ivt updates
TRANSCRIPT
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Nurs ingDocumentat ion
Your License may depend on i t !
Nelia B. Perez RN, MSN
PCU - MJCN
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Taking a Poll
1. Have you been involved in a patient
complaint against your institution?2. Do you feel like your documentation
would support you in a court of law?
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A patient you cared for 9months ago is unhappy withthe outcome and has filed a
malpractice lawsuit againstyou.
Now what?
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The Court
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Legal Case Studies
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Duty of Care
Based on existence of the nurse-patientrelationship
A legal status created when the nurse islegally obligated to provide nursing care toa patient
Law will demand that the nurse perform asa reasonably prudent nurse
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Breach of Duty
Nurses care fell below the acceptable
Standard of CareResults:
malpractice case compensatory $$$
loss of nurses license
loss of job / ability to work
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Nursing Negligence /
Malpractice
Any action by a nurse that falls
below generally accepted standardsof nursing care, and causes in juryto
a patient
Even if nurses actions were onlycontributing cause to the injury
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Proximate Cause
PROOF
Requires that there be areasonably close connection
between the nurses conductand the resultant injury
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Foreseeability
Nurse has a responsibility to foresee
harm before it occurs and eliminaterisks
Admission Screens
Fall Risk
Suicide Risk
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Illusion of Negligence
Ev idence o f the tru th as
to what real ly happened
is unavailab le
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Damages
Compensated when:
Suffered loss or injury through the act,omission, or negligence of another
Medical costs
Loss of earnings
Impairment of future earnings
Past / future pain & suffering
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Objectives
1. Explain the importance of documentation as a
health care provider.
2. Identify the legal aspects of nursing
documentation.
3. Identify the basic information that is required whendocumenting.
4. Describe specific issues that require
documentation.
5. Discuss documentation concerns regarding faxingof records.
6. Discuss computerized documentation concerns.
7. Discuss documentation Dos and Donts.
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Objectives8. Identify how the nursing process impacts nursing
documentation.9. State characteristics of reasonable documentation.
10. Explain what constitutes Nursing Malpractice
related to the role of documentation.
11. Identify common charting errors.12. Identify the consequences of poor documentation
13. Discuss the future of documentation standards.
14. Evaluate the medical record documentation issues
in selected legal cases.
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Questions
What do you want to know?
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Who Cares?
Regulations
Client / Patient
Insurance
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"if it's not documented it was
not done"
To avoid litigation, health careproviders must comply with
established standards of care.
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Standards of Care
Legislation / Statutes
Practice Guidelines
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Prudent Nurse
Knowledge Skill
Care Diligence
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Why Is the Chain of Command
Important?
Courts have held that nurses have a duty
to question a physicians order if it is notconsistent with standard medical
practice.
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Initiation of the Chain
Nurse
becomes concerned
Physician
unresponsive or insufficiently responsive
might not return a page
tells the nurse not to call again about thesame problem, or informs the
nurse he or she will come in later
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Examples
Clinical Situations The dose of a
medication isexcessive or
inadequate. IV fluid orders are
incomplete orinconsistent.
The nurse is
concerned about fetalheart rate monitoringin a patient in labor.
The postoperativelaparoscopiccholecystectomy
patient begins havingsymptoms of an acuteabdominal process.
The patient has widelydivergent intake
versus urinary output. The patient is allergicto the medication thephysician orders.
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Make Documentation Easier
The Dos
The Donts
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The Dos
Correct Chart
Reflect the Nursing Process
Write Legibly
Permanent Black Ink
Complete / Concise / Accurate
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Clear / Concise / Accurate
Wrong Way: Communication withpatient's family begun today to specify
the manner in which his condition isprogressing and suggest a probableconsequence of that progression.
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Clear / Concise / Accurate
Right Way:I contacted Mr. Boons wife at
1415 hours. I explained that his cardiacstatus was worsening and that he wasbeing prepared for a cardiac
catheterization procedure scheduled for1600 hours.
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Dos
Medications
Route
Clients response
Precautions / Preventive Measures
Side rails
Restraints
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Dos
Nursing Procedures
Name of procedure When it was performed
Who performed it
How it was performed
How well the client tolerated it
Adverse reactions
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Dos
Phone calls
Health Care Team visits
Dont wait to Chart
Client refusals
Clients subjective data
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Dos
Medication omission
Late Entry
Not Applicable
Charting Frequency
Facility P&P / Standards
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Dos
Approved abbreviations & symbols
Discharge instructions
Commonly misspelled words
Look-a-Like / Sound-a-Like
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Dos
Continuation
Triplicate / Carbonated Copies
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The Don'ts
Complaints
Opinions
Altering the Record
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Red Flags
Adding Information
Dating the entry Dates / Times conflict
Inaccurate Information.
Destroying records
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Dont
Unapproved Abbreviations
Shorthand
Vague
Excuses
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Dont
Chart for someone else
Chart Opinions
Use Negative Language
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Dont
Use vague terms
Chart ahead
Misspelled words
Incorrect Grammar
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Dont
Chart staffing problems
Chart staff conflicts
Chart casual conversations
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Fraud
Charting care that you haven'tperformed is considered fraud
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When you make a Mistake
White out / Eraser
The word Error
Correct the Entry
Oops
Sad Faces
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Dont
Leave empty lines / spaces
Write in the margins
Make reference to incident reports
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Dont
Use words that suggest that there is aclients safety risk
Violate client confidentially
HIPPA
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Common Charting Mistakes
Failing to recordpertinent health ordrug information
Failing to recordnursing actions
Failing to record that
medications havebeen given
Recording on thewrong chart
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Common Charting Mistakes
Failing to document adiscontinuedmedication
Failing to record drug
reactions or changesin the patientscondition
Transcribing ordersimproperly ortranscribing improperorders
Writing illegible orincomplete records
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Failing to record pertinent health
or drug information
The nurse neglected to recordher patients penicillinallergy in the admissionnotes.
Because the intern didnt knowthe patient was penicillin-allergic, he gave the patienta penicillin injection.
The patient, who wasincoherent and couldnt tellthe intern about the allergy,
went into anaphylacticshock and sufferedirreversible brain damage.
At the trial, the court found thenurse guilty of negligence.
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Failing to record nursing actions
The evening nurse notices heavy drainage from thewound.
She checks the nurses notes and finds no evidence thatthe dressing was changed.
She considers the amount of drainage normal for a periodof several hours.
She changes the dressing but, like the day nurse, forgetsto chart her action.
The night nurse does the same.
Is the condition getting more serious? Is the patients lifein jeopardy? No one knows because no one realizesthat the patients wound is seeping more than it should.
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Failing to record that medications
have been given
A day nurse gave a patient heparin by intravenous
push just before she went off duty.
An hour later, the evening nurse saw the order forheparin--but no indication that it had been given.
So she gave the patient the same dose.
The patient began to hemorrhage and went intohypovolemic shock.
He recovered--then successfully sued the hospital.
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Recording on the wrong chart
Mrs. B. Moyer and Mrs. C. Moyer were on thesame unit.
Mrs. B. Moyer was being treated for severe
hypertension;Mrs. C. Moyer, for acute thrombophlebitis.
Mrs. C. Moyers doctor ordered 4,000 units ofheparin for her.
The nurse mistakenly transcribed the heparinorder onto Mrs. B. Moyers chart andadministered the heparin.
Mrs. B. Moyer started bleeding.
Failing to document a
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Failing to document a
discontinued medication
A doctor suspected that his patient, who was takinghigh doses of aspirin for arthritis, had developedan ulcer.
So he discontinued the medication.
But the patients nurse forgot to record the order onthe medication sheet, and she and the othernurses continued giving aspirin.
The ulcer bled, and the patient eventually
underwent a partial gastrectomy because hercondition deteriorated.
She sued the hospital for the nurses negligenceand won.
Failing to record drug reactions
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Failing to record drug reactions
or changes in the patients
condition
A patient complained of nausea, dizziness,abdominal pain, and itchy skin shortly afterreceiving his first 100-mg dose ofnitrofurantoin macrocrystals (Macrodantin).
His nurse wasnt concerned, though.
By evening, after two more doses of the
medication, he was vomiting and had a highfever, urticaria, and early symptoms of shock.
He sued his nurse for negligence.
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Transcribing orders improperly or
transcribing improper orders
A doctor ordered 5 ml of atropine for a patient
on the coronary care unit.He meant to order 0.5 ml, but he didnt includethe zero or write the decimal point clearly.
The nurse transcribed the order as 5 ml,
although she didnt think it seemed right.She decided the doctor knew best and didnt
check the dose before recording it.
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Writing illegible or incomplete
records
To play it safe:
Print
Sign your full name and title Dont leave blank spaces, lines, or boxes on charts
Dont use unapproved abbreviations
Record every nursing action as soon as possible Write enough to convince the reader
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METHODS (STYLES) OF CHARTING
NARRATIVE
SOAP
SOAPIER
FOCUSDATA
ACTION
RESPONSE
PIE
EXCEPTION CHARTING
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NARRATIVE
CHRONOLOGICAL
BASELINE CHARTED QSHIFT
LENGTHY, TIME-CONSUMING
SEPARATE PAGES FOR EACH
SOURCE-ORIENTED
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SOAP
USED FOR PROBLEM-ORIENTED CHARTS
S SUBJECTIVE. WHAT PT TELLS YOU. 0 OBJECTIVE. WHAT YOU OBSERVE, SEE.
A ASSESSMENT. WHAT YOU THINK IS GOING ONBASED ON YOUR DATA.
P PLAN. WHAT YOU ARE GOING TO DO.
CAN ADD TO BETTER REFLECT NURSING PROCESS I INTERVENTION (SPECIFIC INTERVENTIONS
IMPLEMENTED)
E EVALUATION. PT RESPONSE TO INTERVENTIONS.
R REVISION. CHANGES IN TREATMENT.
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EXAMPLE OF SOAP CHARTING
#1 ALTERATION IN COMFORT. ABDOMINAL
PAIN.
S COMPLAINS OF PAIN IN RUQ
O IS PALE AND HOLDING RIGHT SIDE
A RECURRING ABDOMINAL PAINP PUT ON NPO AND NOTIFY PHYSICIAN
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FOCUS CHARTING
USES NARRATIVE DOCUMENTATION
(DAR) DATA SUBJECTIVE OR OBJECTIVE THAT
SUPPORTS THE FOCUS (CONCERN)
ACTION NURSING INTERVENTION
RESPONSE PT RESPONSE TO INTERVENTION
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EXAMPLE OF FOCUS CHARTING
D COMPLAINING OF PAIN AT INCISION SITE
ON LEVEL OF #7
A REPOSITIONED FOR COMFORT. DEMEROL
50MG IM GIVEN.
R (CHARTED AT A LATER DATE.) STATES A
DECREASE IN PAIN, FEELS MUCH BETTER.
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PIE CHARTING
Similar to SOAP charting
Both are problem-oriented PIE comes from the Nursing Process,
SOAP comes from a Medical Model.
P-Problem
I-Intervention
E-Evaluation
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SAMPLE OF PIE CHARTING
P#1 Risk for Infection r/t IV Therapy site.
IP#1 Checked IV Site periodocally.
EP#1 No sign of redness and swelling on IVsite
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CHARTING BY EXCEPTION
USES FLOWSHEETS
EMPHASIS ON ABNORMAL (WHAT IS ABNORMALFOR THIS PATIENT.
ALTHOUGH IT MAY BE ABNORMAL FOR THENORMAL PERSON, IF IT IS ABNORMAL FORYOUR PATIENT ON A CONSISTENT BASIS, IT ISNO LONGER CONSIDERED AN EXCEPTION.
ADVANTAGE
COMPUTERIZED CHARTING
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COMPUTERIZED CHARTING PASSWORD. NEVER SHARE. CHANGE
FREQUENTLY. LEGIBLE
CAN BE VOICE-ACTIVATED, TOUCH-ACTIVATED.
DATE AND TIME AUTOMATICALLY RECORDED.
ABBREVIATIONS AND TERMS ARE SELECTED BYA MENU PROVIDED BY THE FACILITY.
TERMINALS ARE USUALLY EASILY ACCESSIBLE,IN PT ROOMS, CONVENIENT HALLWAY
LOCATIONS. MAKE SURE TERMINAL CANNOT BE VIEWED BY
UNAUTHORIZED PERSONS.
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KARDEX
QUICK REFERENCE
CHANGED AS NEEDED
NOT PART OF PERMANENTRECORD
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ABBREVIATIONS
YOU MUST USE YOUR FACILITYS
APPROVED ABBREVIATIONS.
BE AWARE THAT A LOT OFCOMMONLY USED ABBREVIATIONS:EG. TID, BID, QOD, HS ARE NOLONGER ALLOWED AND SHOULDBE CURRENTLY BEING PHASEDOUT OF YOUR FACILITY.
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CHANGE OF SHIFT REPORT
PERSON TO
PERSON BE PREPARED
AVOIDGOSSIP/SOCIALIZ
ATION
TAPE RECORDER
INCIDENT REPORTS
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INCIDENT REPORTS OBJECTIVE
DO NOT BLAME OR ADMITLIABILITY
WHAT DID YOU DO?
DO NOT INCLUDENAMES/ADDRESSES OFWITNESSES
DOCUMENT TIME/NAME OFDOCTOR
DO NOT FILE IN CHART
DO NOT WRITE INCIDENT
REPORT MADE
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CORRECTING ERRORS
IF YOU SPILL SOMETHING ON THE CHART, DONOT DISCARD NOTES. RECOPY, PUT ORIGINALAND COPIED SHEETS IN CHART. WRITECOPIED ON COPY.
DO NOT SCRIBBLE OUT CHARTING.
AVOID USING ERROR OR WRONG PATIENTWHEN MAKING CORRECTION.
FOLLOW YOUR FACILITIES POLICY.
DO NOT ALTER CHARTING, IT IS A LEGAL
DOCUMENT.
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Lessons Learned
Documentation validates Nursing Care
A high-risk patient requires complete
assessment and frequent monitoring.
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Defensive Documentation
Chronological
Comprehensive
Complete
Concise
Descriptive
Factual
Legally aware
Legible
Relevance
Standardabbreviations,
symbols, and termsThorough
Timely
Documentation The right way!
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Future
National Standards
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