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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