9 documentatin & reporting nurses by m.fathoni 2013
TRANSCRIPT
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Documentation and Reporting
Ns. Mukhamad Fathoni, S.Kep., MNS
Jurusan Keperawatan, Fakultas
Kedokteran Universitas Brawijaya
Email : [email protected]
mailto:[email protected]:[email protected]:[email protected]:[email protected] -
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INTRODUCTION
A good nurse needs to have great reporting skills.
Since it takes time to develop great reportingskills, you should work on this area if you're
trying to land a job as a clinical nurse or
manager.
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Documentation as
Communication
Communication is a dynamic, continuous,and multidimensional process for sharinginformation.
Reporting and recording are the majorcommunication techniques used by healthcare providers.
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Documentation as
Communication The medical record serves as a legal
document for recording all client activitiesby health care practitioners.
Documentation is defined as writtenevidence of:
The interactions between and among healthprofessionals, clients, their families, and health
care organizationsThe administration of tests, procedures,
treatments, and client education
The results or clients response to these
diagnostic tests and interventions
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Documentation as
Communication Nurses rely on charting, records, and
systems that support the implementation of
the nursing process. Systematic documentation is critical to
presenting the care administered by nursesin a logical fashion.
Critical thinking skills, judgments, and
evaluation must be clearly communicated
through proper documentation
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Purposes of Health Care
Documentation
Professional Responsibility andAccountability
Communication
Education Research
Legal and Practice Standards
Recording provides written evidence ofwhat was done for the client, the clients
response, and any revisions made in the
care plan
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Purposes of Health Care
Documentation Recording documents compliance with
professional practice standards and
accreditation criteria.
Written records are a resource for review,
audit, reimbursement, and research.
Documentation provides a written legalrecord to protect the client, institution and
practitioner.
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Purposes of Health Care
Documentation Education
Health care students use the medical record as a
tool to learn about disease processes, diagnoses,complications, and interventions.
Clinical rounds and case conferences rely
heavily on information contained in the medical
record.
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Purposes of Health Care
Documentation Research
Researchers rely heavily on medical records as
a source of clinical data.
Documentation can validate the need for
research.
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Purposes of Health Care
Documentation Legal and Practice Standards
In 80% to 85% of malpractice lawsuits
involving client care, the medical record is thedetermining factor in providing proof of
significant events.
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Legal and Practice Standards
Informed Consent
Advance Directives
Indonesian National Nurses Association
(INNA) Standards of Care
State Nurse Practice Acts
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Legal and Practice Standards
Informed consentmeans that the client
understands the reasons and risks of the
proposed intervention.
Witnessing confirms that the person who
signs the consent is competent.
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Principles of Effective
Documentation Nursing notes must be logical, focused, and
relevant to care, and must represent each
phase of the nursing process.
Nursing documentation based on the
nursing process facilitates effective care.
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Elements of Effective
Documentation Use of Common Vocabulary
Legibility
Abbreviations and Symbols
Organization
Accuracy
Documenting a Medication Error
Confidentiality
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Elements of Effective
Documentation Use of Common Vocabulary
Enhances the quality of documentation.
Supports the efforts of research.
Improves communication and lessens the
chance of misunderstanding between members
of the health team.
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Elements of Effective
Documentation Legibility
Print if necessary.
Do not erase or obliterate writing.
Draw one line through an erroneous entry.
State the reason for the error.
Sign and date the correction.
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Elements of Effective
Documentation
Correcting a documentation error
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Elements of Effective
Documentation Abbreviations and Symbols
Always refer to the facilitys approved listing.
Avoid abbreviations that can be misunderstood.
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Elements of Effective
Documentation Organization
Start every entry with the date and time.
Chart in chronological order.
Chart in a timely fashion to avoid omissions.
Chart medications immediately after
administration.Sign your name after each entry.
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Elements of Effective
Documentation
Charting a late entry
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Elements of Effective
Documentation
Charting a prn
medication
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Elements of Effective
Documentation Accuracy
Use factual, descriptive terms to chart exactly
what was observed or done.Use correct spelling and grammar.
Write complete sentences.
Maintain continuity of care by recording withrespect to notes made on previous shifts.
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Elements of Effective
Documentation Documenting a Medication Error
Chart the medication on the MAR.
Document in the nurses progress notes: Name and dosage of the medication
Name of the practitioner who was notified of the
error
Time of the notification
Nursing interventions or medical treatment
Clients response to treatment
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Elements of Effective
Documentation Confidentiality
The nurse is responsible for protecting the
privacy and confidentiality of clientinteractions, assessments, and care.
The clients significant others, insurance
companies, or other parties not directly
involved in care provided by the health team
may not have access to clients records.
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Methods of Documentation
Narrative Charting
Source-Oriented Charting
Problem-Oriented Charting PIE Charting
Focus Charting
Charting by Exception (CBE)
Computerized Documentation
Case Management with Critical Paths
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Methods of Documentation
Narrative Charting
Describes the clients status, interventions and
treatments; response to treatments is in storyformat.
Narrative charting is now being replaced by
other formats.
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Methods of Documentation
Source-Oriented Charting
Narrative recording by each member (source)
of the health care team on separate records.
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Methods of Documentation
Problem-Oriented Charting (POMR)
Uses a structured, logical format called
S.O.A.P. S: subjective data
O: objective data
A: assessment (conclusion stated in form of
nursing diagnoses or client problems)
P: plan
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Problem-Oriented Charting
(POMR) Uses flow sheets to record routine care.
A discharge summary addresses each
problem.
SOAP entries are usually made at least
every 24 hours on any unresolved problem.
SOAP was developed on a medical model.
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Problem-Oriented Charting
(POMR) SOAPIE and SOAPIER refer to formats that
add:
I: Intervention
E: Evaluation
R: Revision
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.
Problem-Oriented Charting
(POMR)
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Methods of Documentation
PIE Charting
P: Problem
I: Intervention
E: Evaluation
Key components are assessment flow sheets
and the nurses progress notes with anintegrated plan of care.
PIE charting is a nursing model.
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Methods of Documentation
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Methods of Documentation
Focus Charting
A method of identifying and organizing the
narrative documentation of all client concerns.Includes data, action, response.
Uses a columnar format within the progress
notes to distinguish the entry from otherrecordings in the narrative notes.
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Methods of Documentation
Charting by Exception (CBE)
The nurse documents only deviations from
preestablished norms.Avoids lengthy, repetitive notes.
Enables the identification of trends in client
status.
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Methods of Documentation
Computerized DocumentationIncreases the quality of documentation and save
time.
Increases legibility and accuracy.
Enhances implementation of the nursing
process. Enhances the systematic approach to
client care.
Provides clear, decisive, and concise key words(standardized nursing terminology).
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Methods of Documentation
Point-of-Care System
A handheld portable computer is used for
inputting and retrieving client data at thebedside.
Provides each health care practitioner with all
pertinent client data to ensure continuity of care
without duplication.
Provides crucial client information in a timely
fashion.
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Methods of Documentation
Case Management Process
A methodology for organizing client care
through an illness, using a critical pathway.A critical pathway is a monitoring and
documentation tool used to ensure that
interventions are performed on time and that
client outcomes are achieved on time.
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Forms for Recording Data
Kardex
Flow Sheets
Nurses Progress Notes
Discharge Summary
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Forms for Recording Data
TheKardexis used as a reference
throughout the shift and during change-of-
shift reports.Client data
Medical diagnoses and nursing diagnoses
Medical ordersActivities
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Forms for Recording Data
Flow sheetsreduce the redundancy of
charting in the nurses progress notes.
The information on flow sheets can beformatted to meet the specific needs of the
client.
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Forms for Recording Data
Nurses progress notesare used to
document the clients condition, problems
and complaints, interventions, responses,achievement of outcomes.
Progress notes can be completely narrative
or incorporated into a standardized flowsheet.
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Forms for Recording Data
Discharge Summary
Clients status at admission and discharge
Brief summary of clients care
Interventions and education outcomes
Resolved problems and continuing need
ReferralsClient instructions
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Trends in Documentation
Standardized data bases are required to
ensure accuracy and precision in nursing
information systems.
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Trends in Documentation
Nursing Minimum Data Set (NMDS)
Nursing Diagnoses (Taxonomy II)
Nursing Intervention Classification (NIC)
Nursing Outcomes Classification (NOC)
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Reporting
Report: Is oral, written, or computer- basedcommunication intended to convey
information to others.
Record: Is written or computer based, the
process of making an entry on a clients record
is called recording, charting, or documenting.A clinical record, also called a chart or client
record is a formal, legal document that
provides evidence of a clients care.
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Reporting
Verbal communication of data regarding the
clients health status, needs, treatments,
outcomes, and responses Summary of current critical information to
facilitate clinical decision making and
continuity of client care
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Reporting
Reporting is based on the nursing process,
standards of care, and legal and ethical
principles. Reports require participation from everyone
present.
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Reporting
Summary Reports
Walking Rounds
Telephone Reports and Orders
Incident Reports
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Summary Reports Commonly occur at change of shift (or
when client is transferred).
Assessment data
Primary medical and nursing diagnoses
Recent changes in condition, adjustments in
plan of care, and progress toward expected
outcomesClient or family complaints
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Walking Rounds
Nursing, physician, interdisciplinary
Occur in the clients room and include the
client
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Telephone Reports and Orders
Report transfers, communicate referrals,
obtain client data, solve problems, inform a
physician and/or clients family membersregarding a change in the clients condition.
Telephone orders are documented in the
nurses progress notes and the physicianorder sheet.
D ti T l h
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Documenting a Telephone
Order
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Incident Reports
Used to document any unusual occurrence
or accident in the delivery of client care.
The incident report is not part of themedical record, but it may be used later in
litigation.
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LETS PRACTICE!! Divide your class into 10 small groups Each group must present CASES of patients in different areas
Grup 1 : fractures
Grup 2 : Infectious disease
Grup 3 : Pediatric patient
Grup 4 : Gerontology patient Grup 5 : pregnant woman in labour
Grup 6 : emergency patient in hospital settings
Grup 7 : emergency patient in pre hospital settings
Grup 8 : discharged patient
Grup 9 : mental health patient Grup 10 : dead patient
Each individual of the groups should prepare their own cases ofmaximum 5 minutes reporting
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LETS PRACTICE!!
In the next 2x50, report your work in your
group by role play.
Make a pair in your group. One does thereporting and the other does note taking
Change the turn.
Discuss in pair.
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REFERENCE
Lhynnely. (2012). Nursing Abbreviations
[Electronic Version]. Retrieved June 4,
2012, from http://nursingcrib.com/nursing-notes-reviewer/fundamentals-of-
nursing/nursing-abbreviations/
Kozier, E.2008. Fundamental of Nursing.5th Edition. Lippincott: William Wilkins
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Questions? Comments?