documentation student outline
TRANSCRIPT
Subtitle
Documentation and RecordingCommunication with the Healthcare Team
Document and Reporting
• Ensures quality of care• Regulatory agencies require it• Medicare reimbursement depends
upon it• Shows nursing action• Serves as a legal document
Reporting
• Summary of activities, observations, and actions performed
• Objective and non-judgmental
Reports
• Oral or written• Shift report• Verbal reports to physicians• Miscellaneous–Written lab reports– Dietary reports– Social workers notes– PT, OT, Speech therapies
Types of Reports
• Change of shift– Oral, audiotape, rounds
• Telephone• Transfer• Incident– Any event not consistent with routine care of
client– Concise, objective– Not a part of the chart– Oral, audiotape, rounds
Confidentiality
• Law protects any information gained by exam, observation, conversation, or treatment
• Information not discussed or shared with anyone not directly involved in patient’s care
• Nurses are legally and ethically obligated to keep patient information confidential
Medical Records
• Permanent written communications• Continuing account of care status• Discussion, discharge planning,
conferences, consultations• All caregivers can benefit from
information and plan accordingly
Purpose of Records
• Communication• Financial billing• Education• Assessment• Research• Auditing and monitoring• Legal documentation
Documentation
• Anything written or printed that is relied upon as a record of proof for authorized persons
Standards for Documentation
• Federal regulations-Medicare and Medicaid
• State and Federal regulations – JCAHO
• Professional standards – ANA• Facility policies- charting techniques
and responsibilities
Legibility
• All charting should be easy to read• Reduces errors• May be used in court years after care
given
Factual
• Descriptive, objective information• Decreases misinterpretation• Do not use “seems”, “appears”,
“apparently”, “good” “well”• Subjective information is
documented with client’s own words in quotations
• No opinions
Complete and Concise
• Thorough, exact, brief, and NO blah, blah, blah blah
• Clear and succinct• Eliminate irrelevance• Short and to the point (long notes
difficult to read)• Too abbreviated gives impression of
being hurried and incomplete
Timeliness
• Delay in reporting can result in serious omissions and delays in care
• Late entries may be interpreted as negligence• Certain things must be reported at time of
occurrence• Routine activities need not be charted
immediately • Military time used• No leaving until important information
recorded• Avoids errors and duplication of care
Accurate
• Reliable and precise• Exact measurements when possible• Use only accepted abbreviations• Spell correctly
More accuracy
• No charting for someone else• Student’s notes are countersigned by
person who assured care was given• Descriptive entries signed with full
name and status (first initial, last name, and title)
Guidelines for Documentation and Reporting
• Certain abbreviations not acceptable• Abbreviations used
Organization
• Logical format and order• Chronological flow of events
Chart Components
• Data base– Assessment data
• Problems list• Care plan• Progress notes– Narrative– Flow sheets– Discharge planning summaries
Documentation Methods
• Problem oriented medical record– S.O.A.P. or S.O.A.P.I.R– P.I.E.
• Source records• Charting by exception– Flow sheets
• Focused charting– D.A.R.
Problem Oriented Medical Record
• Focus on patient’s problems• Follows the nursing process• Organized by problems or diagnoses• Coordinated care
Advantages of POMR
• Easy to retrieve information and follow progress
• Easy to monitor for QA purposes• SOAP notes establish structure that
reflects what nurses do
PIE Charting
• PIE• Daily assessment data appears on
flow sheets• Continuing problems documented
daily• Focuses exclusively on single client
problem
Source Records
• Each discipline has a separate section of the chart for recording
• Can easily locate proper section• Examples: admission sheet,
physician's order sheet, history and physical, flow sheets, nurses notes, medication record
Charting by exception
• Reduces repetition• Clearly defined standards of practice
and predetermined criteria• Nurses documents only significant
findings or exceptions• Preventive and wellness-focused
functions not documented
Focus Charting - DAR
• Easily understood and adaptable to most settings
• Reflects analysis and conclusions• Does not indicate problem
assessment
Standardized Care Plans
• Pre-printed and established guidelines for clients with similar problems
• Improved continuity• Less time to document• Inhibits unique or individualized
therapies
Writing the Nursing Care Plan
• Prioritize problems– ABC’s–Maslow– Problems perceived by patient
Formats
• 5 columns– Assessment data or defining characteristics– Diagnosis– Goals/outcomes– Interventions– Evaluation
• Concept Map– Same five components linked by rationales– Better indicates process of critical thinking
Critical Pathways
• Documentation tool to integrate standards of care for multiple disciplines
• List problems, key interventions, expected outcomes, expected timelines
• Attempt to control and decrease length of stay
Discharge Summaries
• Multidisciplinary involvement is required by HCFA
• Client leaves hospital in timely manner with the necessary resources
• Client signs original for chart and takes copy home
Kardex
• Information• Medication• IV’s• Treatments• Diagnostic procedures• Allergies• Data • Problem list
Computer Documentation
• Saves time in storage and retrieval• Information is permanent• Various departments can coordinate
information• Can be used at the bedside
Protocol Charting
• Newest method• Primary use in outpatient care• Written for use as a references or
guide for care• Individualized, current, according to
intended purpose