Transcript Documentation Guidelines - Greater Baltimore Medical Center

Documentation Guidelines
Greater Baltimore Medical Center
General Documentation
Information
• Most nursing documentation is completed on the
computer using Meditech PCS
• Agency nurses will be required to take an 8 hour
Meditech course taught by GBMC before
beginning to work at the hospital
• This class will cover order entry, documentation,
and barcoding medication delivery / using the
electronic medication administration record
Patient Care System (PCS)
– PCS is the system for documentation that
reflects the nursing process, encourages clear
and concise charting, is legally sound, and
focuses on patient interventions to support
patient outcomes
– All information entered through PCS can be
viewed in the EMR (Enterprise Medical
Record)
With PCS, you are able to:
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Fill out the Admission Database
Record vital signs and I&Os
Document the patient’s Past Medical History
Document your head-to-toe assessment (using System
Flowsheets)
Enter nursing notes
Add Care Plans and record outcomes
View and print Kardexes and patient reports
Enter lab, radiology, respiratory, diet, and nursing orders
through order entry
Document medication administration through the
electronic MAR
Shift
– A shift is defined as 12 hours
– Documentation that is required q shift is to be
documented once every 12 hours, unless
physician orders or unit specific policies
dictate otherwise
– Change in patient status or change of care
provider necessitates a repeat of the q shift
documentation (i.e. Patient System
Flowsheets)
Real Time Documentation
• Documentation completed at the time the intervention is
performed
• In the event that “real-time” documentation is not
possible, documentation that occurs within one hour of
the intervention is acceptable, except for those
interventions with a time interval less than one hour (i.e.
q15min)
• Any documentation entered into Meditech after the one
hour time interval must be retrospectively documented by
defining the exact time the intervention was actually
completed
• Continuous reassessment of the patient is a nursing
expectation, with documentation expected as changes
occur
Standard of Care
• Upon admission, each patient will have the
appropriate “Standard of Care” (SOC) added to
their intervention list in Meditech
• The SOC is a predefined set of interventions that
are designed for that patient’s population
• Once the SOC and all physician orders are
entered through Meditech order entry, the
intervention list the nurse will document from
will be complete and ready to be documented on
Plan of Care
• The plan of care for the patient includes all
computer documentation, entered orders, as well
as a defined Care Plan
• Every admitted patient must have a care plan
added within 24 hours of admission
• Care plans all have problems and expected
outcomes that are documented against once every
12 hours
• Care plans can be updated as needed to reflect
new problems or change in patient status
Notes
• Nursing notes are entered on
a patient in the following situations:
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Admission
Transfer
Discharge
When an unusual event occurs or with change of
patient status
– When an appropriate intervention cannot be found to
document on
Documentation Details
• A nurse can skip a question on an
assessment if he/she is unable to assess the
question due to patient condition or if the
question is not applicable for the patient at
that time
• Any retrospective documentation can be
entered up to 3 days following patient
discharge
Documentation Details
• Changes to documentation may only be
made by the person who recorded the
documentation
• Partially documented entries,
documentation editing, and undoing
documentation can be completed by
clicking in the History column for the
appropriate intervention
Transfer of Patients
• Transferring unit will change the status of any
appropriate interventions from “Active” to
“Complete” by clicking in the Status column
– Completed Admissions Documentation
– System Flowsheet
• Receiving unit stops all nursing orders initiated in
order entry, enters transfer orders according to
policy and procedure, and the nurse will add on
the correct system flowsheet for the patient on
the intervention list using the “Add Intervention”
Function
Order Entry
• All paper physician order sheets
must be faxed to pharmacy upon
admission
• Pharmacy will enter any medications and IVs
into Meditech – the list of current medications
can be viewed in the EMR by clicking on the
Medications tab
• All non-medication orders will be entered by
the nurse or secretary into the Meditech order
entry system
Order Entry
• It is the RN’s responsibility to verify ALL orders
(lab, radiology, nursing, etc.) are entered into
Meditech from the Physician Order Sheet (Use
Order History in the EMR)
• Initial each individual order with red ink after
verification that the order is in Meditech
• After all orders have been entered and verified, a
Kardex will be printed from the Meditech desktop
using the Reports button
Verification of Physician Orders
• For ancillary department orders requiring
pager notification (Respiratory Therapy)
the time of the page is written on the order
sheet next to the order
• Co-sign each set of
physician orders with
initials, title, date, and time
24-hour Chart Checks
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Performed on 11pm – 7am shift
Review ALL orders written during the
previous 24 hours and verify they are in
Meditech by accessing the EMR (order
history section, sorted by date)
Sign entire physician’s order sheet with
name/initials, title, date and time in red
ink
Legal Medical Record
– Combination of the Patient’s PCS archived
discharge summary and the archived notes, as
well as any documentation from the paper
chart
– The Medical Records Department archives
these items 60 days after discharge
– The discharge summary and notes are
available upon request from the Medical
Records Department
Admission Documentation
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Document all interventions that have a frequency of “On Admission”
Also required to document the following, as appropriate:
– System Flowsheet
– Fall Risk / Safety Assessment Tool
– IV Assessment / Invasive Line Status
– Pain Assessment / Reassessment
– Skin Risk Assessment
– CAM
– General Education Record
• Nursing Note with Admission Details
• Add a Care Plan to patient using
“Process Plan”
• Print Out Home Medication Report from Meditech Desktop after entering in
list of Patient’s Home Meds during admission
Discharge Documentation
• The physician writes the discharge instructions
• The nurse is responsible for reviewing all instructions
with the patient and obtaining the patient signature
• Carenotes can be printed out from the Infoweb (click on
Micromedix link to access) for patient education
• The nurse should make sure the patient understands the
complete list of medications the patient is to take once
being discharged (compared to any medications the
patient was taking on admission), as part of the
medication reconciliation process
• Original form goes to medical records and a copy is given
to the patient upon discharge
Blood Administration
Documentation
• Blood Transfusions are documented as an Intervention
Set, which can be added using the “Add Intervention”
link on the Intervention worklist (search for “set”)
• The set is comprised of:
– Blood Administration Verification (completed just prior to
starting infusion)
– Blood Product Infusion (start time and initial rate)
– Infusion Changes (any rate changes during infusion)
– Blood Product Completion (completed at end of infusion)
– Blood Vital Signs (baseline vitals taken at start, then q15min x 2
after initiation, then hourly)
Documentation of Wounds
• Wounds are documented as an Intervention Set,
which can be added using the “Add Intervention”
link on the Intervention worklist (search for
“set”)
• The set is comprised of:
– Wound / Pressure Ulcer Status Assessment: for initial,
weekly, and change of status wound documentation
(more detailed)
– Wound Care / Dressing Change Assessment: for daily
documentation of dressing changes (focused
assessment specifically for dressing changes)
Critical Lab Values
Documentation
• The lab will call the nurse (as well as the
physician) responsible for taking care of the
patient with the critical lab value
• The telephonic critical result, upon receipt, will
be read back to the technologist/technician and
documented as having been read back. If that
does not happen, the technologist/technician will
request that the nurse receiving the critical result
read it back.
Critical Lab Values
Documentation
Procedure
1. Verify the result by verbally reading the result
back to the technologist/technician
2. Notify the nurse assigned to the patient of the
critical result if she/he was not the one to
receive the telephonic notification.
3. Document receiving the phone call about the
critical value, the critical result, and what you
did about the result on the Critical Lab Values
Intervention in Meditech PCS.
EMR
• The Enterprise Medical Record (EMR) is where
all the documentation for your patient is located
• To open the EMR from PCS, click on “Open
Chart”
• Once in the EMR, you can click
on the options on the right side
of the screen to view documentation,
reports, labs, orders, etc.
Computer Downtime
• In the event of a computer downtime, the
documentation system reverts back to paper (all
paper forms will be stocked on units)
• For downtime less than 4 hours (med/surg) and 2
hours (critical care), information that is recorded on
paper will need to be entered into PCS
• For downtime exceeding 4 hours (med/surg) and 2
hours (critical care), the paper system will replace
PCS until the end of the shift and until the system is
back up – the only data that must be re-entered into
PCS in this case are the Vital Signs and the I&O, so
the EMR record will be accurate
Unscheduled Downtime
• A 24-hour report, by unit, will be available upon
request from the MIS Helpdesk, x3725. The unit
is responsible for picking up this report from the
MIS department, building 9, 5th floor. The report
includes the following documentation:
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Vital Signs
Intake and Output
System Flowsheet
Pain Assessment
PCA: IV and Epidural
Scheduled Downtime
• The unit is responsible for printing the following reports one hour
prior to the downtime:
– Nursing Downtime Flowsheet
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Click on Reports button from desktop
Click on Patient Reports
Select Flowsheet Report
In Format box, Press F9 and select Nursing DT Flowsheet
Fill in Patient Last name and press F9 in Patient section
Select correct patient and click on green check mark to print
– Patient Kardex
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Click on Reports button from desktop
Click on Patient Reports
Select Profile Report
Fill in Patient Last name and press F9 in Patient section
In Use Profile Format box, press F9 and select Pt Kardex – Treatment record
and click on green check mark to print
Meditech Help
• Can be found on the nursing page of the
Infoweb
Scroll down on the
nursing page and click
on Meditech Help
Link
What stays on paper?
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Consent forms
Admission / Transfer Summaries
OR/Recovery Documentation
Physician Order Sheets
Documentation During Patient Codes
Pre-op Checklist
Discharge Instructions
Labor Event – Triage up until Delivery
Monitoring Strips
Paper Documentation Guidelines
• When your signature is required on any form,
legibly sign your full name and status (i.e RN)
• Before using your initials on any paper form, be
sure to sign the Signature/Initial record in front of
the medical record
• Use black or blue ink pen for all entries, except
when signing off medications – which should be
done using red ink
• If part of the paper medical record is damaged in
any way (spills, tears), do not destroy the form –
simply cross-reference to a newly initiated form
Documenting a Telephone Order
from a Physician
• Indicate date/time order was received
• Document order as stated by physician
• Read the written order back to the physician to
verify accuracy
• Document under the order RBO (read back
order) and the recorder’s initials
• Sign order: v.o. Dr. Jones / Kay Smith RN
• Place a “sign here” sticker next to order
• Flag the record green for a regular order and red
for a STAT order for the secretary
Time-Out VISA
• To be completed on ALL surgical and
invasive procedures for which consents are
required. This includes bedside procedures
such as central lines, chest tubes,
thoracentesis, etc.
• 3 Sections: Patient Verification, Site
Marking, and Time Out for Procedure or
Operating Room
Section 1: Patient Verification
• Two identifiers: patient name and date of
birth
• Compare to ID band, consents, diagnostic
images, and all other patient
documentation related to the procedure
• All areas on the VISA under section 1 are
to be initialed
Section 2: Site Marking
• Completed whenever laterality may become an issue
• Performed by physician or person performing the invasive procedure
• Exceptions
– If not multiple digits/structures
– Procedure occurs through an orifice (dental, colonoscopy, etc)
– NICU babies
• Green bracelet used on operative side
when patient refuses site marking
• All areas to be initialed
if appropriate
Section 3: Time-Out
• Completed just prior to the beginning of the
procedure
• Includes the patient
• All members present for the Time-Out must be
identified
• All areas to be initialed and form signed
• References: Verification of Correct Site, Correct
Procedure, Correct Patient and “Time-Out” for
Invasive or Surgical Procedure; and Guidelines
for Completing Procedure Visa