What is the purpose of documentation?
- Communication among health professionals and continuity of care
- PLaning and evaluation of a Patient's Care
- ● Legal documentation
- ● Education of health professionals
- ● Legislative requirements
- ● Quality improvement - Joint Commissions, review written and electronic records
- ● To meet professional standards of care - (Nurse documents - relevant data, diagnoses, expected outcomes, plan of care, implementation, coordiatnion of care, results of the evaluation...)
- ● Identification of the cost of care for reimbursement and utilization review - using health record to determin of whether the medical treatments and interventions were necessary and appropriate.
- ● Health-related research
What are different systems for recording client information?
- The source-oriented record: is organized according to discipline. Each discipline charts in its defined section of the chart.
- The problem-oriented record PORs: is organized around a patient problem list. All disciplines chart on shared notes that are referenced to the identified problem. 5 components: Problem list, Initila Plan, Progress Notes (This is where you record SOPIER info), Discharge Summary
- The EHR Electronic: can contain both source-oriented and problem-oriented records.
- In a CBE(charting by exception) system: only significant findings or exceptions to standards and norms of care are charted. CBE uses preprinted flowsheets to document most aspects of care, and it assumes that unless a separate entry has been made (an exception), all standards have been met, prescribed care has been done, and the patient has responded normally. Normal responses for various assessments are defined on the form.
What are different methods for recording client information?
- Narrative Documentation
- SOAP Charting
- PIE Charting
- Focus Charting
- Charting by exception (CBE)
In a CBE(charting by exception) system: only significant findings or exceptions to standards and norms of care are charted. CBE uses preprinted flowsheets to document most aspects of care, and it assumes that unless a separate entry has been made (an exception), all standards have been met, prescribed care has been done, and the patient has responded normally. Normal responses for various assessments are defined on the form.
Narrative chart entry
Narrative format tells the story of the patient’s experience in a chronological format. Patient status, activities, and response to treatment may all be included in narrative charting.
PIE Problem - Intervention-Evaluation
PIE format is organized according to problem, interventions, and evaluation. Problems are identified at the admission assessment. Subsequent entries begin with identification of the problem number. This type of charting establishes an ongoing care plan.
- This format may be used to address single problems or to write summative patient notes.
- Subjective data: What the patient or familymembers tell you about the client's signs and symptoms. Quote the actual words said.
- Objective data: Factual, measurable clinical findings
- Assessment: Conclusion drown from the subjective and objective data, problem, diagnoses.
- Plan: Short-term and long-term goals and strategies that will be used to releive the patient's problem.
- Interventions: Actions
- Evaluations: An analysis of the interventions
- Revision: Changes made to the original care plan
Focus® charting is not necessarily organized according to problems. It can highlight the client’s concerns, problems, or strengths. Charting occurs in three columns. The first column contains the time and date. The second column identifies the focus or problem addressed in the note. The third column contains charting in a DAR format. DAR is an acronym for data, action, and response.
FACT system is similar to CBE in that it includes only exceptions to the norm. It includes four key elements: (1) Flow sheets individualized to specific services, (2) Assessment features standardized with baseline parameters, (3) Concise, integrated progress notes and flowsheets documenting the client’s condition and responses, and (4) Timely entries documented when care is given.
What are the general guidelines for documenting?
- Use accurate, nonjudgmental Language: avoid labeling patients or members on the care team. Alsow avoid documenting judgments about decisions made by members of the team
- Provide details about patients' codition: give examples
- Avoid words such as good, average, or normal
- Use only the abbreviations authorized by your organization
- Use correct spelling and grammar
- data and time all your notes
- Think about what you say
- Do not assume that everything you see already documented is correct.
- Chart your own nursing actions: Never allow anyone to chat for you.
- Do not document other's actoins: as though you had performed them.
- If you need to document the actions of someone else, be sure to designate that cearly: Ex. J.Scott, NAP, ambulated patient to bathroom.
- Don't chart what someone else said, heard, felt, or smelled.
Legal aspects of documentation
- accurate documentation is one of the best defenses for legal claims associated with nursing care
- chart Immediately after care is provided
- In a court of law "care not documented is care not provided.
Describe forms for recording client information
- Progress notes
- Nursing Administration Data forms
- Discharge Summary
- Flowsheets and graphic records
- Medical Administration Records
- Kardex or Patient Care Summary
- Intergrated PLan of Care - IPOC
- Occurance reports
- Handoff Report
Nursing Administration Data
when patient enters the healthcare system.
is the last entry made in the paper chart. In electronic chart, discharge summary can be begun any time after admission and revised.
Flowsheets and Graphic Records
- assessments and care that are performed frequantly. Vital signs...
- Intake and Output Records
Medication Administration Record (MARS)
- contain info about hte meds that have been prescribed for the client. Document according to the times they are given:
- Scheduled medications: meds that are to be given on a regularly scheduled basis
- Unscheduled Meds: to be given on call at the appropriate time
- Continuous infusions: are IV fluids that are running consistently
- PRN: as needed after administering a PRN medication, document the time and date the medication was given and the location of administration if the medication was injected on the medication administration record (MAR). In the nurses’ notes, state the reason for administering the medicine, the amount given, and the patient’s response to the medication.
- Stat: med is given immediatly and only once
- Single-order: med is given once at a specified time, not necessarily immediately
Kardex or Patient Care Summary
is a special paper form that briefly summarizes a patient's status and plan of care.
Intergrated Plan of Care
- IPOCs are combined charting and care plan form. They are costomized to best fit common patient situations in a unit.
- Maps out, day by day, the patients goals, outcomes, interventions, and treatments for a specific diagnosis from admission to discharge.
- Help predict length of stay, monitor cost of stay, nursing teaching about what the patient can expect during hospital stay.
An occurrence report is a formal record of an unusual occurrence or accident. This is an agency report and is not part of the patient’s chart. An occurrence report is filed in many circumstances. Examples of reportable events include falls or other patient injury, loss of patient belongings, or administration of the wrong medicine. Occurrence forms are used to track problems and identify areas for quality improvement.
are orgonized according to the problem list. each discipline charts on share notes. charting is labeled according to problem number.
Approved Abbreviations for charting
- abd abdomen or abdominal
- BRP bathroom privileges
- DM diabetes mellitus
- fx fracture
- NKDA no known drug allergies
- OOB out of bed
- pc after meals
- PRN as needed
- STD sexually transmitted disease
- tid three times per day
- q every (note that the abbreviations Q.O.D., QOD, q.o.d., qod, Q.D., QD, q.d., and qd are on the Joint Commission “do not use” list. The letter “q” in other combinations is not on that list.
- LUQ left
- upper quadrant
- LOOK ON PAGE 183 VOL 2
Oral report on a patient
- Patient/Problem: include patient's name, room number, diagnoses, reason for admission, and recent prcedures. State the present problem. Briefly summaraize medical history relevant to the current problem
- Assessment/Changes: Coninuing needs and potential changes
- Evaluation: evaluation of responses to nursing and medical interventions, progress toward goals, and effectiveness of the plan.
- Assessment of situation
Describe ways in which handoff report may shared?
- The handoff report may be written or oral. Oral report allows interaction. Oral report may be given at the bedside or in a conference room and may be audio recorded.
- Bedside report
- Face to face oral report
- Audio-recorded report