Transcript Reporting, Documenting, Conferring and Using Informatics

Reporting, Documenting, Conferring
and Using Informatics
Objectives
 List guidelines for giving an effective report
 Understand 24-hr clock
 Identify common abbreviations used in charting
 Describe the purposes of patient records
 Compare and contrast the different methods of
documentation
 Describe the nurse’s role in communicating with other
members of the health care team
 Understand the rationale for documentation guidelines
Objectives
 Understand the purpose of each of the following:
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Nursing assessment
Nursing Care Plan
Progress notes
Flow sheets
Discharge summary
Critical/collaborative pathways
Homecare documentation
Reporting
 Def: the oral, written or computer-based communication of
patient data to others.
 Purpose of report: to communicate something that has been
seen, heard, done or considered.
 It can be written, oral, audio taped, computerized
 Ex:
1. Lab reports
2. Procedure reports (x-ray, biopsies)
Nursing Reports
 Use SBAR format:
 Situation: Patient identification, diagnosis, MD’s name,
vital signs
 Background: Assessment findings, lab values
 Assessment: Your assessment of patient’s current condition
 Recommendation: Do you think any changes are
necessary?
Types of nursing reports
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End of shift report: Off-going nurse gives necessary
information about patient/patients to On-coming nurse
May be written, face to face orally, audio taped, or videotaped
Telephone report: To or from other departments, to or from
MD’s
Transfer and Discharge Reports: To other departments/
nurses who will be caring for the patient
To family members and significant others: to inform
about the patient’s condition
Incident Reports: documents anything out of the ordinary
that has the potential to harm the patient
Morning Report
Nurse to nurse report
Group Report
Nurse’s worksheet - or “Brain”
Report Form
End of Shift Report
 Occurs at: (for 8 hr. shifts)
 0700: night shift to day shift
 1500: day shift to evening shift
 2300: evening shift to night shift
 OR: at 0700 and 1900 for 12 hr. shifts
24 Hour Time
Methods of Reporting
 Face-to-face meetings
 Telephone conversations
 Written messages
 Audio-taped messages
 Computer messages
Bedside End-of-Shift Report at the
Patient’s bedside
Change of Shift Report: Include
 Basic identifying information about each patient
 Current appraisal of each patient’s health status
 Changes in medical conditions and patient response to therapy
 Where patient stands in relation to identified diagnoses and
goals
 Current orders (nurse and physician) and unfilled orders
 Summary of each newly admitted patient
 Report on patient transferred or discharged
End of Shift Report: Guidelines
 Be professional
 Be courteous
 Be concise
 Ensure that you have all the necessary data at hand
 Keep report focused on the patient
 No gossip, rumor
 Students: Tell the RN/LPN all of the patient care that you
delivered; also anything not done
 Do not speak disrespectfully about the patient or
family
Documentation
Documentation
 Def: the written or typed legal record of all pertinent
interactions with the patient: assessing, diagnosing, planning,
implementing, and evaluating.
 Patient record: compilation of the patient’s health
information
 Everything contained in the medical record is confidential
information and protected by HIPPA law
Documentation
 Purposes for the medical record
1. Communication: means by which health care team members
communicate client needs and progress, therapies, client
education and discharge planning
2. Legal documentation: to limit nursing liability nursing
documentation must clearly indicate that individualized,
goal-directed nursing care was provided to the client based
on the nursing assessment. Nurses need to indicate all
assessments, interventions, client responses, instructions, and
referrals in the medical record
Documentation: Purposes for the
medical record
Diagnostic and Therapeutic Orders
3.
a)
b)
4.
Verbal orders/Telephone orders: repeat back to MD to
verify; write on chart; must be signed by ordering MD within
24 hours
written or computerized orders: must contain MD’s name,
patient name, date and time, medication name or treatment,
amount, frequency, route
Care Planning: Outlining Nursing or interdisciplinary
goals for the patient’s care
Purposes of the Medical Record
4.
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Financial Billing: Reimbursement from insurance
companies and Medicare and Medicaid (DRG’s)
Education
Research (Requires consent from the patient)
Auditing/Monitoring (Quality Improvement)
Historical Documentation: because entries are by date and
time, can give a history of patient’s condition
Decision Analysis: Organizational strategic planning about
treatment methods, patient services
Characteristics of Effective Documentation
 Consistent with professional and agency standards
 Complete
 Accurate
 Concise
 Factual
 Organized and timely
 Legally prudent
 Confidential
Documentation Guidelines
 See attached p. 326 from textbook
 Also documentation should be:
1. Factual - be objective not subjective; quote the patient, if
necessary
2. Accurate - use exact measurements: “Midline abd. incision
measure 5” in length and 1” in depth with no obvious drainage or
odor”; not “Incision healing well”.
3. Complete - If it wasn’t charted, it wasn’t done
4. Current - vital signs, medications, treatments, changes in
condition, test preps
5. Organized - should be in a logical, time sequential order,
written in 3rd person, not 1st person, and in passive tense
Documentation
 Ex:
“Patient medicated for pain with Morphine 2 mg. IV
for a complaint of pain of 8/10 @ 8:45.”
Not:
“I gave the patient 2 mg. of Morphine because he said he was in sever
pain”
 Ex:
“Patient prepped for colonoscopy per order with 1
Liter Golytely prep.”
Not:
“ I prepped the patient for the colonoscopy like the order said to.”
Documentation
 These are actual excerpts from medical records:
 “Patient has chest pain if she lies on her left side for over a year”
 “On the second day the knee was better, and on the third day it
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disappeared.”
“The patient is tearful and crying constantly. She also appears to
be depressed”
“The patient has been depressed since she began seeing me in
1993”
“Discharge status: Alive but without my permission”
“Healthy appearing decrepit 69year old male, mentally alert but
forgetful”
Documentation
 “The patient refused autopsy”
 “The patient has no previous history of suicides”
 “Patient has left white blood cells at another hospital”
 “She is numb from her toes down”
 “While in ER, she was examined, X rated, and sent home”
 “Patient stated she has been constipated most of her life, until
she got a divorce”
 “I saw your patient today, who is still under our car until she
is seen by physical therapy”
Documentation
 “Patient was seen today by Dr. Blank, who felt we should sit
on the abdomen, and I agree.”
 “Rectal exam revealed a normal sized thyroid”
 “I saw your patient today, who is still under our car until she
is seen by physical therapy”
Methods of Documentation
 Source-oriented records
 Problem-oriented medical records
 PIE charting
 Focus charting
 Charting by exception
 Case management model
 Computerized documentation
 Electronic medical records (EMRs)
Methods of Documentation
 Source-Oriented Records: each healthcare discipline has its
own section of the chart; sections for MD’s, nursing,
laboratory, social services, physical therapy, procedure
reports; use progress and narrative notes
 Problem-Oriented Medical Records: all healthcare
disciplines use the same forms referencing patient problems;
uses SOAP or SOAPIE or SOAPIER (subjective, objective,
assessment, plan, intervention, evaluation, response
Patient Chart
Electronic Medical Record
Computerized Bedside Charting
Methods of Documentation
 PIE: Problem, Intervention, Evaluation; problems are
identified by number and addressed in the documentation
used flow sheets; no formal care plan
Sample PIE Patient Care Note
Sample Focus Patient Care Notes
Case Management Models
 Collaborative pathways
 Variance charting
Major Components of POMR
 Defined database
 Problem list
 Care plans
 Progress notes
Formats for Nursing Documentation
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Initial nursing assessment
Kardex and patient care summary
Plan of nursing care
Critical collaborative pathways
Progress notes
Flow sheets
Discharge and transfer summary
Home healthcare documentation
Long-term care documentation
Types of Flow Sheets
 Graphic record
 24-hour fluid balance record
 Medication record
 24-hour patient care records and acuity charting forms
Incident Reports- Include
 Complete name of person and names of witnesses
 Factual account of incident
 Date, time, and place of incident
 Pertinent characteristics of person involved
 Any equipment or resources being used
 Any other important variables
 Documentation by physician of medical examination of
person involved