad view permitting charting on any significant area not just problems, concise, flexible works well in longer term or ambulatory care Disadvantage: Not multidisciplinary, difficult to identify chronologic order, progress notes may not relate to the care plan
q1d
Daily
What is point of care documentation (POC)?
Documentation that takes place as care occurs. Is another strategy used to maximize accuracy and timeliness of entries.
Organized
Each entry must clearly show a logical and systematic grouping of important information by problem or occurrence. Computerized charting provides templates that organize data entry and required fields to ensure that important information is not omitted. There must be a chronologic flow of information about patient care according to time and procedures completed, with the patient's reaction documented. Recording as the events of the day unfold can prevent out of sequence or fragmented entries that may cause confusion.
What is a never event and give examples?
Events that should never occur Ex. Foreign objects left in the body after surgery, air emboli, infusion of incompatible blood, falls resulting in trauma, catheter-associated urinary tract infection, certain infusion-associated infections, and pressure ulcers.
q.d or QD
Every day
q6pm, etc.
Every evening at 6 PM
q.o.d or QOD*
Every other day
Care planning
Formulation of a plan of care flows from assessment data in the patient record. The nurse considers all data on the patient record when developing problems, goals, outcome criteria, interventions, and evaluation criteria for and with patients. An individualized plan of care is essential for each patient and becomes part of the permanent patient record.
Concise
Good charting is concise and brief. In narratives, use partial sentences and phrases drop the patient's name and terms referring to the patient. Use abbreviations but only those that are commonly accepted and approved by your facility.
HS
Half-strength
What are clinical pathways? (Sometimes referred to as collaborative pathways or care maps).
Helps guide the care of patients who have specific and generally predictable conditions. Ensure quality of care. The pathway may be for patients who require complex care (after organ transplantation) or for frequently encountered situations (home care visits for patients who have undergone hip replacement surgery)
Complete
Information about the nursing process must be complete. Note all relevant data to support and assessment and plan.
What are narrative notes?
Information provided in written sentences or phrases; usually time sequenced. Advantage: Easy to learn, easy to adjust length as needed, can explain in detail Disadvantage: Time-consuming difficult to retrieve information, irrelevant information often included, possibly unfocused and disorganized
IJ
Injection
What is the electronic medication administration record (eMAR)?
Interfaces medication orders with pharmacy dispensing and allows direct computer charting of medication administration.
IU
International unit
IN
Intranasal
What is the patient care summary or patient profile?
Is a document that provides current patient information.
What is the SOAP notes?
Is a progress note that relates to only one health problem. The patient's progress on that particular problem can be assessed without sorting through the whole chart. The team members need only read down the left-handed column of the interdisciplinary progress notes and read the notes of all disciplines that relate to that numbered problem.
What is an audit?
Is a review of records.
What is an incident?
Is any unusual happening, such as a fall, medication error, malfunction in equipment, or injury to a patient, visitor, or employee, that occurs during the performance of healthcare activities.
What is the most significant disadvantage of CBE?
Is the time it takes for each agency to develop and maintain standards and flow sheets; also, some agencies worry about legal challenges.
What is the goal of RAI?
Is to coordinate the efforts of all team members of the healthcare team to optimize the resident's quality of care and quality of life.
What is a computer-based personal record (CPR)?
It is a single record for each citizen
What charting is done in the in-home care setting?
It is done immediately after the visit or during. It includes the reason for the visit, the patient's health status, nursing interventions performed, and evaluations of interventions or outcomes. Plans and recommendations for future visits are also included.
What is documentation?
It is either written or typed, serves as a permanent record of patient information and care.
What is HIPPA?
It regulates all areas of information management, including reimbursement, coding, and security of records.
What is a clinical surveillance tool?
It scans in real time the medical record of all patients to detect assessment data indicating problems.
What is confidentiality?
Means keeping information private.
What are some identifiable information?
Medical record number, name, birthday, agency name
What does MAR stand for and what does it do?
Medication administration record. Documents medication administration.
Education
Members of the healthcare team, including students of nursing, medicine, and other disciplines, use the patient record as an educational tool. It contains valuable information about signs and symptoms of disease, diagnostic tests, treatment modalities, and patient responses to the disease and to treatment.
qhs
Nightly at bedtime
qn
Nightly or at bedtime
What do you do if a patient refuses a medication?
Note the reason the patient did not receive the drug
Accurate
Nurse must only chart observations that they have seen, heard, smelled, or felt. An observation made by another healthcare professional must be identified as such. Photographs can be used for documentation.
Assessment
Nurses and other team members gather assessment data fro the patient record. By reading about the patient's history and initial assessment and comparing these data with additional subjective and objective information that has been obtained, current health status and progress toward goals can be determined.
Research
Nursing and healthcare research is often carried out by studying patient records. Data may be gathered from groups of records to determine significant similarities in disease presentation, to identify contributing factors, or to determine the effectiveness of therapies.
What is a variance?
Occurs when the patient does not proceed along the pathway as planned. K
1/D
Once daily
o.d or OD
Once daily
What is a handoff?
Or transfer of care for a patient from one health provider to another, significantly increases the risk of errors.
What does OASIS mean?
Outcome and Assessment Information. The OASIS tool accurately measures the patient's status at various specific points during an episode of care, thus providing the basis for measuring patient outcomes.
What is PIE?
P- Problem I- Intervention E- Evaluation Advantage: Plan of care incorporated into progress notes; outcomes included, which increase quality assurance, daily review to determine progress, less redundancy, easily adapted to automated charting Disadvantage: Must read progress notes to determine plan pf care, if problem has not been identified, difficult to chart, not multidisciplinary
What is charting by exception (CBE)?
Permits the nurse to document only those findings that fall outside the standard of care and norms that have been developed by the institution. Is a shift away from the concept previously held that "if it hasn't been documented, it hasn't been done."
What is the risk assessment report?
Provides risk scores on sepsis, pressure ulcers, falls, abnormal laboratory reports, and other criteria of interest.
What must be recorded when given a PRN note?
Record the time at which it is given as well as the drugs indication and effectiveness.
What does RAI mean?
Resident Assessment Instrument. Governs documentation in long-term care settings. Tracks goal achievement among long-term residents and includes (A) minimum data set (B) triggers (C) resident assessment protocols and (D) utilization guidelines.
AD, AS, AU
Right ear Left ear each ear
OD, OS, OU
Right eye Left eye each eye
What are SOAP notes?
S- subjective data O- Objective data A- Assessment P- Plan Advantage: All charting focuses on identified patient problems, interdisciplinary - all team members chart on the same progress notes, easy to track progress for identified problem, steps in the nursing process are mirrored. Disadvantage: Difficult to master, specific focus makes it difficult to chart general information without identifying a problem, lengthy and time-consuming; assessment identification difficult for nurses and confusing, because assessment data are provided in S and O
What is SOAPIER?
S-subjective O- Objective A- Assessment P- PLAN I- Intervention E- Evaluation R- Revision
Communication
SBAR: Situation Background Assessment Recommendations Call-out Check-back Handoff
What is a plan of care?
Should be generated at admission and revised to reflect changes in the patient's condition. The trend is to involve the patient and all team members in the development and revision of the plan of care, however the nurse often is the point person to promote good communication among all team members. It contains nursing diagnoses or problems, goals, outcome criteria, interventions, and evaluation.
What is SBAR?
Situation: What is happening at the present time? Background: What are the circumstances leading up to this situation? Assessment: What do I think the problem is? Recommendations: What should we do to correct the problem? It is a shared mental model for improving communication between and among clinicians.
Situational monitoring:
Situational awareness: Knowing what is going on around you Cross monitoring: Monitoring the action of all team members, providing a safety net, catching mistakes early Steps: 1. Assess status of the patient (patient history vital signs medications, POC, physical exam, psychosocial status 2. Assess team members (fatigue, workload, skill, stress, task performance 3. Assess environment (equipment, triage acuity, human resources, information) 4. Assess progress toward goal (established goals of team status of patients, actions of team, plan still appropriate)
SSI
Sliding scale insuin
SSRI
Sliding scale regular insulin
What are quality assurance memos?
Some facilities use incident reports related to nursing procedures as a way to evaluate the quality of care. These reports are used to assess patterns of errors and the need to change the procedures involved.
What is PIE notes?
System simplifies documentation by incorporating the plan of care into the progress notes. Patient assessments are note part of the PIE, because they are reported on the flow sheets.
What is reporting?
Takes place when two or more people share information about patient care, either face-to-face (as in team meeting or handoff) by audiotape or voice mail, or by telephone (as in reports to a case manager or physician from a nurse making home visits)
Mutual support
Task assistance: Actively seek and offer assistance to team members to ensure patient safety; protect team members form work overload Feedback: Information provided to improve team performance (timely, respectful, specific, considerate, and directed toward improvement) Advocacy and assertion Two challenge rule CUS: I am concerned I am uncomfortable This is a safety issue Collaboration
What is TeamSTEPPS?
Team strategies and tools to enhance performance and patient safety- is a safety curriculum designed to improve patient outcomes by cultivating teamwork among healthcare providers.
What is standardizes vocabulary?
The advent of electronic documentation has given impetus to the use of standardized medical and nursing vocabularies in the patient record. The ANA endorse the development of nursing databases to support clinical practice. These databases using standardized vocabularies, can assist in describing the practice of nursing, supporting research, and identifying the cost and effectiveness of nursing interventions.
What is the kardex?
The information was entered and updated by a unit secretary onto a card kept in a portable file. It is not part of the patient's record. Entries are made in pencil so that they can be erased when updating is needed.
What are handheld devices and their importance?
The personal digital assistant (PDA), sometimes referred to as a palm pilot, is a compact, handheld computerized unit capable of providing the nurse with a wealth of information at the point of care in the hospital, clinic, or home setting. They can provided up-to-date information to teams on infection control or IV therapy, to enhance evidence-based clinical decisions.
What are FOCUS system notes?
This system is broader in its view because a focus can be a problem area (nursing diagnosis) but does not need to be. An entry can be made on a significant event, positive growth, or learning that occurs during a teaching session. In this way, patient documentation can focus on the patient's strengths as well as problem areas. The data section describes subjective and objective information that support the focus of the note.
U or u
Unit
What is batch charting?
Waiting until the end of your shift to document on several patients. This may cause a nurse to omit important information data or enter inaccurate information.
Admission entries
When a patient enters the healthcare system, a nursing history is competed. Nutrition, activity, sleep, and coping patterns are assessed and documented, as they are pertinent medical history and the history relating to the reason for current care. A complete physical assessment is performed and documented, usually within 24 hours. This information may be entered on the nursing admission history and physical assessment sheet, on another standardized form, or in nursing progress notes.
Objective
When documenting observation of patient behavior, the nurse must main observations of patient behavior, the nurse must maintain objectivity by describing the actual behaviors rather than attempting to interpret the behaviors. Ex. The nurse should chart that a patient is withdrawn and answers questions with one- or two worded answers. The nurse should not describe the patient as depressed or angry.
hs
at bedtime, hours of sleep
ss
sliding scale
SC, SQ and q
subcutaneous
