Professional Documents
Culture Documents
AND REPORTING
NUR 152-Nursing
Theory & Science I
Fall 2016
REASONS FOR
DOCUMENTATION AND
Facilitate communication
REPORTING
Promote good nursing care and continuity of care
Meet professional and legal standards (Quality of Care)
Planning/Evaluation of Outcomes
Education and Research
Reimbursement and Utilization Review/Accrediting Agencies
2
DOCUMENTATION
The act of recording patient status and care in written
or electronic form
Creating a record of assessments and care
Oral communication is reporting
Care is provided in chronological order
PATIENT RECORD
Legal documentation of patients healthcare
experience
Confidential & permanent
Available to all members of healthcare team
DOCUMENTATION
SYSTEMS
5
MAIN DOCUMENTATION
SYSTEMS
Source-oriented- Each discipline
records findings separately
Problem-oriented- Organized
around patient problems
Charting by Exception- Only
significant findings or exceptions
charted
SOURCE-ORIENTED
DOCUMENTATION
Each discipline charts separately
Variety of sections
Advantage:
COMPONENTS OF
SOURCE ORIENTED
RECORD
Admission data
Laboratory data
Advance directives
Nurses notes
H&P
Graphic data
Physicians orders
Progress notes
Diagnostic studies
Discharge planning
PROBLEM-ORIENTED
DOCUMENTATION
Organized around patient problems
No separate sections for disciplines
Advantage:
COMPONENTS OF
PROBLEM ORIENTED
RECORD
Database
Problem list
Plan of care
Progress notes
10
CHARTING BY EXCEPTION
Chart only significant findings or exceptions to norms
Streamlines charting and saves time
Uses preprinted forms and checklists
Abnormals documented in narrative note
11
CBE
Advantages:
Reduces charting time and repetitive
charting
Easier to read & understand
Highlights variations from expected POC
Disadvantages:
Inadvertent omissions
Assumes care has been done
Fragments care into tasks
12
NURSES NOTES
13
COMMON TYPES OF
NURSES NOTES
Narrative
PIE
SOAP
Focus
FACT
14
NARRATIVE CHARTING
Used with both source & problem-oriented documentation
Story of care in chronological format
Tracks patients changing status & progress towards goals
Can be lengthy and disorganized
Clear, concise and accurate
Begin with Report received
15
NARRATIVE CHARTING
EXAMPLE
8/30/14 1100-Pt arrived to floor from PACU
in bed. VSS-refer to flow sheet. Drowsy,
but easily arouses to verbal stimuli.
Oriented x3. PERRLA. O2 at 2L via NC. Sat
98%. Abd dsg CDI. No BS noted. Denies
N/V. Foley intact and draining clear yellow
urine. Reports pain 2/10 to abd/incision.
Denies need for pain meds at present.
---------------------------------------George White,
RN---------------16
FOCUS CHARTING
Highlights the patients concerns, problems, or
strengths in 3 columns:
17
FOCUS CHARTING
Advantages
Holistic
Disadvantages
18
FOCUS CHARTING
EXAMPLE
8/30/15
1100
8/30/15
1130
Focus:
Post-op
Pain
19
PIE CHARTING
Problemobtained from admission data
Interventionincludes assessment
Evaluationclient response
20
FORMS FOR
DOCUMENTATION
21
DOCUMENTATION FORMS
Admission database
Flowsheets
Graphic records
Medication records (MAR)
Progress notes
Kardex or Pt care
summary
Care plans
D/C summary
Incident reports
22
ADMISSION DATABASE
Record of baseline data:
Chief complaint or reason for admission
Physical assessment data
Vital signs
Allergy information
Current meds
ADL status & D/C planning info/ needs
Data about support system & contact
info
23
24
25
MEDICATION
ADMINISTRATION
RECORD (MAR)
26
27
PROGRESS NOTES
Used to communicate nursing assessments,
interventions carried out, and the impact of these
interventions on outcomes
Separate from physicians progress notes
28
29
PROGRESS NOTES
INCLUDE:
Assessments before & after administration of PRN
medications
Information reported to HCP & providers response
Patient teaching & D/C planning
Pertinent data collected while providing care
30
CARE PLANS
Documents specifying nursing actions
necessary for the care of a specific
patient
Map out:
Problems
Outcomes
Interventions
Treatments
Evaluations
31
D/C SUMMARY
Last entry in paper chart; started at any point during
the patients stay and revised throughout their
hospitalization
Completed when
32
DISCHARGE SUMMARY
INCLUDES:
Time of departure and method of
transportation
Individual(s) accompanying patient at
discharge
Patient condition at discharge
Teaching conducted and
handouts/informational matter provided
Discharge instructions
Follow-up appointments or referrals given
33
34
COMPLETING AN
INCIDENT REPORT
Include:
COMPLETING AN
INCIDENT REPORT
Avoid
Heresay
Your opinion or who is at fault
Assumptions about what caused the
incident or any circumstances you did not
observe
Suggestions as to how this could have
been prevented
Filing the report in the medical record
Documenting in the Medical Record that
an incident report was completed
36
ELECTRONIC
MEDICAL RECORDS
37
ELECTRONIC HEALTH
RECORD/ELECTRONIC
MEDICAL RECORD
Records recorded via computer
Typically combine source-oriented & problem-oriented
styles
38
ADVANTAGES OF
EHR/EMR
Enhanced communication & collaboration
Improved access to information
Saves time
Embedded protocols
Improved quality of care
Privacy and security
39
DISADVANTAGES OF
EHR/EMR
Expensive
Downtime
Difficulties associated with change
Lack of integration between departments
40
COMPUTERIZED
CHARTING REMINDERS
Dont leave data displayed on a screen where others
can see it
Follow protocol for correcting mistaken entries
Allows log out when leaving computer
Never share your password with anyone
41
DOCUMENTATION
GUIDELINES
42
GUIDELINES FOR
DOCUMENTATION
Factual
Objective vs Subjective terms
No vague terms
Accurate
Exact measurements
Abbreviations
Spelling
Date, time, signature
Full Name, SN, SCC
43
MILITARY TIME
44
GUIDELINES FOR
DOCUMENTATION
(CONT.)
Complete
Current
Timely entries are essential
Increases accuracy and decreases
unnecessary duplication
Organized
Communicates information in a logical order
45
COMMON CHARTING
ERRORS
Failing to record meds given
Failing to record nursing actions
Failing to record changes in patient condition
Transcribing orders incorrectly
Illegible/Incomplete documentation
Wrong medical record used
Failing to document a response to an intervention
46
47
48
EXAMPLES OF ITEMS TO
INCLUDE IN CHARTING
Head-to-toe assessment
Response to
interventions
Pain evaluation
Bleeding/unusual
discharge
Sleep, hygiene, and
ADLs
Safety measures
Teaching
needs/teaching
done
Psychosocial and
spiritual needs
Discharge planning
needs
49
DOCUMENTATION DOS
Make sure you have the
correct chart before
beginning
documentation
Be accurate, objective,
and nonjudgmental
Write legibly
Provide details
50
DOCUMENTATION
SHOULD BE:
F: Factual
A: Accurate
C: Complete
T: Timely
51
FACTUAL
Only info you see, hear, collect through your senses
Describe behavior, do not label
52
ACCURATE
Quantify when possible
Identify who gave care
Accurately double check math calcs
Not Documented = Not Done!
53
COMPLETE
Include any condition change, patient response
Chain of command
Communication with patient/family
Do not leave blanks
54
TIMELY
Date/Time are CRITICAL when determining a timely
response to a patients needs
Try not to leave documentation until the end of the
shift
Do not document in advance = falsifying
55
DOCUMENTATION
DONTS
Use subjective terms
Chart about a s/s
without charting what
you did about it
Alter a patients
record-THIS IS A
CRIMINAL OFFENSE
Use abbreviations
that arent widely
accepted
Chart ahead of the
current time
Chart that you have
filled out an incident
report
Leave blank lines
56
57
COMMUNICATING WITH
SBAR
Situation
What is happening at the present time?
Background
What are the circumstances leading up to the
situation?
Assessment
What do I think the problem is?
Recommendation
What should we do to correct the problem?
58
HANDOFF REPORT/ORAL
REPORT
Name, age, room #
Diagnosis
Relevant past medical hx (PMH)
Treatments received
Upcoming tests, surgeries, or treatments
Restrictions
Plan of Care
Significant assessment findings
59
SOME QUESTIONS
Which of the following findings would the nurse note
when assessing a client with a stage 1 pressure ulcer?
1. Redness noted (measurements included)
2. Deep pink, red, or mottled skin noted
(measurements of area included)
3. Subcutaneous damage noted
4. Damage to the muscle or possible bone involvement
noted
60
61
62