documentation: documentation: do it right do it right

DOCUMENTATION:DOCUMENTATION:

DOCUMENTATION:DOCUMENTATION:

DO IT RIGHTDO IT RIGHT

Understanding Documentation Fundamentals

• In the 19th century, nurses recorded their observations of patients under the direction of physicians.

• A checklist of simple observations, such as how the patient ate or slept.

• Chief purpose was to record that the doctor’s orders were followed and facility’s policies were observed.


• Florence Nightingale in the 19th century stressed the importance of obtaining patient information in a clear, concise, and organized manner.

• In the 1970’s nurses created their own vocabulary for documentation based on nursing diagnoses.


• Documentation is one of the most important critical skills a nurse performs.

• High quality documentation is at the core of nursing practice.


• What nurses chart today may be read in the future by many people: team members, accreditation, Medicare/Medicaid Services, insurance companies, etc.

• No matter how skilled a nurse you are, poor documentation will undermine your credibility.

Purposes of Documentation

• Effective documentation provides a complete picture of the care a patient receives, his/her response to care, and need for further treatment.

• A nurse must describe the care given and provide evidence why it was necessary.

Purposes of Documentation

• Document the patient’s response to the care and any changes needed in the plan of care.

• Always assess your quality of charting.

“If I were the next nurse responsible for this patient’s care, would these notes allow me to make good nursing decisions.”

Coordination of Care

• Always document the patient’s status and progress or lack of progress to other team members (important means of communication).

• If documentation is accurate/complete on a patient’s information, more effective health care can be done between team members.

Meeting Accreditation & Licensing Standards

• JCAHO certifies that health care organizations meet specific standards in providing health care.

• The healthcare facility must demonstrate to JCAHO that they provide quality care.

• Reviews medical records to make sure the care is consistent throughout the facility.

Meeting Accreditation & Licensing Standards

Most accrediting organizations require that the record contain:

1. Assessment2. Plan of Care3. Medical Orders4. Progress Notes5. Discharge Summary

Requirements for Reimbursement

• Documentation impacts the amount of reimbursement a facility receives for patient care services.

• The government uses a payment system based on DRGs to allocate reimbursement covered.

The Main Focus

Today more than ever, your documentation plays a key role in ensuring reimbursement by verifying and justifying your actions in providing care.

Performance Improvement Activities

• Mandated by state and JCAHO regulations.

• Committee members monitor and evaluate patient care, indicators of quality care and how to improve patient care.

The Main Focus

The documentation that is found in the medical record can be used to measure how well quality indicators are being met, and to plan corrective action when necessary.

Legal Protection

• Medical records are often used as evidence in malpractice cases.

• What you document/or don’t document can mean the difference between winning or losing a case.

The Main Focus

• Make Sure When You Document: – Adhere to professional standards of nursing

care

– Follow your employer’s documentation policies/procedures

– Document carefully to legally protect yourself and your employer

Performance Improvement Activities

• Mandated by State & JCAHO regulations

• Used by State & JCAHO to develop indicators of quality care

• The medical record is a tool to measure these indicators & plan for corrective action

Documentation Guidelines

1) Record information as soon as possible after the event

a) Less likely to forget important detailsb) Charting will be more accuratec) Easier to defend your actions if you become involved in

litigation

2) If you can’t document at once, note the time you chart-explain the delay, and note the time the event occurred


3) Record all pertinent health or drug information when admitting patients

a) Failure to do so could lead to complications/death for the patient

b) A possible lawsuit for the hospital and you!


4) Document Legibly & Spell Correctly

5) If someone reviews the chart and the writing is sloppy, with poor grammar and spelling they may conclude the nurse was unprofessional

6) If the documentation is weak or not clear it could be difficult to convince a jury you gave appropriate care


7) Play it Safea) Print if your handwriting is

difficult to readb) Use a dictionary to spell

correctlyc) Write enough to convince a

reader that the patient was adequately cared for

d) Remember, ineligible handwriting wastes valuable time trying to decipher it!


8) Use Correct Abbreviationsa) Use only abbreviations approved by LHS

b) Do not use the unapproved abbreviations per JCAHO

c) If you are not sure if it is an approved LHS abbreviation, write out the word


9) Correct Errors & Omissionsa) Correct the error as soon as possible

b) Never erase, cover, write over, or make an entry unreadable

c) Before documenting. Make sure you have the right chart


10) Document Only the Factsa) Document accurately and objectively

b) Chart the patient’s exact words

c) Document the words in quotes when possible

d) If from a reliable source, cite the source


10) Document Only the Facts (continued)e) Chart exact measurements in feet or yards, but not to

one end of the hallway

f) When documenting quantities, avoid generalizations such as a small emesis, but measure the amount

g) Exact measurements in size & amount may be critical


10)Document Only the Facts (continued)h) Describe the incision: “Wound on abdomen

measures 12cm x 6cm, pink granulation tissue at wound edges, all sutures intact, with no drainage noted.”

i) Do not write: “Patient’s incision appears to be healing.”


10) Document Only the Facts (continued)j) Never make an assumption about the event

before chartingi. “Found patient’s IV out of patient’s arm, bed

linens covered with blood.”

k) Avoid subjective references to a patient’s behavior such as “Patient seems frustrated” or “appears anxious.”

i. Instead paint a picture of the behavior: “Patient repeatedly ringing call light, asking about lab results.”


11) Document what you see, hear, smell, or feel

12) Document care only that you have personally given or a PCA that you have directly observed

13) Appropriate documentation is a commitment in writing in a patient’s chart only statements you’d be comfortable showing in public

PLAN OF CARE

• The basis for effective and meaningful documentation.

• STEPS in the NURSING PROCESS1) ASSESSMENT2) NURSING DIAGNOSIS3) PLANNING4) INTERVENTION5) EVALUATION

ASSESSMENT

Data collection begins with the initial admission assessment and continues throughout the patient’s hospital stay as you obtain additional information about his/her changing condition.

ASSESSMENT

JCAHO standards require the initial assessment be completed by the RN and address the patient’s physical, psychological, and social status.

ASSESSMENT

1) Physical factors include relevant physical findings from the initial physical assessment.

2) Psychological factors include the patient’s concerns related to his health care status.

3) Social status factors may include family structure and his role in the family, his occupation, income and economic concerns related to the current illness.

ASSESSMENT

4) Other important assessment areas must include the patient’s nutritional status, functional status, learning needs, and discharge planning needs.

5) This information needs to immediately be communicated to all members of the healthcare team by prompting multidisciplinary referrals.

NURSING DIAGNOSIS

1) Evaluate the patient’s assessment data to formulate the nursing diagnosis.

2) A nursing diagnosis is based on actual or potential problems, related factors, or be associated with the manifestations the patient presents.

PLANNING 1) Every nursing diagnosis must have a projected

relevant expected outcome or goal that the patient should reach as a result of nursing intervention.

2) This is the first step that links assessment information from admission to problem identification.

PLANNING

3) The plan of care should be reviewed every shift and if new problems arise during the patient assessment, nurses need to note it on the problem list and implement appropriate nursing interventions.

4) If a problem is resolved, it should be crossed off but be reassessed for recurrence based on the patient’s length of stay.

NURSING INTERVENTION

1) The outcome/goal that the patient reaches as a result of nursing intervention, for example can include either an expected improvement in the patient’s functional abilities, such as an increase in walking endurance, or the partial resolution of a problem, such as a decrease in pain.

NURSING INTERVENTION

2) Intervention can also include collaboration generated with other departments within the hospital.

3) If the nurse has identified during the assessment who the patient can benefit assistance from and has made a referral to that department, then the patient is in a win-win situation!

EVALUATION

1) The final step in the nursing process.

2) Involves documenting the effectiveness of treatment interventions and proposing changes in the plan of care if necessary.

3) Overall, it is the assessment of the outcome of the plan of care.

THE 5 RIGHTS of DELEGATION

1) Staff members who supervise others (including registered nurses who supervise other LPNs or other unlicensed assistive personnel) are expected to know the skills, experience, and expertise of staff when making assignments.

2) Know and follow Ohio’s nurse practice act about delegation.

FIVE RIGHTS

1) Right Task for a specific patient:– A task that recurs frequently daily– Doesn’t require nursing assessment or

judgment– Doesn’t require application of the nursing

process– The results are predictable– The risk is minimal

FIVE RIGHTS

2) Right Circumstances:– Appropriateness of patient setting– Available resources

3) Right Person:– One who has the appropriate skill set

FIVE RIGHTS

4) Right Communication:– Clear, concise description of the task,

including objective limits and expectations

5) Right Supervision:– Appropriate monitoring, evaluating, and

monitoring as needed

documentation: documentation: do it right do it right

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