Transcript DOCUMENTATION

“In God we trust, all others must document.”
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Patient’s record or the chart
Three Major Purposes
 Acts as a vehicle for communication among
members of the healthcare team.
 Documents compliance with standards of care
and standards of various accrediting organizations
such as JCAHO and the state health department.
 Documents that patient care meets safe, effective
and legal requirements.
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Ongoing assessment.
Patient teaching, including the patient’s
response to teaching and indication that the
patient has learned.
Response to therapy.
Relevant statements made by the patient.
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Contributes to quality patient care by
providing a physical record of the care you
provided
Facilitates communication between all
members of the health care team
Acts as a legal safeguard against allegations
of negligence and litigation, which why EDs
across the country are developing their own
specialized documentation forms and
systems
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Timely vital signs.
Reporting of changes in patient condition.
Medications given.
Patient response to medication, treatments
and interventions.
Discharge teaching.
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Take time to
document
accurately,
objectively, and
thoroughly
Be consistent and
document legibly
“If it wasn’t
documented,
it wasn’t
done.”
FACTUAL
Only information you see,
hear or otherwise collect
through your senses.
 Describe, don’t label.
 Be specific.
 Use neutral language.
 One of the most common
errors in documenting is
stating value judgments
and not facts.
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FACTUAL
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Factual documentation
also applies when you
make an error. That is,
state exactly what you did,
or failed to do, that you
notified the patient’s
physician and the
physician’s response.
ACCURATE
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Be precise. Quantify
whenever possible
COMPLETE
Condition change.
 Patient responses,
especially unusual,
undesired or ineffective
response.
 Your use of chain-ofcommand.
 Communication with
patient and family.
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COMPELETE
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Make entries in all spaces
on all relevant assessment
forms. Use N/A or other
designation per policy for
items that do not apply to
your patient.
TIMELY
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Date and time are critical in
establishing a timely
response to a patient need.
Some facilities make
timely charting easy by
locating the record close to
the patient.
TIMELY
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Computer entries are
automatically date and
time stamped at the time
of entry, but if your entry
refers to earlier events, be
sure that you note the time
to which you are referring.
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The best and safest practice is to document
as soon as possible after the event you are
documenting.
 You may forget key pieces of information when
rushing through documentation at the end of the
shift.
 Managing a load of many patients may cause you
to confuse or forget details.
 If your documentation is ever reviewed for legal
reasons and you have not documented
completely, you will be forced to rely on your
memory of events.
 Charting as your shift progresses will help keep
your documentation at the end of the shift to a
more manageable load.
 Professionals in other disciplines and nurses who
might provide temporary coverage need to have
up-to-date information available in the record.
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HOWEVER, avoid documenting
beforehand. This practice is illegal and has
contributed to errors and confusion.
NEVER document in advance! Too many
events can intervene to render your charting
inaccurate. Documenting in advance is
falsification of a legal record and can have
serious consequences in a legal action.
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Nurses too must exercise vigilance to keep
handwriting legible.
Clear communication is threatened not only
by messy handwriting or handwriting in
which all letters look alike, but also by neat,
pleasant styles that create ambiguous letters.
LETTERS
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a, c, e, o
b, d, f, h, I ,k, l, t
g, j, q, p, y
m, n, r, s
u, v, r
e, i
NUMBERS
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2, 7, 8
0, 4, 9
1, 7
3, 8
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You may need to slow down to write more
clearly.
You may need to resort to printing rather
than cursive writing.
When you encounter illegible handwriting of
physicians or others, do not guess the
intended meaning. Get clarification!
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On an obstetric nursing note:
 “The infant was born by virginal delivery.”
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On a nursing note on a medical patient:
 “When she fainted, her eyes rolled around the
room.”
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On an admission history and physical:
 “Diagnosis: Atomic dermatitis.”
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Nursing note:
 “The lab test indicated an abnormal lover function.”
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Nursing note:
 “The patient was alert and unresponsive.”
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Pre-surgical note:
 “The patient was to have a bowel resection.
However, he took a job as a stockbroker instead.”
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Emergency room note:
 “When the patient was in the ER, she was
examined, x-rated, and sent home.”
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Physical therapy note:
 “I saw your patient today who is still under our car.”
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Delivery room note:
 “The baby was delivered, the cord clamped and cut
and handed to the pediatrician, who breathed and
cried immediately.”
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Mistake
Accidentally
Somehow
Unintentionally
Miscalculated
Confusing
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Names of others
(roommates)
Appears
Apparently
May be
Could be
Assume
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Trailing zeros (Write 5 instead of 5.0, which
may be mistaken for 50.).
Leading zeros (Write 0.5 instead of .5, which
may be mistaken for 5).
“cc”; instead use “mL” and write out the word
“unit.”
“μ”; instead use mcg; often confused for mg.
< and >: instead write out “less than” and
“greater than.”
If you are countersigning with a student or
another nurse, review carefully the content of
the documentation.
 Similarly, if you take responsibility for doublechecking a colleague’s mathematical
calculations, be certain that you perform the
calculation yourself.
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The most widely accepted procedure for
correcting errors has been to draw a single
line through error and note “mistaken
entry,” “error,” or the error notation that is
required by your facility, followed by the date
and your initials.
Since your signature follows the original
entry, your initials are sufficient unless facility
policy requires otherwise.
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Never erase an entry or use correction fluid,
liquid paper, or “white out.” If you need to
replace several words, you may need to add
an addendum sheet and follow the procedure
for late entries.
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Document the time of your entry. Within the
body of your note indicate the time of the
occurrence to which you are referring.
Do your best to avoid late entries since they
raise suspicion. However, entering pertinent
information is better done late than never.
Shorter lengths of stay on inpatient units
increase the likelihood of the need for late
entries.
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Stick strictly to the facts and include no
assumptions about what you think probably
occurred or contributed to the event. Include:
 Your observations of the event.
 Your specific interventions with the patient and
the patient’s response.
 Any statements by the patient concerning the
event. Be sure to identify in quotation marks as
patient statements, making it clear that this is the
patient’s description and not your observation.
 Any change in the medical or nursing care plan
because of this event, including changes in
monitoring or medications.
 Full names of personnel you notified of the event.
 Do not indicate that you completed an incident
report or notified the risk management
department.
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Leave no blank spaces in your notes. If you
are starting a new page, be certain there are
no blanks on the page before.
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Use the appropriate form and document in
ink.
Verify that the correct patient’s name and ID
number are on every page of the chart.
Record the complete date and time of each
entry.
Use only standard, facility-approved
abbreviations, acronyms and symbols.
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Use a medical term only if you are sure of its
meaning.
Document symptoms by using the patient’s
own words.
Document objectively.
Write legibly.
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Locate and orient yourself to all
interdisciplinary forms, progress notes and
flow sheets.
If you replace a page on which information
has been recorded, retain the original and
place it in the medical record according to
policy.
Write on every line.
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Sign your full name and title.
Chart any omission or late entry as a new
entry. Do not backdate or add to previously
written notes.
THANK YOU FOR
LISTENING...
All ED nurses need
to be especially
conscientious about
communication and
documentation. It is
especially critical
that you familiarize
yourself with ED
policies and
procedures and
follow them
faithfully.