-
Discussion
Report
Record
- •Discussion-
- –informal conversation
- •Report-
- –oral, written, computerized. Ex: end of shift
- •Record-
- –written or computer
- –making an entry on client record (chart) is referred
- to as charting or documenting, recording
-
Legal and Ethical
Standards for Documentation
- •Client’s record is a legal document
- •May be used to provide evidence in court
- •ANA- “duty to maintain confidentiality of all patient
- information”
- •HIPAA (Health Insurance Portability & Accountability Act)-
- –protects health information that it transmitted or
- maintained in any forms
-
Maintaining Confidentiality of Records
- •Restrict access
- •Ethical codes and legal responsibility
- •Adhere to policies and procedures to ensure privacy and confidentiality
-
Security for Computerized Records
- •Passwords required & should not be shared
- •Logged in?- don’t leave the computer terminal unattended
- •Do not leave client information displayed
- •Shared all unneeded computer-generated worksheets
- •Know the facility’s policy & procedure for correcting an entry error
- •Follow agency procedures for documenting sensitive material
- •Firewalls- protect server from unauthorized access
-
Purpose of Client Records
- •Communication
- •Planning client care
- •Auditing health agencies
- •Research
- •Education
- •Reimbursement
- •Legal documentation
- •Health care analysis
-
Documentation Systems
- •Source-Oriented Record (SOR) (traditional chart - each dept makes notes in separate areas of chart - fragmented - have to read all pages to know what's going on)
- •Problem-Oriented Medical Record (POMR)
- –SOAP
- - - narritive charting
- •PIE
- •Focus charting
- •Charting by Exception
- •Computerized Charting
-
Source-Oriented Records (SOR)
- •Traditional client record
- •Each department/discipline makes notations in a separate section of chart
- •Information about a particular problem distributed throughout the record
- –Advantage- easy to locate section/forms
- –Disadvantage- info scattered through chart
- •Narrative charting used
-
Narritive Charting
- •Notations about
- –Care
- –Findings
- –Problems
- •Data is organized, systematic
- 1. What assessment data are relevant?
- 2. What nursing interventions have I completed?
- 3. What is my evaluation of the results of the interventions and/or what is the client's response to the interventions?
-
Problem-Oriented Medical Records (POMR)
- •Data arranged according to client problem
- •Members of healthcare team contribute to the problem list, plan of care & progress notes
- •Uses SOAP, SOAPIE, SOAPIER documentation
- •Advantages
- –Encourages collaboration
- –Easier to track status of problems
- •Disadvantages
- –Vigilance required to maintain problem list
- –Less efficient documentation process
-
SOAP Documentation
- •S- subjective data
- •O- objective data
- •A- assessment (conclusions drawn)
- •P- plan to resolve problem
- •I- interventions performed
- •E- evaluation of client’s response to interventions or treatment
- •R- revisions needed
-
PIE Documentation
- •Groups information into three categories:
- –Problem (NANDA, problem gets a #)
- –Interventions
- –Evaluation
- •Consists of client assessment, flow sheet, & progress notes
-
Focus Charting
- •Focus on client concerns and strengths
- •Progress notes organized into format
- –D- data
- –A- action
- –R- response
- •Holistic perspective of client and client’s needs
- •Nursing process framework for the progress notes
-
Charting by Exception CBE
- •Incorporates flow sheets, standards of nursing care, bedside chart forms
- •Agencies develop standards of nursing practice
- •Documentation according to standards involves a check mark
- •Exceptions to standards described in narrative form on nurses’ notes
-
Computerized Documentation
- •Manages large volumes of information
- •Computers used to
- –look up data (labs)
- –chart data
- –revise care plans
- –document client’s progress
- –transmit information from one care setting to another
-
Documenting Nursing Activites
- •Admission
- •Nursing Care Plans
- •Kardex - important facts, Name, vital signs, main interventions
- •Flow sheets
- –Graphic record (VS), I & O, Braden scale, medications
- •Progress
- •Discharge/referral summaries
- •Variance report
-
Documenting Nursing Activities
- •Regardless of documentation system used, the client record should show:
- –Client’s ongoing status
- –Use of the nursing process
-
Guidelines for Recording Client Data
- •Timing
- •Legibility
- •Permanence
- •Accepted terminology
- •Correct spelling
- •Signature
- •Accuracy
- •Sequence
- •Appropriateness
- •Completeness
- •Conciseness
- •Legal prudence
-
Reporting
- •Change of shift (Box 15-3 & 15-4 p. 263)
- •Telephone
- –Report
- –Orders - some need to be witnessed by second nurse
- •Care Plan Conference
- •Nursing Rounds
- •What information will you report to your nurse at the end of your day?
-
Guidelines for Reporting Client Data
- •Should be concise, including pertinent information but no extraneous detail
- •Follow a particular order
- •Provide basic identifying information
- •For new clients provide the reason for admission or medical diagnosis/es, surgery, diagnostic tests and therapies in the past 24 hours
- •Significant changes in client’s condition
-
Framework for Communication to a Physician
- •(S)Situations – What is happening at present time?
- •(B)Background – What are the circumstances leading up to the situation?
- •(A)Assessment – What do I think the problem is?
- •(R)Recommendations – What should we do to correct the problem?
-
Guideline for Receiving Telephone and Verbal Orders
- •Know the state nursing board’s position on who can give and accept
- •Know the agency policy
- •Ask prescriber to speak slowly and clearly
- •Ask prescriber to spell out the medication if unfamiliar
- •Question the drug, dosage, or changes if seem inappropriate
- •Write the order down or enter into a computer
- •Read the order back to the prescriber
- •Use words instead of abbreviations
- •Write the order on the physician’s order sheet, record date, time, indicate it was a telephone order, and sign name with credentials
- •When writing a dosage always put a number before a decimal, but never after a decimal
- •Write out units
- •Transcribe the order
- •Follow agency protocol about signing the telephone order
- •Never follow a voice-mail order
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