Transcript Slide 1

Nursing Documentation
Make It Your Best Friend
Presented by, L. Lydia Junco, RN,
BSN, WOCN/Legal Nurse Consultant
Quick and Dirty
• Why did you come to the patient/resident?
– Initial assessment: complete and sign in a timely
manner
– Routine assessment: Document all findings. If it
is a form fill in everything or indicate it was not
applicable. Blanks are open to interpretation.
– Acute issue: See example of acute intervention
OBJECTIVE DATA ONLY
Quick and Dirty
• What were your findings? ALL YOUR
FINDINGS
– Please don’t chart by exception, most people
don’t understand the concept. Document all vital
signs.
Quick and Dirty
• What did you do?
– Call MD,
– Start med,
– Give a prn (as needed),
– Initiate nursing interventions
Quick and Dirty
• Patient/resident response:
– Better
– Worse
– Same
Why did I come to bedside?
• Example: 09:30: Responded to CNA report of
resident has wrist pain.
My Findings
• Responded to CNA report of resident has right
wrist pain. Splint to right wrist in place. Able
to move fingers, brisk capillary refill in right
fingers. Reports pain as 5/10.
What did I do?
• Provided ice pack. Called Dr. Jones on his cell
(555-5555) and received orders for
acetaminophen now and prn. (See flow sheet
for vital signs). Nurse Purse
• 09:50: Acetaminophen 500 mg given by
mouth for wrist pain 5/10. Nurse Purse
Resident Response
• 10:30: resident reports wrist pain 2/10 and
wants to be taken to the Coffee Social. Nurse
Purse.
Example
• 09:30: Responded to CNA report of resident has
wrist pain. Splint to right wrist in place. Able to
move fingers, brisk capillary refill in right fingers.
Reports pain as 5/10. Provided ice pack. Called Dr.
Jones on his cell (555-5555) and received orders for
acetaminophen now and prn. (See flow sheet for
vital signs). Nurse Purse
• 09:50: Acetaminophen 500 mg given by mouth for
wrist pain 5/10. Nurse Purse
• 10:30: Resident reports wrist pain 2/10 and wants to
go to Coffee Social. Nurse Purse.
Start Over
• Then start over:
– Why am I at the bedside
– Findings (all findings)
– What did I do, who did I call
– What was resident response
Where do you document?
• In the medical record
– Not the 24 hour report or other tracking form.
• Sometimes in more than one place!
– CDR is used to count the controlled substances
– MAR tells that the drug was administered
– Back of the MAR must be completed for PRN’s
– Nursing notes
Mistaken entries
• DON’T
– Try to cover up
any charting
– Use correction
fluid
– Use black (or dark)
markers
– Don’t scribble
over the entry.
• DO
– Line through with one
line
– Write “mistaken entry”,
“EIC” or “void” above
or beside the entry.
– Enter date, time and
initial.
– Enter correct
information
Random Entries
• Example:
• 12/10/07 with an entry,
– followed by an entry dated 12/2/07
– followed by 12/10/07.
• Or, 12/10/07
– Followed by 12/13/07
– Followed by 12/10/07
• All on the same page.
Blanks
• Blanks in the MAR’s/TAR’s
• Blanks in the CNA delivery of care
• Blanks in routine follow-up: antibiotics, falls,
other acute problems (bleeding)
Documenting future events
• Will monitor with no further
documentation.
–If you “will monitor”, then you must
document your findings.
WILL is in the future.
• If plan of care:
– Plan: continue to monitor.
• Still must document findings.
(continued)
Documenting future events
• Don’t:
– Will tell nurse on next shift to do _______.
• Do:
– “Reported resident’s complaint of double and
blurred vision to day nurse, S. Syringe, RN and
requested she notify the physician and family.”
(continued)
Documenting Future Events
• Any care documented after the resident has
left the facility or expired
– CNA flow sheets
– Nursing flow sheets
– Meals
– Progress notes
TIMELY
Not timely and going to cause problems at the time
of litigation.
• Care documented for the whole shift at the
beginning of the shift.
• Charting parties
• Care documented after the patient/resident has
been discharged from the facility or has expired.
• Medications documented prior to administration.
TIMELY
• Numerous late entries
• Untimed entries
– Physician’s progress notes
– Nursing progress notes
– Telephone orders
– Verbal orders
NO Blaming
• Please do not point fingers at your fellow
healthcare providers.
– Document the objective facts
– If there is a problem report it to your department
head and keep it out of the medical record.
Blaming example
• 4/3/00: reported left lower
extremity skin tear to
charge nurse for follow-up.
• 4/4/00 Reported the skin
tear to the charge nurse, S.
Syringe, yesterday and again
today. She hasn’t done
anything about it. Now the
resident has an open,
oozing wound on her left
lower extremity.
• 4/3/00: Reported left lower
extremity skin tear to
charge nurse for follow-up.
• 4/4/00: Reported left lower
extremity skin tear to
charge nurse for follow-up.
3 cm x 2 cm skin tear on left
lower extremity with scant
serous exudate at margins.
Skin flap adherent to 90% of
surface. Cleansed with
sterile normal saline.
Resident with pain 3/10…
No Name Calling
• Refer to family members, patients, residents,
visitors and fellow co-workers by their names
(if known). No descriptors are necessary.
– Explain behaviors objectively, without name
calling.
– Don’t: Resident’s daughter is crude and bossy.
– Do: Resident’s daughter shouted obscenities at
the staff when I explained that we could not tie
her mother down to the bed. DON responded.
Weak Documentation Practices
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Improper late entries
Misspellings
Incoherent entries
Entries not related to care you provide
Medical diagnoses
Lack of interdisciplinary communication
Out of sequence entries
Fragmented records
Strong Documentation Practices
• Include all discussions with patient/family
• Include all discussions with
physician/extender
• Orderly records
• Timely records
• Retention of records
• Time/date/signature
1.
2.
Why am I seeing
this patient? Or,
reason for
admission.
What are my
assessment
findings?
3.
What did I do?
All my findings.
4.
5.
Patient/resident response:
better, worse, same.
If better, document findings
supporting that and
appropriate monitoring.
If not better go back to #1.
Thank You
QUESTIONS
All photos © L. Lydia Junco