The act of recording client assessments and care in written or electronic form; Creating a record of client assessments and care
Documentation
Name at least 4 purposes for a written patient record (there are 7 total):
1. Communication b/w providers
2. Educational tool (something to give the patient when discharged)
3. Legal documentation
4. Quality of improvement (chart audits from Medicare and Medicaid)
5. Research
6. Reimbursement (some insurances will only pay for certain things so long, so nurses <case managers> manage this by going through patient charts while hospitalized)
7. Education
Type of documentation system: Disciplines charted seperately; variety of sections; info can become scattered (Common type used)
Source-oriented documentation system
Type of documentation system: Organized around patient problems; components are database, problem list, plan of care, and progress notes; allows greater collaboration (Main type used)
Problem-oriented documentation system
What are the 7 types of charting?
1. Narrative
2. SOAPIER
3. Charting by Exception (CBE)
4. Focus
5. PIE
6. Fact System
7. Electronic Entry Format
Type of charting: Can use with source oriented or problem oriented; story of care in chronological format; tracks the client's changing status; can be lengthy and disorganized
Narrative
Type of charting: Used only in problem oriented charting; Esatblished an ongoing plan of care; Problems, Interventions, Evaluations (of intervention)
PIE
Type of charting: Subjective data, objective data, assessment, plan, intervention, evaluation, revision
SOAPIER
Type of charting: Highlights the client's concerns, problems, or strengths in three columns; 1-time and date, 2-focus or problem being addressed, 3-charting in DAR format (Data, Action, Response)
FOCUS
Type of charting: Chart only signifigant findings or exceptions to norms; streamlines charting and saves time; uses preprinted forms and checklists; inadvertant omissions are the biggest problem
Charting by Exception (CBE) - used in most all hospitals and offices with electronic medical records
Type of charting: Flow sheets (individualize specific services), Assessment (with baseline data), Concise (progress notes), Timely (entries)
FACT
Admission database: The chief complaint needs to be worded in what way?
Exactly what the patient states, enclosed with "quotations"
What all does the Admission Database encompass?
Chief complaint, Physical assessment data, Vital signs, Allergy information, Current medications (and possible side effects), Activities of daily living (ADL) and discharge information/needs, and Data about client support system and contact information
A document that: makes it easy to record routine aspects of care, document assessments according to body system, track client response to care, intake and outtake record, and graphic records (used to record vital signs)
Flow Sheets
What does MAR stand for?
Medication Administration Record
Comprehensive list of all ordered medications; provides information on a client's medication allergies; documents scheduled, PRN, STAT, or omitted medications
Medication Administration Record
A worksheet for nurses that is not part of the legal chart; includes demographic information, medical diagnoses, allergies, diet/activity orders, and safety precautions, IV therapy orders, ordered treatments, summary of meds ordered,and special instructions; this document is discarded upon the patient's discharge
KARDEX
What does IPOC stand for?
Integrated Plans of Care
A combined charting and care plan form; maps out on a daily basis from admission to discharge (client outcomes, interventions, treatments for a specific diagnosis or condtion, lab work, diagnostic testing, meds, and therapies included in the pathway
Integrated Plans of Care
The nurse has just medicated a client for pain. Documentation of this intervention would be found on:
D) The progress notes and the MAR
Informing other caregiversabout the client's condition; Passage of vital information related to the client's status/plan of care; given nurse to nurse, or nurse to physician
REPORTING
A document that is never part of the patient's medical record, meant for quality control only; formal record of unusual incident
Occurrence Report (aka Incident Report)
What is the most common type of "hand-off" report?
Walking Rounds
Never leave the floor without telling another nurse what is going on with your patient; you would be guilty of abandonment and could possibly lose your license. What type of communication is this referring to?
Hand-off Reporting
How do you keep it CUBAN?
Confidential
Uninterrupted
Brief
Accurate
Named Nurse -- FIRST AND LAST NAME
What is a transfer report?
This is a report given to another healthcare provider from another facility that is accepting a patient through transport
Is it important to get the last name of the nurse you speak with in regards to transferring a patient to another facility?
ABSOLUTELY! There could be more than one nurse with the same first name and to make sure you have covered all your bases, you must be thorough!
What is a discharge summary?
This is a document created for the sole purpose of documenting the client's condition upon discharge. The information should include time of departure, method of transportation, name and relationship of person accompanying patient upon discharge, teaching and handouts given to the patient before discharge, instructions to follow (including medication, treatments, and activity), AND follow up appointments or referrals given.
Type of physician order: Spoken to you, often during a patient emergency; should be made for critical change in patient's condition
VERBAL ORDERS
Type of physician order: Received by phone and transcribed onto chart order sheet; this type has an increased risk for errors
TELEPHONE ERRORS
True or False: In regards to verbal/telephone physician orders, it is common for a nurse to document an order that was received by a team nurse.
FALSE - you are only to document orders that have been directly given to you by the physician!
How long does a physician have to coutersign a verbal/telephone order they gave?
24 hours
What does MDS stand for?
Minimum Data Set
Minimum data set for resident assessment and care screening must be completed within 4 days of admission and updated every 3 months - What type of facility follows this procedure?
Long-term care facilities (ex. Nursing Homes)
True or False: When an Occurrence Report is filled out for a patient who fell out of bed and fractured a hip, the report is a legal binding document that must be charted in the patient's medical record.
FALSE - this form is for internal purposes only
When charting by hand, what two color inks are acceptable?
Black or Blue
If a patient refuses medication, what should you do?
Record on the medication administration record in narrative form
If you make a hand-written mistake in the chart, what should you do?
Draw a single line through the error and initial the changes
