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Reports:
- 3 Types:
- ¡ Verbal
- ¡ Taped
- ¡ Walking / Bedside
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Report should answer:
- Why are they here?
- What has happened – prior hospitalization / visit, this shift…
- What is needed for the next shift?
- What is the overall plan?
- What information is needed for optimal care of this patient?
- Organization of report:
-
Multiple ways to give / organize report:
- Body systems
- Head to Toe
- Exceptions
- PACE -- P: Patient / Problem A: Assessment / Actions C: Continuing / Changes E: Evaluation
- SBAR -- S: Situation B: Background A: Assessment R: Recommendation / Request
- 4 P’s -- P: Purpose P: Picture P: Plan P: Part
- DATA’S -- D: Demographic / Diet A: Assessment / Allergies T: Tests and Results A: Alerts S: Status in plan of care
- CUBAN -- C: Confidential U: Uninterrupted B: Brief A: Accurate N: Nurse
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Barriers to an effective report:
- Multiple interruptions
- Incorrect information
- Lack of information
- Assumptions
- Side conversations
- Not ready to give report
- Lengthy
-
Keys to effective report:
- Be ready by change of shift.
- Have pertinent information at your fingertips.
- Make sure you have missed information ready for the next shift.
- Be brief, direct, and thorough.
- Report any task started but not completed.
- Report any task due on upcoming shift.
- Practice Time -- S = situation / B = background / A= assessment / R = recommendation
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Assessment:
- Systematic gathering of information
- Essential element of care
- Used to identify and assign priorities for care
-
Quick guide:
- Vital signs
- Pain
- General Appearance
- Skin
- Eyes
- Ears
- Nose
- Mouth / Throat
- Respiratory
- Cardiovascular
- GI / Abdomen
- GU
- Extremities
- Safety precautions
- Neurological
-
Documentation / Charting
- Legal document of care / QUALITY of care delivered.
- 1st thing consulted should any questions arise.
- Payment from insurance based on what is charted.
-
What to chart:
- Assessments
- Change in condition
- Objective descriptions
- Statements
- Interventions
- Use of safety devices / equipment
- Deviations or achievement of outcomes
- MD notification
- Procedures
- Consultations
- Involvement of family / others
- Activities
-
Documentation / Charting Do’s
- Documentation / Charting Do’s
- Begin at start of each shift
- Document accurately
- Know the requirements for your facility
- Provide details about client condition
- Remember that it is a permanent record and all information within is confidential.
- Document as soon as you provide care or make an observation.
- Chart chronologically.
- Date and Time all notes.
- Use a pen – blue or black
- Use a single line to mark out an error.
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Types of charting:
- Narrative
- ¡ Write out all the details
- SOAP
- ¡ Subjective data
- ¡ Objective data
- ¡ Assessment
- ¡ Plan
- PIE
- ¡ Problem
- ¡ Intervention
- ¡ Evaluation
- Exception
- ¡ Facility has a set of standards, only chart when those standards are not met.
-
Focus: DAR / DIR
- ¡ Data
- ¡ Action / Intervention
- ¡ Response
-
Pitfalls:
- Gaps
- Bias
- Deviation from policy and procedure
- Safety / Security of information contained on / in computer
- Does not reflect patient needs
- No descriptions of events / situations that are out of the ordinary
- Content is incomplete / inconsistent
- Handwriting / signature is illegible.
-
HIPAA: Health Insurance Portability and Accountability Act
- Created in 1996
- “…protects the privacy of individually identifiable health information, and the confidentiality provisions of the Patient Safety Rule, which protect identifiable information being used to analyze patient safety events and improve patient safety.” (www.hhs.gov/ocr/privacy; 9/23/09)
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How can HIPAA be violated?
- Report
- Conversations
- Computers
- Phone calls
- Cell phone use
- Facebook
- Blogs
- MySpace
- YouTube
- Twitter
- Email
- “All information about patients is considered private or confidential, whether written on paper, saved on a computer, or spoken aloud.”
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