Download Lecture Notes - Napa Valley College

8/23/2016
Chapter 3
Documentation
All items and derived items © 2015, 2011, 2006 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
Purposes of Patient Records

Five basic purposes

Documented communication
Permanent record for accountability
 Legal record of care
 Teaching
 Research and data collection

All items and derived items © 2015, 2011, 2006 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
2
Purposes of Patient Records (Cont.)

Auditors

Peer review
Quality assurance, assessment, and improvement
 Diagnosis-related groups (DRGs)

All items and derived items © 2015, 2011, 2006 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
3
1
8/23/2016
Purposes of Patient Records (Cont.)

Diagnosis-related groups (DRGs)

System classifying patient by age, diagnosis, and
surgical procedure, producing 300 different
categories used in predicting the use of hospital
resources, including length of stay
 Basis for reimbursement rates for Medicare and
Medicaid
 Many private insurance companies use a similar
system for reimbursement
All items and derived items © 2015, 2011, 2006 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
4
Purposes of Patient Records (Cont.)

Nurses’ notes

Where nurses record observations, care given,
and patient’s responses
 Institutions are reimbursed by insurance
companies or government programs only for
documented care
All items and derived items © 2015, 2011, 2006 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
5
Question 1
Patient records are used for all of the following
except:
1.
2.
3.
4.
permanent record for accountability.
legal record of care.
research and data collection.
It is not a concise, accurate, and permanent
record of medical care.
All items and derived items © 2015, 2011, 2006 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
6
2
8/23/2016
Electronic Health Record (EHR) and
Personal Health Record (PHR)




Use of the record
Ease of use and documentation
Point-of-care
Computers on wheels (COWS)
All items and derived items © 2015, 2011, 2006 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
7
Electronic Health Record (EHR) and
Personal Health Record (PHR)
(Cont.)

Security
All items and derived items © 2015, 2011, 2006 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
8
Electronic Health Record (EHR) and
Personal Health Record (PHR)
(Cont.)


Information contained in PHR
Input information into system
All items and derived items © 2015, 2011, 2006 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
9
3
8/23/2016
SBAR



Situation, background, assessment, and
recommendation
Communicates between provider and nurse,
nurse and nurse
Joint Commission states “it meets the
National Patient Safety Goals”
All items and derived items © 2015, 2011, 2006 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
10
Question 2
When communicating with a health care provider and
with an oncoming nurse, it is important to use a format
such as SBAR, which stands for:
1.
2.
3.
4.
assessment, background, recommendation, and situation.
situation, background, recommendation, and assessment.
background, recommendation, situation, and assessment.
situation, background, assessment, and recommendation.
All items and derived items © 2015, 2011, 2006 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
11
Basic Guidelines for Documentation




Quality and accuracy of the nurse’s notes are
extremely important
Correct spelling, grammar, and punctuation,
as well as good penmanship and other writing
skills are important in documentation
Information recorded in the chart should be
clear, concise, complete, and accurate
The registered nurse (RN) is responsible for
the initial admission nursing history, physical
assessment, and development of care plan
All items and derived items © 2015, 2011, 2006 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
12
4
8/23/2016
Basic Guidelines for Documentation
(Cont.)

Charting rules






All sheets should have correct patient name,
identification number, date of birth, date, and time
if appropriate
Use only approved abbreviations and medical
terms
Be timely, specific, accurate, and complete
Write legibly
Follow rules for grammar and punctuation
Leave no empty lines; chart consecutively
All items and derived items © 2015, 2011, 2006 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
13
Basic Guidelines for Documentation
(Cont.)

Charting rules






Chart after care is given
Chart as soon and as often as possible
Use direct quotes as appropriate
Be objective in charting
Describe each item as you see it
Avoid judgmental terms and placing blame
All items and derived items © 2015, 2011, 2006 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
14
Basic Guidelines for Documentation
(Cont.)

Charting rules

Sign each entry
Chart all ordered care as given
 Note patient responses to treatments and/or
medications
 When patient leaves unit, chart time and method
of transportation on departure and return

All items and derived items © 2015, 2011, 2006 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
15
5
8/23/2016
Basic Guidelines for Documentation
(Cont.)

Charting rules

Use only hard-pointed, permanent, black ink pens;
no erasures or correcting fluids are allowed on
charts
 If a charting error is made, identify the error
according to facility policy and make the correct
entry
 When making a late entry, note it as a late entry,
and proceed with the entry
 Follow each institution’s policies and procedures
for charting
All items and derived items © 2015, 2011, 2006 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
16
Basic Guidelines for Documentation
(Cont.)

Charting rules

Avoid general, empty phrases such as “status
unchanged” or “had good day”
 If you question an order, record that clarification
was sought
All items and derived items © 2015, 2011, 2006 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
17
Basic Guidelines for Documentation
(Cont.)

Common medical abbreviations and
terminology


Standard medical abbreviations and terminology
Most facilities have a published list of generally
accepted medical abbreviations and terms
approved
All items and derived items © 2015, 2011, 2006 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
18
6
8/23/2016
Question 3
Abbreviations can be used when documenting
care for the patient as long as the:
1. abbreviations are approved by the facility.
2. nurse understands what the abbreviation stands
for.
3. nurse is using the abbreviations on the
unapproved Joint Commission list.
4. nurse’s notes are clear when using the
abbreviations.
All items and derived items © 2015, 2011, 2006 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
19
Recording Methods

Traditional chart

Divided into specific sections
• Emphasis placed on specific information sheets
• Typical sections include admission sheet, physician’s
orders, progress notes, history and physical, nurse’s
admission notes, care plan, nurse’s notes, graphics, and
laboratory and x-ray reports
All items and derived items © 2015, 2011, 2006 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
20
Recording Methods (Cont.)

Narrative

Care given is descriptive
Written in abbreviated story form
 Includes
• Patient need or problem data
• Whether someone was contacted
• Care and treatments provided
• Response to treatment

All items and derived items © 2015, 2011, 2006 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
21
7
8/23/2016
Recording Methods (Cont.)

Problem-oriented medical record (POMR)

Scientific problem-solving system or method
• Principal sections: database, problem list, care plan, and
progress notes
• Database: History and physical, diagnostic tests, identify
and prioritize the health problems on the medical and
other problem lists
All items and derived items © 2015, 2011, 2006 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
22
Recording Methods (Cont.)

Problem-oriented medical record (POMR)

Problem list
• Active, inactive, potential, and resolved problems
• Care plan with nursing diagnosis is developed for each
problem by disciplines involved in care
All items and derived items © 2015, 2011, 2006 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
23
Recording Methods (Cont.)

Problem-oriented medical record (POMR)

SOAPIER
• S – Subjective
• O – Objective
• A – Assessment
• P – Plan
• I – Intervention
• E – Evaluation
• R - Revision
All items and derived items © 2015, 2011, 2006 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
24
8
8/23/2016
Recording Methods (Cont.)

Focus charting


Modified lists of nursing diagnoses
Nursing process used with focus on patient needs
All items and derived items © 2015, 2011, 2006 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
25
Recording Methods (Cont.)

Charting by exception

Complete physical assessments, observations,
vital signs, IV site and rate, and other pertinent
data charted at beginning of each shift
 During the shift, only additional treatments given
or withheld, changes in patient condition, and new
concerns are charted
 More detailed flow sheets, which reduce time
needed to chart, are used
All items and derived items © 2015, 2011, 2006 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
26
Alternative Recordkeeping Forms



Make medical documentation easy and quick
Eliminate duplication of data
Unnecessary to document each time
medication is given
All items and derived items © 2015, 2011, 2006 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
27
9
8/23/2016
Alternative Recordkeeping
Forms (Cont.)

Kardex/Rand

Consolidate orders and care needs
All items and derived items © 2015, 2011, 2006 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
28
Alternative Recordkeeping
Forms (Cont.)

Nursing care plans

Preprinted guidelines used to care for patients
with similar health problems
 Developed to meet nursing needs
 Based on nursing assessment and nursing
diagnoses
All items and derived items © 2015, 2011, 2006 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
29
Other Documentation Forms

Incident reports

Used for any event not consistent with routine
care of a patient
 Give only objective information
 Do not admit liability or give unnecessary details
 Do not mention incident report in nurse’s notes
All items and derived items © 2015, 2011, 2006 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
30
10
8/23/2016
Other Documentation Forms (Cont.)

24-hour patient care reports and acuity forms

Accurate assessment information and
documentation of activities of daily living
 Use flow sheets and checklists

Acuity charting


Rates each patient’s severity of illness
Determines efficient staffing patterns
All items and derived items © 2015, 2011, 2006 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
31
Other Documentation Forms (Cont.)



Discharge summary
Pertains to patient’s continued health care
after discharge
Concise and instructive form
All items and derived items © 2015, 2011, 2006 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
32
Documentation and Clinical (Critical)
Pathways

Clinical pathways

Coordinates medical and nursing interventions
All disciplines develop integrated care plans for
projected length of stay for specific case type
 Monitor patient’s progress and documentation tool

All items and derived items © 2015, 2011, 2006 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
33
11
8/23/2016
Question 4
An incident report:
1. is used to document an event not consistent with
the routine operation of health care or the routine
care of a patient.
2. is documented in the nurse’s notes.
3. can be submitted in a legal hearing.
4. is used to admit liability for the event
All items and derived items © 2015, 2011, 2006 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
34
Home Health Care Documentation



Documentation provides quality control and
reimbursement from Medicare, Medicaid, and
private insurance companies
Must note patient education a demonstration
of learning
Coordination of services and compliance of
regulation reflected by all members of the
health care team
All items and derived items © 2015, 2011, 2006 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
35
Long-Term Health Care
Documentation



Omnibus Budget Reconciliation Act (OBRA)
of 1987 regulates standards for resident
assessment, individualized care plans, and
qualifications for health care providers
Department of Health (DOH) for each state
governs frequency of written nursing records
of residents
Supports multidisciplinary approach in
assessment and planning processes of
patient care
All items and derived items © 2015, 2011, 2006 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
36
12
8/23/2016
Special Issues in Documentation

Record ownership and access

Property of institution or health care provider
Usually does not have immediate access to full
record
 To gain access, need to follow established policy
of facility
 Lawyers can gain access to chart with patient’s
written consent

All items and derived items © 2015, 2011, 2006 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
37
Special Issues in
Documentation (Cont.)

Confidentiality

Patient’s Bill of Rights and the law guarantee the
patient’s medical information will be kept private
unless the information is needed to provide care
or patient gives permission for others to use it
 The nurse should not read a record unless there is
a clinical reason and should hold the information
regarding the patient in confidence
All items and derived items © 2015, 2011, 2006 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
38
Special Issues in
Documentation (Cont.)

Electronic documentation

Institutions have mainframe computers for data
processing tasks
 Progressive hospitals’ computers handle provider
orders, pharmacy, laboratory, diagnostic imaging
orders, central supply requests, care planning,
documentation, and billing
 Most efficient computer systems have bedside or
handheld terminals for data entry
All items and derived items © 2015, 2011, 2006 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
39
13
8/23/2016
Special Issues in
Documentation (Cont.)

Electronic documentation

Do not share password used to log into computer
Do not leave computer terminal unattended
without logging off
 Follow correct protocol for correcting errors
 Be sure stored records have backup files
 Do not leave information about a patient displayed
on a monitor where others can see it

All items and derived items © 2015, 2011, 2006 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
40
Special Issues in
Documentation (Cont.)

Use of fax machines

Transmit information between offices, hospitals,
and other facilities
 Vital for rapid information transmission and are as
important as computers for documentation and
data handling
All items and derived items © 2015, 2011, 2006 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
41
Question 5
When using computerized charting, the nurse
completes all of the following except:
1. shares password used to log into the computer.
2. follows the protocol for correcting errors.
3. leaves information about the patient displayed on
the monitor.
4. leaves the computer unattended without logging
off.
All items and derived items © 2015, 2011, 2006 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
42
14