Transcript Record

Healthcare Core Curriculum
Competency 5: Report & Documentation
Dede Carr, BS, LDA
Karen Neu, MSN, CNE, CNP
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Explain the components of accurate and
appropriate documentation and reporting
including common medical abbreviations
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Report: An oral, written or computer-based communication
intended to convey information to others (Ramont & Niedringhaus,
p. 85)
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Record: Written or computer-based collection of data
(Ramont & Niedringhaus, p. 85)
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Medical or Clinical Record:
◦ Collection of all documents that are filed together to form a
complete chronological health history of a particular patient
(Juliar)
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◦ Formal, legal document that provides evidence of the
client’s care (Ramont & Niedringhaus, p. 85)
Charting/Recording/Documenting: Process of making an
entry into the client’s clinical record
(Ramont & Niedringhaus, p. 85)
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Notes and documents that health care workers
add to the medical records
Medical documentation is crucial for medical care
and health care services.
Aids in standard of care.
Allows proper reimbursement for treatment.
Neglecting to document a patient’s condition or
treatment may have serious consequences in the
future.
“If it is not documented, it didn’t happen.”
(Juliar)
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Communication
Planning client care
Legal documentation
Education, research, & healthcare analysis
Auditing
Reimbursement
(Ramont & Niedringhaus, p. 86, 88)
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Communication
 Vehicle or way by which different healthcare
professional who interact with the client
communicate with each other
 Prevents fragmentation, repetition, and delays in
client care
 Record also provides a central location for notifying
health professionals of the client’s needs, progress, &
current status
(Ramont & Niedringhaus, p. 85)
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Planning Client Care
 Each healthcare professional uses data from client’s
record to plan care for the client
 Example: Physician may determine that laboratory
values indicate presences of certain microorganisms
causing infection so orders an antibiotic
 Nurses use baseline & ongoing assessments to
determine effectiveness of interventions & the
nursing care plan
 Record provides a base from which all healthcare
disciplines (workers) may coordinate client’s care
(Ramont & Niedringhaus, p. 85)
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Legal Documentation
 Record is a legal document & admissible in court
 In some jurisdictions, it may be inadmissible in
court if the client objects, because information
given to a physician or nurse practitioner is
confidential
(Ramont & Niedringhaus, p. 85)
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Education, Research, & Healthcare Analysis
 Students use client’s records as an essential educational
tool
 Record can be a comprehensive view of the client, illness,
treatment strategies, & factors that affect outcome of illness
 Record information can be valuable source of data for
research
 Review of treatment plans for clients with similar health
problems can yield helpful information when treating new
patients with same problem
 May assist healthcare planners to identify agency needs
(can highlight overused or underused services
 Can identify services that cost agency money & those that
generate revenue (Ramont & Niedringhaus, p. 85)
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Auditing
 An audit is a review of records
 Client’s records are audited for quality improvement
 Example: Joint Commission (JCAHO) may review
client's records to determine if a particular health
agency is meeting its stated standards
(Ramont & Niedringhaus, p. 85)
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Reimbursement
 Documentation helps a facility receive
reimbursement (payment) from the federal
government
 Example: For a facility to obtain payment through
Medicare, client’s clinical record must contain
certain diagnosis-related group (DRG) codes &
reveals that the appropriate care was given
(Ramont & Niedringhaus, p. 85)
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History, Physical, and Consultations
◦ Report on the initial finding of all physicians seeing the
patient. Includes personal, family and social history of the
patient.
Physician’s Orders
◦ Written record of all medications & treatments prescribed
for the patient.
Diagnostic Tests
◦ Any report that includes findings in an attempt to diagnosis
the patient
(Juliar)
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Admissions
◦ Completed forms and consent
Surgical Procedures
◦ Consents for and reports related to any surgical
procedures performed.
Medication Record
◦ Includes all the medications that the patient is taking
Progress Notes
◦ A written chronological statement about a patient’s care
(Juliar)
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Because client’s record is legal document & may be
used to provide evidence in court must consider
many factors in recording.
Health care workers must maintain
◦ Confidentiality of clients’ record
◦ Legal standards in process of recording
(Ramont & Niedringhaus, p. 85)
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Date and time
Timing of documentation
Legibility
Permanence
Accepted Terminology
Correct spelling
Signature
Accuracy
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Sequence
Continued notes
Appropriateness &
completeness
Conciseness
Legal prudence
Additional tips for
documentation
(Ramont & Niedringhaus, p. 85)
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Date & Time
 Document date & time with each entry
 Make entries as soon as possible after performing
observation/assessment; task/intervention
 Record time using either conventional time
denoting AM or PM, or using 24-hour clock
(military time)
 Avoid block-style charting in which an entire shift is
documented under one date & time
(Ramont & Niedringhaus, p. 85)
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Timing of Recordings
 Follow agency policy regarding frequency of
documenting
 Adjust frequency of documentation as client’s
condition indicates--an unstable client requires
more frequent observation & documentation (client
in restraints needs frequent checking, observation,
& documenting)
 NEVER record nursing care before it is provided
(Ramont & Niedringhaus, p. 86)
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Legibility
 Make all entries legible & easy to read to prevent
interpretation errors
 Print your entries if cursive writing is difficult to
read
 Follow agency policy regarding handwritten
recording of healthcare worker’s notes
Permanence
 Make all entries on client’s chart permanent, nonerasable blue or black ink according to policy
 Ensure record is permanent & changes can be
identified
(Ramont & Niedringhaus, p. 86)
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Accepted Terminology
 Use commonly accepted abbreviations, symbols, &
terms specified by agency policy
 Write a term out in full if in doubt about whether to
use an abbreviation
Correct Spelling
 Use correct spelling to ensure accuracy in
documentation
 Look words up in a dictionary or other resource book
if unsure of correct spelling
 Spell similar medication names correctly to avoid
medication errors
(Ramont & Niedringhaus, p. 86)
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Signature
 Sign entries made in notes at the time you make the
entry
 Use name & title in the signature-Example: J. Green,
CNA would be correct, depending on facility policy
 Full signature should appear at least once on each page
 Use correct title abbreviations: RN=registered nurse;
LPN=licensed practical nurse; SN=student nurse in RN
program; SPN=student nurse in practical nurse
program
(Ramont & Niedringhaus, p. 86, 88)
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Accuracy
 Check that you have correct chart by verifying client’s
name & identification information stamped or written
on each page before making an entry or filing a report
 Make accurate notations—ones that consist of facts or
observations rather than opinions or interpretations
 [Describe what you see & hear, not what you think or
interpret for client actions]
 Quote client directly in client’s exact words when
documenting client’s concerns
(Ramont & Niedringhaus, p. 86)
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Accuracy
 Chart specific data rather than using general terms,
such as large, good, or normal that can be
misinterpreted [Example: “2 cm by 3 cm bruise”]
 Document a description of behavior you observed
rather than using terms such as anxiety or agitation
 Document objectively-what you see, hear, feel by
touch, smell
 Correct an error in documentation by drawing a single
line through it & writing the word error above it, with
your initials, or name, depending on agency policy
(Ramont & Niedringhaus, p. 86, 88)
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Accuracy
 Do not erase, overwrite, blot out, or use corrective
fluid
 Write on every line but never between lines
 Draw a line through any blank space & sign the
notation. In this way no additional information can be
recorded at any other time or by any other person
 Never leave a blank lines about your entry or between
your entries
(Ramont & Niedringhaus, p. 86, 88)
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Sequence
 Document events in order in which they occur:
observations, tasks/interventions, & client’s responses
 Make a late entry by clearly labeling your entry as late
according to facility policy
◦ Example: “Late entry [date] [time]” or ‘[date] [time] Late
entry”
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Do not make a late entry more than 24 hours after the
event. This is usually not permitted
(Ramont & Niedringhaus, p. 86, 88)
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Continued Notes
 Continue entries to another page by indicating that
note continues & signing the entry. On next page, enter
date/time of note & start it by indicating that it is a
continuation
Appropriateness & Completeness
 Record only information that pertains to client’s health
problems & care
 Record all observations, dependent & independent
interventions, client’s problems, progress toward goals,
& communication with other disciplines
(Ramont & Niedringhaus, p. 88)
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Appropriateness & Completeness
 Document any care that was omitted & include why it was
omitted & who was notified
 Use descriptions that are appropriate & accurate [avoid
stereotyping]
Conciseness
 Do not use client’s name when charting [since this is
client’s chart you do not need to use terms such as client,
resident, & patient (Check facility’s policy & procedures
 End each thought or sentence with a period; it is not
necessary to use full sentences
 Write notes so that data that follows comma is associated
with data that preceded it (Ramont & Niedringhaus, p. 88-89)
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Legal Prudence
 Document accurately & completely to protect
healthcare staff, the facility, & client
 Clinical record is legal document that provides
proof of the quality of care given to the client
 Follow general principle, “If its not charted, it’s
wasn’t done.”
 Follow agency policy & procedures for intervention
& documentation in all situations, especially highrisk situations
(Ramont & Niedringhaus, p. 89)
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Client’s clinical record is legal document &
admissible in chart which can be scrutinized by
attorneys,
Client may object because of confidential
information
Client’s record is property of facility
Client has right to a copy of information, but will
need to make a written request & pay for copying
When charting, be sure to use objective, factual
information rather than opinions & interpretations
(Ramont & Niedringhaus, p. 90)
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When charting, be sure to use objective, factual
information rather than opinions & interpretations
Not all data about a client should be recorded; any
personal information that client shares & does not
pertain to health problems or cares is inappropriate
for the record
Documentation is the determining factor in a great
percentage of malpractice cases involving client care
Important that you document client care clearly,
concisely, & accurately
(Ramont & Niedringhaus, p. 90)
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Accuracy – Just the facts. Only the facts and not opinions or
feelings.
Legible – Make sure that whatever is charted can be clearly
read
Date – Be aware of what format is to be used.
 Example: 01/25/11 or 25/01/11
Time – 12 hour clock or 24 hour clock
Full signature and title
Correct spelling
Because each healthcare facility may have their own
abbreviations, avoid using them (Juliar)
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Never erase, use white out, or corrective tape
Draw a single line through the error
Write in the correct information
Date and initial the correction (Juliar)
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Client’s record private & access restricted to health
professionals directly involved in giving care to client
Insurance companies have not legal right to demand access to
medical records, even though they may be determining
compensation to client.
Therefore a client who is making a claim for compensation
may ask to have medical history as evidence.
In order for an agency to provide requested information,
client must sign an authorization for review, copying, or
release of information from the record. This form must
specifically indicate what information is to be released & to
whom
(Ramont & Niedringhaus, p. 90)
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Each healthcare worker has a password to enter &
sign computerized files [Do not share these]
After logging on, never leave a computer terminal
unattended [If handheld, do not leave either]
Do not leave client information on monitor where
others can see it
Follow agency procedures for documenting
sensitive material
Conditions for confidentiality same for computer
records as they are for paper
(Ramont & Niedringhaus, p. 90)
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Either oral or written
Purpose: to communicate specific information to
person or group of people
Report should be concise with only pertinent
information
Change-of-Shift Report: report given to all nurses on
next shift—To provide continuity of care for clients to
provide new caregivers with quick summary of clients’
needs & detail of care given
May be written or oral, either face-to-face exchange or
by audiotape recordings; sometimes given at bedside
so all can participate (Ramont & Niedringhaus, p. 90)
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Health professionals give reports about clients to
healthcare providers and visa versa, to family
members, and patients
When receiving a telephone message, one should
document:
 Date & time
 Name of person giving the information
 What information was received
 Sign notation
Person receiving the message should repeat the
information back to the sender to ensure accuracy
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Juliar, K. (2003) Minnesota Healthcare Core
Curriculum (2nd ed.). Clifton Park, NY: Delmar
Publishers
Ramon, P.R. & Niedringhaus, D. M. (2008). Client
communication. Fundamental nursing care (2nd
ed.). (pp. 226-242). Upper Saddle River, NJ: Person
Prentice Hall
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