Transcript Challenges facing today’s nursing facilities

IS “FDT” AN APPROVED
ABBREVIATION?
KEY CONCEPTS OF
DOCUMENTATION IN TODAY’S
NURSING FACILITIES
KAREN LEE MCDONALD, BSN, RN
PRESIDENT & CEO, KLM & ASSOCIATES,
LTC CONSULTING, LLC
www.klmltcconsulting.com
Objectives
1. Identify three of the most common forms
of documentation of patient care in skilled
nursing facilities.
2. Identify the main components of an audit
of a medical record.
3. Identify the common “Do Not Use”
abbreviations as supplied by The Joint
Commission.
4. Identify strategies for assisting the
nursing staff to document the
observations and care provided for the
residents in Skilled Nursing Facilities.
Our prime purpose in this life is to help
others. And if you can't
help them, at least don't hurt them.
- The Dalai Lama
First Things First
How is Your Memory?
Your memory is the basis
for any documentation!
•
•
•
•
•
•
•
•
•
•
Hill
Elephant
Stranger
Boat
Cup
Swimming
Book
Hole
Happy
Lamp
How Are Your Powers of
Observation?
Now:
Write down as many of
the words we just saw 2
slides ago.
Litigation
• Average time between
occurrence and a claim is
about 16 months.
• Average time from claim to
resolution is between three
to five years.
Can any of us really recall,
recollect, or remember ALL
details 16 months to 3 or
even 5 years later?
What is the Best Type of
Documentation?
• When deciding which type of form to use
for nursing documentation, first weigh the
inherent positives and negatives of each
general type--narrative, template, and
electronic.
• Above all, documentation forms must be
efficient, comprehensive, and reasonable,
and must prompt nurses to document
appropriately
Documentation Do’s “?”
• Key Things to Look for in Audits
– Correct chart?
– Documentation reflect the nursing process?
• APIE
–
–
–
–
Reflect that nurses professional capabilities?
Legible?
Response to medications?
Precautions or preventive measures used
documented?
– EACH phone call to a physician, including the
exact time, message, and response
documented?.
Documentation Do’s “?”
• Key Things to Look for in Audits
–
–
–
–
Patient care documented at the time provided
Late entries noted per policy?
Is the entire story told?
Use of “quotations” if observations being
attributed to someone else (family too)
– If it’s not charted, it wasn’t done
• Continually challenge your nurses on that!
– Objective charting, factual information only
• Subjective: “Patient drinking well
• Objective: “Consumed 1500 cc liquids between 8
am-12 pm.”
Documentation Don'ts
•
•
•
•
•
•
•
Charting symptoms without interventions
Altering a patient's record
Non approved shorthand or abbreviations
Imprecise descriptions
Early documentation
Charting “parties”
Use of negative patient labels
– “Resident is a whiner”
• Disciplinary documentation
– Noting that a nurse forgot something
Types of Documentation
• Narrative documentation
– Blank canvas which SOULD be based in
SOAP (Subjective, Objective, Assessment, and
Planning) template.
– Pro
• Flexible, especially for documenting complications,
new diagnoses, and other unforeseen occurrences
– Con:
• Completely up to the nurses to decide what they
document,
• Inefficient and leads to a lot of documentation errors
Narrative
Nurses Note courtesy of MedPass
Types of Documentation
• Checkbox/template
– Template form of documentation, combines a
string of checkboxes with an area for narrative
notes– Pro
• Convenient, efficient, and comprehensive approach.
Reminds staff what they need to document.
• Narrative area allows nurses to make extra
comments about the care or any unforeseen
complications.
– Con
• Paper based
• Nurses stop thinking for their residents
Check Box / Template
Skilled Nurses Note courtesy of MedPass
Types of Documentation
• Electronic documentation
– Despite the fact that many nursing homes have
not yet made the transition to electronic health
records (EHR), this is the preferential means of
documentation.
– Pro
• EHRs may be customized to capture whatever
information your facility deems necessary.
• Promotes the capture of uniform documentation.
• Eliminates the filing of loose paper
• Optimum for fighting litigation (paper trail)
– Con
• Start Up Cost
• Flexibility to alter once set up
But don’t let the computer be your master!
You still need to use your critical thinking skills!
Documentation Pitfalls
(Litigation)
• Bad documentation can make a good case
look bad and a bad case look even worse.
• One questionable entry can harm the
integrity of the entire record.
• Inconsistency = credibility issue.
• So what can we look for?
Altering of a Medical Record
“1/2 side rails x 2
indicated”
Late Charting,
Altering of the Situation
Nursing Note 10/7/99 10:45 p.m. :
“Patient found with right lower leg
caught in lowered side rail and left foot
caught under…error FD 10/7/99 11:45
p.m.”
“Resident stated he crawled over the side
rail and fell on the floor on right
side…..patient resting in bed…incident
happened at 5:05 p.m….”
Failure to Follow Physician Orders
Order: “Cipro 500 mg
PO QD x 3 days UTI”
MAR: Administered
Cipro only 1 day
Example of Medication Errors
Pt. Narcotic Record:
Vicodin administered
2/21/01, 2/22/01,
2/25/01
Vicodin “d/c’d 2/15/01”
Inaccurate (“Sloppy”) Charting
Care Plan:
“8/1/00”
• Care Plan dated 8/1/00
• Resident not admitted
until 8/2/00
“Copy Cat” Charting?
7/16/05-7/31/05 ADL
Flow Sheet: Charted
foley care 15 x after
foley d/c’d
7/10/05 Order:
“D/C Foley”
Defensive Documentation – Example of Inaccurate Charting
Note the
omissions…
Defensive Documentation – Example of Inaccurate Charting
Notice how the acuity level is
different on the activity
assistance level??
Independent
vs.
Extensive Assistance
Example of Failure to Notify
-Culture results received by facility 6/24/06
-Faxed to MD 6/25/99; no response received
-Infection resistant to Cipro
-No follow-up by facility until 10 days following initial UA
and 4 days following culture report
Accurate Narrative Charting
Notice the Times Entered
Auditing For Acceptable Practice
• The practice of nursing is an art.
Acceptable practice is guided by your
education and your “community” standard.
“…roasted like
chicken…”
Documenting Incidents, Adverse
Events and Meetings
• Patient Record
– Document only the details of the event
– No blame, the record is NOT and Incident
Report
• Incident Reports
– Must be complete, they are your record of
findings
• Meetings
– QA&A (PI) is the most important aspect. All
adverse events MUST be noted in a PI format
and reviewed for changes in system as
required
Abbreviations
• Each facility / organization should adopt
their own approved abbreviation list
• Update annually
• Compare to the Joint Commission list next
(small)
• Key is to utilize and audit to such
“Unofficial” Do Not Use
List
•
•
•
•
•
•
•
FTD
GLM
GOMER
POA
FLK
OG-FROG
WOW
What Can I Do?
• Master log of initials, identify who did the
documentation 5 years AFTER the incident
• Sample audit, amend to YOUR
documentation system
• If able, begin to move towards an EMR
that is intuitive to nursing “critical thinking”
skills
• Stand firm, recognize excellence, correct
observed opportunities
• And remember…..
"The most important
practical lesson than
can be given to nurses
is to teach them what
to observe."
- Florence Nightingale
Questions and answers