302 Documentation

  1. Written or typed, legal record of all pertinent interactions with the patient
  2. What does Documentation contain data for?
    • Facilitate patient care
    • Serve as financial and legal record
    • Help in clinical research
    • Support decision analysis
  3. Compilation of a patient’s health information:
    Patient Record
  4. Joint Commission on Accreditation of Healthcare Organizations (JCAHO)-
    • Specifies that nursing care data be implemented into the patient record.
    • Patient assessment
    • Nursing diagnosis
    • Patient needs
    • Nursing interventions
    • Patient outcomes 
  5. Documentation Guidelines:
    • žAim: complete, accurate, concise, current, factual, and organized data communicated in a timely and confidential manner to facilitate care coordination and serve as a legal document.
    •    Content
    •    Timing
    •    Format
    •    Accountability
    •    Confidentiality
  6. Content documenting Guidelines:
    • *Avoid words such as "good, aerage, normal, or sufficient"
    • *Record patient findings NOT opinions
    • *Avoid generalizations (ie: "feels comfortable")
    • *Note problems IN THE ORDER they occur
    • *Chart precautions or preventive measures used
    • *Document medical visits
    • *Document in legally prudent manner
    • *Document nursing response to questionable medical orders/treatment
  7. Timing documenting Guidelines:
    • *Chart in a timely manner
    • *Date and time of entry and time of observations/interventions
    • *Military time
    • *NEVER document before carrying out an intervention
    • *Write a progress note for:
    •    --admission, transfer to another unit, discharge
    •    --when procedure is performed 
    •    --receiving a patient postoperatively
    •    --upon speaking w/ physician about critical patient info
    •    --ANY change in patient's status
  8. Format documenting Guidelines:
    • *make sure you have the correct chart
    • *as designated by agency policy
    • *legible writing in dark ink (use standard terminology)
    • *Date/Time each entry
    • *never skip lines
  9. Accountability documenting Guidelines:
    • *Sign your fist initial, last name and title to each entry
    • (ex: K, Davis)
    • *Do not use dittos, erasures, or correcting fluids
    • *Identify each page of the record with the patient's name and ID number
    • *recognize that the patient record is permanent
  10. Confidentiality documenting Guidelines:
    • *Patients have a moral/legal right to expect that the information contained in their patient health record will be kept private
    • *Most agencies allow students access to patient records for educational reasons
  11. Military Time:
    Image Upload 1
  12. Problems in Documenting:
    • žCrucial Omissions
    • žMeaningless repetitious entries
    • žInaccurate entries
    • žLength of time

    • žProblems
    • -Undermine nurse’s credibility as a professional discipline
    • -Cause legal problems for the nurse responsible
  13. Confidentiality: 
    žAll info about patients is considered private or confidential.

    • Written on paper
    • Saved on computer
    • Spoken out aloud
    • Names
    • Address
    • Telephone number
    • Fax number
    • Social security
    • Reason person is sick or in the hospital, office, or clinic
    • Treatment
    • Information about PMH
  14. Protected Health Info. may be found in:
    Patient medical record

    Computer systems

    Telephone calls

    Voice mails

    Fax transmissions

    E-mails that contain patient info

    Conversations about patients between clinical staff
  15. Health Insurance portability and Accountability Act (HIPPA)
    ž**Workers must undergo HIPPA training and sign confidentiality agreements

    žPatients have a right to:

    See and copy their health record

    Update their health record

    Get a list of the disclosures a healthcare institution has made independent of disclosures made for the purposes of treatment, payment, and healthcare options

    Request a restriction on certain uses or disclosures

    Choose how to receive health info
  16. Agency Policy
    žEveryone who has access to the record (direct caregivers) is expected to maintain its confidentiality

    žMost agency grant nursing students access for education purposes….must hold info in confidence…Never use patient’s name when preparing written or oral reports

    žAgency policy indicates which personnel are responsible for recording on each form in the record…

    žPolicy also indicates order of chart

    žPolicy may indicate frequency to record entries

    žWhat to record

    • žManner to identify self :
    • Kelli Shugart, RN, GBCN Faculty
    • Sally Cabbage Patch, SN, GBCN
  17. Purpose of Patient Record:
    1. Communication with other workers

    2. Diagnostic and therapeutic orders

    A.Verbal orders-order must be given directly by the physician, or nurse practitioner to a registered nurse or registered pharmacist

    B.The only circumstance in which an attending physician, nurse practitioner, or house officer may issue orders verbally is in a medical emergency, when they are present but unable to write the actual order.

    4.Care Planning

    5.Quality review


    7.Decision analysis


    9.Legal documentation


    11.Historical documentation
  18. Verbal Order Sequence
    žThe RN who receives the order will:

    1.Record the orders in the medical record

    2.Read the order back to verify accuracy

    3.Date and note the time

    4. Record V.O. (verbal orders), name of the MD who issued the orders, followed by the nurse’s name and title

    • žExample:
    • žGive 0.25mg po lanoxin Daily, starting in Am 9/18/09  V.O. Micheal Smith, MD/Kelli Shugart, RN
  19. Verbal Orders:
    žIt is the responsibility of the physician or nurse practitioner who issued the verbal order to:

    1.Review the order for correctness

    2.Sign the orders with his or her name, title, and pager number

    3.Date and note the time he or she signs the orders

    žIt is the responsibility of the unit secretary and/or the registered professional nurse to see that the orders are transcribed according to procedure
  20. Telephone/Fax Orders:
    žAgency policy must be followed

    žEvery T.O. must be repeated back to ensure that the nurse correctly understands what was ordered.

    žMust be on an order sheet

    žCo-Signed by physicians within a specific time

    žFax orders must be legible and issued from a credentialed and privileged individual

    žFollow similar protocol as V.O. (1-3)

    4.Record T.O. (telephone order) and the full name and title of the physician or nurse practitioner (NP) who issues the orders.

    5.Sign the orders with name and title

    žIt is the responsibility of the physician or NP dictating the orders to sign them as soon as practical. With exception of orders for narcotics, anticoagulants, and antibiotics, which must be signed within 24 hours.
  21. Documenting Systems:
    1.Source oriented Records

    žTable 17-3 p. 336

    • -Advantage
    • -Each discipline can easily find and chart data
    • -Disadvantage
    • -Data fragmented

    2. Problem-Oriented Medical Record- (POMR)

    • žExample Box
    • 17-4 p. 337


    • -Entire health team works together to determine list of problems
    • -Collaborative plan of care
    • -Progress notes clearly focus on patient problems

    3.PIE charting system- Problem, Intervention, Evaluation- originated from nursing

    • žExample figure
    • 17-2 p. 338

    • -Does not develop separate plan of care
    • -At beginning of each shift patient problems are identified, numbered and documented in progress notes, and worked up using PIE format
    • -Resolved problems are dropped

    • žAdvantage
    • -Continuity and saves time (no separate Plan of Care)

    • žDisadvantage
    • -Nurses have to read all nursing notes to determine problems and planned interventions

    4.Focus charting

    • žFocus may be on a patient's:
    • Strength
    • Problem
    • Need

    • žTopics may include
    • -Patient concerns and behaviors
    • -Therapies and responses
    • -Changes in condition
    • -Significant events
    • -Narrative section uses the Data, Action, Response (DAR) format- example figure 17-3 p.339

    • žAdvantage
    • -Holistic emphasis on patient
    • -Ease of charting

    • žDisadvantage
    • -Some nurses argue that the DAR categories are artificial and not helpful when documenting care

    5.Charting by exception (CBE)- figure 17-4

    • žAdvantages
    • Decreased charting time
    • Greater emphasis on significant data
    • Easy retrieval of significant data
    • Timely bedside charting
    • Standardize assessment
    • Greater interdisciplinary communication
    • Better tracking of important patient responses
    • Lower cost

    • žDisadvantage 
    • -limited usefulness in response to negligence claims against nurses

    ž6.Case Management Model

    • žAdvantages
    • -Collaboration
    • -Communication
    • -Teamwork among disciplines
    • -Efficient use of time increases quality

    • žDisadvantage
    • -Works for “typical” patient 
    • -Collaborative Pathways/critical pathways/care mapping –
    • Variance Charting
    • žPersonal Health Records (PHRs)
  22. Major Parts of POMR
    • -Defined database
    • -Problem list
    • -Care plan
    • -Progress notes- BOX
    • 17-4 p. 338 narrative progress notes follows the SOAP format
  23. Used to organize data entries in the progress notes of the POMR
    The Acronym SOAP (Subjective, data, Objective data, Assessment, Plan)
  24. Caregivers select a problem from the master list and work up the problem on the _______
    Progress Sheet
  25. PIE Chart Example
    Image Upload 2
  26. Image Upload 3
    Focus Example
  27. žComputerized Documentation and Electronic Medical Records (EMR)
    Calls up admission assessment tool

    Develop plan of care using computerized care plans available (NANDA list)

    Adds to patient database as new data are identified and modifies the plan of care

    Receives a work list showing the treatment, procedures, medication necessary

    Documents care immediately using bedside computer
  28. Guidelines/strategies for safe computer charting
    Never share passwords

    Don’t leave computer unattended

    • Follow protocol when correcting errors, “mistaken entry” add correct info, date and initial entry.
    • If wrong chart, write “mistaken entry – wrong chart”.

    Never create, delete or change entries

    Back up files

    Don’t leave info about patient for others to see

    Never use email to send protect health info

    Follow policy for documenting sensitive material
  29. Nursing Documentation Formats:
    1.Initial nursing assessment- Database

    2.Kardex and Patient Care Summary p. 343

    3.Plan of Care- student example chapter 14

    • Diagnosis
    • Goals
    • Expected outcomes
    • Interventions

    4.Critical/collaborative pathways-chapter 14, Abbreviated case management plan

  30. What is the initial patient database obtained from?
    • Nursing History and Physical Assessment
    • **Provides baseline for later comparison as the patient's status changes
  31. Image Upload 4
  32. Progress Notes:
    There purpose is to inform caregivers of the progress a patient is making toward expected outcomes.

    The method used to record the progress depends on the documentation system used.

    Narrative nursing notes

    SOAP notes

    PIE notes

    Focus charting

    Charting by exceptions

     Flow sheets

    See Table 17-5 for advantages and disadvantages
  33. Flow Sheets
    Image Upload 5
    Graphic (clinical) Record

    24 Hour Fluid Balance Record

    Medication Record

    • 24 Hour Patient Care
    • Record and Acuity Charting Forms

  34. Long-Term Care Documentation
    • Specified by Resident Assessment Instrument (RAI)
    • Helps staff gather information on strengths and needs, and addresses these in individualized plans of care.

    • 4 components:
    • 1.Minimum data set


    3.Resident assessment protocols

    4.Utilization guidelines

    Statutory law, federal regulations, and Health Care Financing Administration specify how the RAI is implemented. 
  35. Documentation content that increases risk for legal problems:
    • *not in accordance with progessional organization standards
    • *content does not include descriptions of situations that are out of the ordinary
    • *content overgeneralizes patient assessment or nursing interventions
    • *content does not include appropriate medical orders
    • *content implues attitudinal bias
  36. Documentation Mechanics that increase risk for legal problems:
    • *lines between entries
    • *countersigning documentation
    • *tampering
    • *different handwriting or obliterations
    • *Illegibility
    • *Sloppiness (some lawyers infer sloppy care from sloppy charting)
    • *Dates & times of entries omitted or inconsistently documented
    • *Improper nurse signature or unidentifiable initials
    • *Transcription errors
  37. Face to Face Reporting:
    • Advantages:
    • Message can be delivered immediately
    • Nonverbal messages are readily conveyed
    • Message can be clarified; reciever's questions can be raised & answered

    • Disadvantages:
    • Both the communicating and the receieving people must be available at the same time, in the same place
    • *Ordinarily, there is no permanent record for later use
  38. Telephone Conversation:
    • Advantages:
    • *Message can be delivered immediately
    • *Message can be clarified; receiver's questions can be raised and answered
    • *Two parties need not be present in the same place

    • Disadvantages:
    • *Only the tone of voice and voice inflections can be communicated- no nonverbal messages
    • *Ordinarily, there is no permanent record
  39. Written Message:
    • Advantages:
    • *message can be exchanged at times convenient for the people involved
    • *Record is available
    • *Time-efficient if message is understood

    • Disadvantages:
    • *Message usually cannot be validated with the sender
  40. Audiotaped Message:
    • *Message can be exchanged at times convenient for the people involved
    • *Record is available
    • *Time-efficient if information communicated is complete

    • Disadvantages:
    • *Message usually cannot be validated with the sender
  41. Computer Message:
    • Advantages:
    • *Message can be delivered immediately even to those at ta great distance
    • *Parties need not be present in the same place
    • *Two-way communication is possible by email
    • *Record is available
    • *Many people can participate in exchange

    • Disadvantages:
    • *No nonverbal messages can be communicated
    • *Privacy concerns remain an issue
  42. SBAR communication:
    • S- Situation
    • B- Background 
    • A-Assessment
    • R- Recommendation
  43. Change of Shift Report:
    žBasic identifying information about each patient

    žCurrent appraisal of each patient’s health status

    (Changes in medical conditions and patient response to therapy... Where patient stands in relation to identified diagnoses and goals)

    žCurrent orders (nurse and physician)

    žSummary of each newly admitted patient

    žReport on patient transferred or discharged
  44. Conferring about Care:
    1.Consultations and Referrals

    2.Nursing and Interdisciplinary team Care Conferences

    3.Nursing Care Rounds
Card Set
302 Documentation
Exam 1