Documentation

PN 103

Introduction

• The “chart” = health care record – LEGAL record

• The process of adding written information to the chart is called:– Charting– Recording– Documenting

• 24 hr record-keeping system• To consolidate nursing records

Introduction

• Good documentation reflects the nursing process

• Documentation is an integral part of the implementation phase of the nursing process

• It is necessary for the evaluation of patient care and reimbursement from payor sources

Purposes of Patient Records

• 1. Provides written communication• 2. Permanent record for accountability• 3. Legal record of care• 4. Teaching• 5. Research and data collection

Basic Guidelines for Documentation

• Hand-out: FON Box 7-1

Legal Guidelines for Documentation

• Hand-out: FON, Table 7-2

Methods of Recording

• The Traditional Chart– Divided into sections - eg. Admission sheet,

physician orders, progress notes, etc.– Nurses use: flow sheets, graphics, and narrative

charting• Narrative Charting – the recording of patient care in

descriptive form to chart observations, care, and responses– Abbreviated story form– Information obtained from nursing assessment is clustered

and organized in a head-to-toe manner

Methods of Recording

• Problem-oriented Medical Record (POMR)– Database: accumulated information from the

medical history, physical exam, and diagnostic tests

– Problem list: of active, inactive, potential, and resolved problems

– SOAPE documentation

Methods of Recording• SOAPE format: – S = subjective information

• What the patient states or feels

– O = objective Information• What the nurse can measure or factually describes

– A = Assessment• A potential diagnosis of the cause of the patient’s problem

or need

– P = Plan• Of care to be given or action to be taken

– E = Evaluation• And appraisal of the the response and effectiveness of the

plan

Methods of Recording• Focus Charting Format• “DARE”: – D = data

• Subjective and objective

– A = Action• Combination of planning and implementation

– R = Response and evaluation• Of the patient; evaluating the effectiveness of the actions

– E = Education and patient teaching• As needed

Methods of Recording

• Charting by Exception = CBE– Will chart per usual at the beginning of each shift : • complete physical assessments• Observations• VS• IV site and rate• other pertinent data

Methods of Charting

• Charting by Exception cont.– The only other notes the nurse will make will be:• Additional treatments done• Planned treatments withheld• Changes in patient condition• New concerns• Notations re: progress or revisions for all active nsg. dx.

Case Study Exercise

• Index Cards• Progress Notes

Record-Keeping Forms

• P. 146-148 FON

• “Kardex” – term for a card or paper system used to consolidate patient orders and care needs in a centralized and concise way– Usually kept in the nurse’s station for quick

reference

Incident Reports

• An “incident” refers to:– An event not consistent with the routine

operation of a health care unit or the routine care of a patient, or

– Other hospital / facility notification form when the patient care delivered is not consistent with the facility or national standards of expected care• Eg. Giving an incorrect dosage of a drug or a wrong

drug

Incident Reports

– Also completed for any unusual event in the hospital or facility:• Needle stick• Patient/visitor/hospital personnel injury

– This information helps the facility risk manager and unit manager prevent future problems through education and other corrective measures

Incident Reports

• FON P. 150, Fig. 7-9/Table 7-3• When filling out:– Give only objective, observed information– Do not admit liability or give unnecessary

information– Do list time, date, care given to the person and

name of physician notified (if it was a pt.)– When charting in the progress notes, do not

mention that an incident report was made

Acuity Charting

• 24 hr scoring system• Rates each patient by the severity of their

illness• Helps to determine staffing patterns

Home Health Care Documentation

• Box 7-4 Documentation Forms Used• 50% of nursing time!• Documentation has different implications in the

home health system:– Fewer witness to the majority of care– Accurate communication to all team members

• Some forms left in the home; others at the agency

– Quality control and justification for reimbursement• Computer influence

Computer Influence

• Communication and assessment via modem linkage– Phone and visual visits– Promotes integration of chart• some parts of the chart left in the home; some in the

chart• Various healthcare disciplines need access

• Box 7-5 p. 155 FON “Guidelines for Safe Computer Documentation

Long-Term Health Care Documentation

• MDS – Minimum Data Set– Dictated by Medicare and Medicaid • OBRA 1987

– Regulated standards for resident assessment, individualized care plans, and qualifications for healthcare providers

Practice

• P. 156, 157 FON Practice NCLEX questions

• SG – Ch. 6 and 7