Transcript Labdocumentation

DOCUMENTATION
Lisa Brock, RN MSN
NUR 102 Lab Module D
Fall 2006
Definition of
Documentation
Documentation is defined as “anything
written or printed that is relied on as
a record or proof for authorized
persons” (Perry & Potter, ed 6, pg 45)
Why do we document?
• Provide a written record of care
given to the patient
• A record is a permanent legal
written document
• IF IT IS NOT CHARTED, IT IS
CONSIDERED NOT DONE
Uses for Documentation
• Provide a record of care for financial
reimbursement
• Clinical research
• Professional development
What do you chart?
• Assessment
• Vital signs
• Any change in your
patient’s condition
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Verbal orders
Procedures
PRN medications
Intake and output
Military Time
• Most facilities
have gone to
military time in
documentation in
which the clock is
read as one 24
hour cycle
Documentation Guidelines
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Factual
Accurate
Complete
Current
Organized
Forms and Formats
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Admission history form
Flow sheets and graphic records
Kardex
Acuity
Standardized care plans
Discharge summary forms
Methods of Recording
• Problem-Oriented Medical Records
(POMR)—data organized by problem
or diagnosis
– Source records
– Charting by exception
Standards of Care
• Use of standardized
language
– NANDA
– NIC
– NOC
(pg 54)
• Case management
and critical
pathways
(pg 54)
Home Care
• Specific guidelines for Medicare and
Medicaid reimbursement
• Accurate assessment skills
• Multi-disciplinary approach
• JCAHO requirements
Long-Term Care
• Called residents, not clients or
patients
• Omnibus Budget Reconciliation Act of
1987
• Governed by Department of Health in
each state
• Frequency of assessment
Change of Shift Report
• Orally, taped, or walking rounds
• MAINTAIN CONFIDENTIALITY
• Do not delegate to assistive
personnel
Important Information
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Background
Assessment
Nursing diagnoses
Interventions
Outcomes
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Evaluations
Family information
Discharge plans
Priorities
Clarification
Purpose of Records
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Communication
Education
Assessment
Research
• Financial billing
• Auditing
• Legal
documentation
Documentation Formats
pg 62, Box 3-4
• SOAP
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Subjective
Objective
Assessment
Plan
• PIE
– Problem
– Intervention
– Evaluation
Continued…
• Focus or DAR
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Data
Action
Response
Additionally—Plan
• Narrative note
– Combine subjective
and objective data
Incident Reports
pg 64, table 3-4
• Incident—any event not consistent
with the routine
• Assist in identifying high-risk trends
• Not a part of the medical record
Complete NCLEX Review
Questions, pg 66