Transcript Documenting And Reporting

JUDITH M. WILKINSON LESLIE S. TREAS
KAREN BARNETT MABLE H. SMITH
FUNDAMENTALS OF
NURSING
Chapter 18:
Documenting & Reporting
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Documentation
• The act of recording client assessments and care in
written or electronic form
• Creating a record of client assessments and care
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Purpose of the Written Record
• Communication between providers
• Educational tool
• Legal documentation of care
• Quality improvement
• Research
• Reimbursement
• Education
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Standardized Language
• Standardized nursing terminology helps to make
nursing care and its effects on patients more visible.
• NANDA International (NANDA-I)
• Nursing Interventions Classifications (NIC)
• Nursing Outcomes Classification (NOC)
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Common Documentation Systems
Source-oriented system
• Disciplines document in separate sections of the chart
• Contains a variety of sections (e.g., admission, H&P,
diagnostic, graphic, nurses’ notes, progress notes, lab, rehab, DC
plan, etc.)
• Data scattered; may lead to fragmentation
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Main Documentation Systems
Problem oriented system
• Organized around client problems
• Four components: database, problem list, plan of care, and
progress notes
• Promotes greater collaboration
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Common Types of Charting
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Narrative
PIE
SOAP(IER)
Focus
Charting by exception (CBE)
FACT system
Electronic entry format
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Narrative Charting
• Can use with source- or problem-oriented system
• “Story” of care in chronological format
• Tracks the client’s changing status
• Can be lengthy and disorganized
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PIE Charting
Problem
Interventions
Evaluation
• Used only in problem-oriented charting
• Establishes an ongoing plan of care
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SOAP Charting
Subjective data
Objective data
Assessment
Plan
Some Add IER
Intervention
Evaluation
Revision
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Focus Charting®
Highlights the client’s concerns, problems, or strengths
in three columns:
• Column 1: Time and date
• Column 2: Focus or problem being
addressed
• Column 3: Charting in a DAR format:
Data, Action, Response
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Charting by Exception
• Chart only significant findings or exceptions
to norms.
• Use this method to streamline charting and save time.
• Use preprinted forms and checklists.
• Note that inadvertent omissions are the
biggest problem.
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FACT Documentation
• Flow sheets individualize specific services
• Assessment with baseline data
• Concise progress notes
• Timely entries
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Nursing Documentation Forms: Nursing
Admission Assessment
• Record of baseline data from which to
monitor change
• Helps forecast future needs
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Admission Database
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Chief complaint or reason for admission
Physical assessment data
Vital signs
Allergy information
Current medications
ADL status and discharge planning information/needs
Data about client support system and
contact information
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Flow Sheets
• Record routine aspects of care (hygiene, turning).
• Document assessments, usually organized according
to body systems.
• Track client response to care (wound care, pain, IV
fluids).
• Use graphic records to record vital signs.
• Record intake and output.
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Nursing Assessment Checklist
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Medication Administration Records
• Comprehensive list of all ordered medications
• Provides information on client’s medication allergies
• Documents scheduled/routine, prn, STAT, or omitted
doses
• Additional explanation may be required for nonroutine or
omitted medications.
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Kardex® or Client Care Summary
• Demographic data
• Medical diagnoses
• Allergies
• Diet/activity orders
• Safety precautions
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Kardex® or Client Care Summary (cont’d)
• IV therapy orders
• Ordered treatments (wound care, physical therapy),
surgery, laboratory, and tests
• A summary of medications ordered
• Special instructions such as preferred intensity of care
or isolation orders
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Integrated Plans of Care (IPOCs)
• A combined charting and care plan form
• Maps out on a daily basis, from admission to discharge
– Client outcomes, interventions, and treatments for a
specific diagnosis or condition
– Laboratory work, diagnostic testing, medications, and
therapies included in the pathway
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ClickerCheck
The nurse has just medicated a client for pain. Documentation of
this intervention would be found on the:
a.
b.
c.
d.
Kardex® and graphic sheet
IPOC and discharge summary
Flow sheet and the assessment checklist
Progress notes and the MAR
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ClickerCheck (cont’d)
Correct answer: D
The nurse would document the administration of the
medication itself on the MAR. He would also
document the intervention and the client’s response
to the intervention in the progress notes.
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Occurrence Reports
• Formal record of unusual occurrence or accident
• Not a part of patient’s health record
• Quality improvement
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Reporting
• Method to inform other caregivers about the client
condition.
• Nurse to nurse; nurse to provider
• Communication of vital information related to the
client’s status/plan of care.
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Handoff Report
May be
• Verbal
• Walking rounds
• Audio-recorded report (not the preferred method)
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Handoff Report (cont’d)
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Client demographics and diagnoses
Relevant medical history
Significant assessment findings
Treatments (e.g., wound care, breathing treatments)
Upcoming diagnostics or procedures
Restrictions (e.g., diet, activity, isolation)
Plan of care for the client
Concerns
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Handoff Report (cont’d)
• Use a standardized format such as SBAR or PACE.
• Keep it CUBAN
• Confidential
• Uninterrupted
• Brief
• Accurate
• Named nurse
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Transfer Reports
Your contact information
Client demographics, diagnoses, reason for transfer
Family contact information
Summary of care
Current status, including medications, treatments, and tubes in
the client—when the next medication is due
• Presence of wounds or open areas of the skin
• Special directives, code status, preferred intensity of care, or
isolation required
• Always ask if the receiver has any questions.
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Discharge Summary
• Time of departure and method of transportation
• Name and relationship of person(s) accompanying client
at discharge
• Condition of client at discharge
• Teaching conducted and handouts/informational matter
provided to client
• Discharge instructions (including medications, treatments,
or activity)
• Follow-up appointments or referrals given
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Verbal/Telephone Physician Orders
• Verbal orders (V.O.)
• Spoken to you; often during a client emergency
• Should be made for critical change in patient condition
• Telephone orders (T.O.)
• Received by phone and transcribed onto the provider order
sheet
• Have an increased risk for errors
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Telephone Orders
• Write the order only if you heard it yourself.
• Make sure the verbal orders make sense with the
client’s status.
• Repeat the order to confirm accuracy.
• Spell unfamiliar names; pronounce digits of
numbers separately.
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Telephone Orders (cont’d)
• Directly transcribe the order on the chart.
• Date/time
• Text
• To be followed by provider’s name
• Your signature
• Providers must countersign within 24 hr.
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Questioning an Order
• Written illegibly
– Contact the provider
• Uncomfortable following an order
– Follow the chain of command
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Documenting Client Care
• Be familiar with facility forms.
• Chart in the required format.
• Include all aspects of care.
• Be accurate, complete, and consistent.
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Computer Documentation
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Home Healthcare Documentation
Homebound status
Assessment highlighting changes in the client’s condition
Interventions performed (wound care, teaching, etc.)
Client’s response to interventions
Any interaction or teaching that you conducted
with caregivers
• Any interaction with the client’s physician
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Long-Term Care Documentation
• Minimum data set (MDS) for resident assessment and
care screening must be completed within 14 days of
admission and updated every 3 months.
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Long-Term Care: Weekly Summary
• A summary of the client’s condition
• An evaluation of the client’s ability to perform ADLs
• The client’s level of orientation and mood
• Hydration and nutrition status
• Response to medications
• Any treatments provided
• Safety measures used (e.g., bed rails)
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Documentation Do’s and Don’ts
• Be accurate and nonjudgmental.
• Adhere to the requirements for reimbursement.
• Provide details about the client’s condition, nursing
interventions provided, and client response.
• Document legibly and as soon as possible.
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Documentation Do’s and Don’ts (cont’d)
• Record significant events or changes in condition.
• Record any attempts you have made to contact the
primary care provider.
• Chart teaching performed.
• Chart use of restraints, including reason for use, type
of restraints, and frequent checks of the client.
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Documentation Do’s and Don’ts (cont’d)
• Do not chart that you have filled out an
occurrence report.
• Chart any client refusal of treatment or medication.
• Document any spiritual concerns expressed by the
client and your interventions.
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Documentation Do’s and Don’ts (cont’d)
• Always use black or blue ink for handwritten notes.
• Date, time, and sign all notes.
• Avoid subjective terms.
• Use proper spelling and grammar.
• Use only authorized abbreviations.
• Document complete data about medications.
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Documentation Do’s and Don’ts (cont’d)
• Record on the medication administration record in
narrative form if a client refuses medication, and chart
the reason given.
• Do not leave blank lines.
• If you make a mistake, draw a single line through the
entry and place your initials next to the change.
• Sign all your charting entries.
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Think Like a Nurse
You note that your client with asthma is having increasing
difficulty breathing.You call the provider who gives you a
telephone order for an asthma medication and then hangs up.
When you enter the order electronically as a verbal order, you
find out the medication is a nonformulary medication that your
pharmacy does not carry.
• Is this an acceptable reason to take a verbal order?
• The provider gets upset when you call back and says, “I
ordered what I wanted.” How would you handle this situation?
• How might this situation have been avoided?
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JUDITH M. WILKINSON LESLIE S. TREAS
KAREN BARNETT MABLE H. SMITH
FUNDAMENTALS OF
NURSING
Chapter 41:
Nursing Informatics
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Definitions
• Informatics
– Managing and processing information necessary to
make decisions
• Nursing informatics
– Managing and processing information applying to nursing
practice, education, and research
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Elements of Informatics
• Data: unprocessed numbers,
symbols, words;
no context
• Information: groupings of
processed data
• Knowledge: meaningful
information created by
grouping and
compiling information
• Wisdom: appropriate use of
knowledge
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Computers
• Electronic means of processing information/data
• Use circuits/microchips
• Functions
– Input
– Process
– Output
– Storage
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How Computers Share Information
• Connectivity
– Wired
– Wireless
– Modem
– Cable
– DSL
– Internet
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Electronic Communication
• Telephone (cell, land line, Internet)
• Videoconferencing
• Fax
• Electronic mail
• Listserv
• Social networking
• Telehealth
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Informatics and Nursing Practice
• Facilitates evidence-based practice
– New model of decision making
– Affords rapid access to most current
health information
– Enables location of best evidence supporting
nursing practice
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Computers and Healthcare Reform
• Electronic medical record adoption
• Patients using computers for health information
• T.I.G.E.R.
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Informatics and Nursing Practice (cont’d)
• Enables the compilation
of electronic health
records
– Improved access to
patient data
– Increased privacy related
to records
– Stored, aggregate data
available to researchers
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Informatics and Nursing Practice (cont’d)
• Reduces errors in healthcare
– Increases ability to share critical patient information (e.g.,
allergies)
– Decreases transcription errors
– Can prevent medication errors through bar-coding
– Enables access by multiple providers
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Ethical Use of Electronic Records
• Use of passwords
• Audit trails
• HIPAA regulations
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How Informatics Enhances the
Nursing Profession
• Reduces barriers to evidence-based practice
• Facilitates a literature search
• Provides online sources for and of nursing research
• Provides literature databases
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Think Like a Nurse
• As a patient, would you prefer a telehealth or a faceto-face consultation? Why?
• Now imagine that you are an accident victim brought
to a rural clinic staffed only with paraprofessionals.
Does the answer change? If so, why?
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