Professional Documents
Culture Documents
What is Documentation
Anything written or printed Relied on as a record of proof for authorized persons Vital part of professional practice
What is Documentation
Nightingale described the need for nurses to record "the proper use of fresh air, light, warmth, cleanliness, & the proper selection & administration of diet".
What is Documentation
In Nightingale's time, documentation was a way to communicate implementation of MD orders & not a means to observe or assess the patient's status, as it is today
Purposes of Documentation
Quality of care
provides evidence that care was necessary describes responses to care describes any changes made in plan of care plan interventions decision making about ongoing interventions evaluation of patient's progress used by all team members
Coordination of care
Purposes of Documentation
JCAHO provides eligibility for government funding JCAHO accreditation demonstrates that facility provides quality care clinical records are reviewed to ensure the facility meets the required standards assessed for ongoing compliance
Purposes of Documentation
Purposes of Documentation
committees use established indicators to monitor & evaluate the contents of the clinical record when the care described in the clinical record doesn't meet an established indicator of care, the committee decides what action to take to correct the problem
Purposes of Documentation
Peer review Requirements for reimbursement Legal protection Research & continuing education
Purpose
Prevention of errors Consistent with standards Complete, Accurate, Relevant, Factual, Timely Orderly & Sequential Legally prudent Confidential
Guidelines
Communication Care Planning Quality Review Research Decision Analysis Education Legal Documentation Reimbursement Historical Documentation
Communication
Care Planning
Plan interventions Decision making about ongoing interventions Evaluation of patient's progress
Quality Review
Provides evidence that care was necessary Describes responses to care Describes any changes made in plan of care JCAHO provides eligibility for government funding JCAHO accreditation demonstrates that facility provides quality care Clinical records are reviewed to ensure the facility meets the required standards Assessed for ongoing compliance
Research
Can supply data for a study [to determine validity of nursing diagnoses] Research studies can then lead to improved documentation
Decision Analysis
Education
Clinical manifestations Effective treatment modalities Factors affecting patient goal achievement
Legal Documentation
To you, other caregivers, facility, & patient Admissible in court as a legal document & serve as evidence Proof of quality of care given What you document - or don't document can mean the difference between winning & losing court cases
Reimbursement
Determine amount of reimbursement Look for inconsistencies in documentation [discrepancy between treatment ordered & treatment provided]
Historical Documentation
Nursing Documentation
Diary or story format: oldest form of documentation oldschool method Paragraph describing patient's status, interventions & treatments, and patient's response to interventions Chronological Problem oriented medical record (POMR) documentation method
Nursing Documentation
PIE
Problem oriented medical record (POMR) Originated from nursing process Documents: problems, interventions, & evaluation of nursing care Incorporates plan of care into daily documentation
Nursing Documentation
PIE contd
Simplifies documentation process, unifies plan of care & progress notes, and provides concise record of nursing care planned & provided Patient care & assessment flow-sheet and progress notes (*) represents deviations from normal Document specific problems on progress notes Generate problem list
Nursing Documentation
Focus Charting
Organizes narrative documentation to include data, action, & response for each identified concern Focus is key word used to describe concerns & eliminates negative connotations of the word problem Focus may be nursing diagnoses or behavior/concern, signs & symptoms, acute change in status, significant patient care event
Nursing Documentation
DAR contd
Organized in columns Data: subjective or objective Action: nursing interventions Response: patient's response to interventions Tasks & assessments documented on flow sheets AIO=assessment; intervention; outcome used at Los Alamitos Hospital basically the same as DAR
Nursing Documentation
Flow sheets and / Place Check-marks if normal Documentation by reference to standards of practice Eliminates repetitive charting: Nursing data base Nursing diagnosis-based care plans Only significant findings or exceptions to norms are recorded =* describe abnormals in narrative style Fast-charting! Often documentation forms (graphs, checklists/flowsheets are at the bedside
Nursing Documentation
CBE contd
Use of specific abbreviations = assessment complete; WNL * = significant abnormal findings; note written p = status remains unchanged from previous asterisk
Nursing Documentation
Nursing Documentation
Computer-based Records
Initial Nursing Assessment Kardex and Patient Care Summary Plan of Nursing Care Critical/Collaborative Pathways Progress Notes Flow Sheets
Flow Sheets
Graphic record 24-hour fluid balance Medication record (MAR) 24-hour patient care records
Acuity charting forms Discharge/transfer summary Home healthcare documentation Long-term care documentation
Do not erase, use white-out, or scribble out errors Do not write retaliatory or critical comments; do not place blame Correct all errors promptly Spell correctly Record all facts in objective terms Document completely [in court - if it's not documented, it wasn't done]
Be accurate about time & chart as soon as possible after an event Document omissions (med not given or treatment not completed) & reason & actions taken Do not leave blank spaces Record legibly & in black ballpoint pen
Use only approved abbreviations Record clarification requests &/or corrections Chart only for yourself Avoid vague statement Begin with time and end with appropriate signature
Reporting
Change-of-shift report
Accurate information Factual information Organized What & how you say it can make a big difference in quality of care Avoid negativism & subjectivity Use written or printed guide to prompt thoroughness & organization
Reporting
Give background information first Be specific & avoid vague terms Describe presence of all invasive treatments Stress abnormal findings and variations from routine or the norm
Reporting
Telephone report
Nurse to MD Nurse to nurse Nurse to lab, dietary, etc Document time, persons involved, information given/received Be clear, accurate, & concise
Reporting
Transfer report
Unit to unit Acute care to LTC Summarize medical progress Background information Current status Current nursing diagnoses Critical assessments or interventions to be completed shortly after transfer Special considerations Need for special equipment
Reporting
Incident report
To document any occurrence not consistent with routine operation or care Used for quality improvement to document trends and areas needing changes Complete even if no injury occurs Routed to risk-management
Reporting
Be concise & accurate; report exactly what was observed & what action was taken Do not try to explain the cause or make excuses Do not place blame in the report Do not specify in the medical record that an incident report was prepared Do not make a photocopy of the report
Conferring
Summary
Documentation
Conferring
Reporting
QUESTIONS