Transcript Documentation and Reporting

Documentation and
Informatics in Nursing
Entry Into Professional Nursing
Summer 2009
Why Document?
 Accreditation (TJC)
 Reimbursement (DRG’s, Medicare)
 Communication (Continuity, education)
 Legal (Not documented, not done)
Multi-Disciplinary Communication
 Reports-Oral: End of shift

Written
 Record-Chart: Permanent, legal,
healthcare management on-going
account
 Healthteam: All disciplines, nursing,
social workers, discharge planning PT,
OT, RT
Documentation
 Anything written or printed that is relied
on as a record of proof for authorized
persons
 Reflects quality of care
 Provides evidence of healthcare team
members care rendered
Purposes of Records
 Communication
 Legal Documentation
 Financial Billing
 Education
 Research
 Audits-Monitoring
Guidelines for Quality
Documentation & Reporting
 Factual
 Accurate
 Complete
 Current
 Organized
Follow TJC Standards
 Physical
 Psychosocial
 Environmental
 Self-care
 Client education
 Discharge Planning
 Evaluation of outcomes
 Nursing Process oriented
Types of Documentation
 Narrative
 POMR
 Source records
 Charting by Exception
 Critical Pathways
 Record Keeping Forms
 Acuity Recording Systems
 Standardized Care Plans
 Discharge Summary Forms
Types of Documentation
 Discharge Summary Forms
 Home Health
 Long Term care
 Computerized
Narrative
 Traditional type of nursing charting
 Story-like, repetitive
 Time consuming
Problem-Oriented Medical
Records
 Data organized by problem or diagnosis
 Ideally all healthcare team members can
contribute to list
 Coordinated plan of care
 POMR Components: Database, problem
list, NCP, progress notes
POMR Database
 History and physical
 Nursing admission assessment
 On-going assessment
 Labs
 Radiology reports
 Record of each hospital visit
POMR Problem List
 Holistic needs based on data
 Chronological list on front of chart
 Dates when problem resolved or new
problem occurs
POMR Progress Notes
 SOAP/SOAPIE Notes: Subjective data,
objective data, assessment, plan,
intervention, evaluation
 PIE Charting: Problem-InterventionEvaluation
 Focus Charting/DAR-Data (subjective
and objective) Action (intervention)
Response of Client (evaluation)
Source Records
 Chart is so organized that each
discipline has own section to record data
 Sections can be easily located
 Disadvantage: Not organized by client
problems
 Narrative style notes
Charting by Exception
 Streamlines documentation
 Reduces repetition, saves time
 Short version to document normals, routine
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care items
Based on established standards
Progress note when standard not met
Assumes all standards are met unless
otherwise charted
Exceptions must be noted
Critical Pathways
 Multi-disciplinary care plans used in case
management
 Key interventions, expected outcomes,
time frame
 Variances charted and analyzed
Record Keeping Forms
 Admission Assessment/Nursing history
 Graphic Sheets (Vitals, weights, I&O)
 Nursing Kardex
 Medication Administration Records
Acuity Reporting Systems
 Staffing patterns based on acuity of
patients
 Numeric rating for interventions
 Varies per unit and standard
 Update every 24 hours and justify
Standardized Care Plans
 Pre-printed established guidelines
 Based on health problems
 Need to modify based on individual
assessment, update and use judgement
 Standards of care are known, promotes
continuity, staff knowledge
Discharge Summary Forms
 DRG’s encourage early discharge, but
must ensure good patient outcomes
 Necessary resources, Client and family
involved in process
 Begins at admission
 Client education integral to process
(food-drug interactions, rehab referrals,
medications, disease process)
Home Health
 Medicare/Medicaid Guidelines
 50% of nursing time is documentation
 Care witnessed by client and family
 Good assessment skills
 Health care team focused
 Direct care in home
 Use of laptops for documentation
Long Term Care
 Residents not clients
 Governmental agencies: Many
standards and policies regarding
assessments, individualized plan of care
 Dept. of Health in each state determines
frequency of charting
 Skilled Nursing Units
Nursing Informatics
 Computer based patient care record
 Assessments, care plans, MAR’s
physician orders
 Maintain confidentiality with pass codes,
looking at other records
 Nursing Information Systems
 Clinical Information Systems
 Electronic Medical Record
Reporting
 Oral or written
 Change of shift
 Nurse to nurse
 Promotes continuity
 Report on client health status, care
required for next shift, significant facts,
head to toe assessment, pertinent labs,
priority needs, treatments, family issues
SBAR Technique for
Communication
 S- Situation
 B- Background
 A- Assessment
 R- Recommendation
End of Shift Report
 Keep professional
 Avoid judgemental language
 Include assistive personnel
Telephone Reports
 Inform physician of changes
 Client transfers to different units
 Result reports from lab or radiology
 Client transfers to different institutions
 Info needed: When call made, to whom,
info given
 Keep clear, accurate, repeat info if
necessary
Telephone Orders
 Physician to RN
 Physician must co-sign within 24 hours
 Nightime, emergency orders
 Guidelines and procedure per institution
 Be careful, precise and accurate with
order
 Write order as said by physician, repeat
it back
Transfer Reports
 Unit to unit report
 Phone or in person
 All pertinent data about patient
 Send all belongings with client
 Review clothing/belonging list prior to
transfer
 Transfer Sheet Documentation
Incident Reports
 Any event not considered routine (falls,
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needlesticks, med errors, accidental omissions,
visitor injury)
Risk Management will analyze trends
Changes in policy/procedure, educational
programs may be related to findings
Notify supervisor, physician of incident
Nurse who witnesses makes out report
Do not assign blame, be objective, facts only
Tips for Documentation
 Accurate, timely, thorough, factual, neat
 Use only approved abbreviations & terms
 Blue or black ink
 Always get and give report
 Focus on a team approach
 Date, time each entry, do not block chart
 Document in a timely fashion
 Follow the nursing process
 Use appropriate forms
Documentation Tips
 Correct errors promptly, using proper
technique
 Write on every line, leave no spaces
 Sign each entry with full signature and
correct title
 Follow institution policy and procedure
for charting
 Military vs standard time