DOCUMENTATION

IME

OAKLAND LVN PROGRAM

LECTURE OBJECTIVE

• Purpose of documentation

• Impact on regulatory requirements, reimbursement and litigation

• List 3 charting tips to assure documentation is accurate and correct

• State 3 legal aspects of nursing documentation

• Explain the importance of using proper spelling and grammar when documenting

• Discuss the role of the licensed nurse related to C.N.A. charting

WHY IS THIS IMPORTANT?

• Regulations based on state and federal legislation or statutes (THE LAW!)

– Following the law reduces the likelihood that you will be found negligent in a lawsuit, your license will be jeopardized or your employer’s license will be at risk!

PRACTICE GUIDELINES

• Practice guidelines are not the Law, but they do establish the standard of your peers

against which you are measured in a legal action

FACILITY POLICIES & PROCEDURES

Policies and procedures are not the law. They are guidelines to help your facility approach

situations consistently however, they are not a substitute for your professional judgment in a

specific situation.

REIMBURSEMENT:PAY 4 PERFORMANCE

• Evidence of the care provided.

• Evidence of quality of care.

• Evidence of necessary and ordered care.

• Failure to document results in loss of

reimbursement!

Protect Your Practice

• Accurate nursing documentation can prevent a lawsuit!!!!!!

• What must Documentation be?– TIMELY

– ACCURATE

– COMPLETE

ELEMENTS OF EFFECTIVE CHARTING

• Everything you write must be legible.

• Print if you must.

• Spelling must be Accurate.

• Sentences must be complete.

Chronology: Date and Time

• Date and Time

• Year

• Military time

DO NOT CHART IN BLOCKS OF TIME (I.E. 0700-1500)

LATE ENTRIES

“Late entry for _____” to designate the time of the events or observations documented!

RESIDENT HISTORY & CONDITION

• Relevant elements of the resident’s history or risky health habits

• Maintain objectivity in your charting and avoid diagnosing a condition in your charting.

• Document what you see, hear, smell, especially changes in health status

Interventions: Medical, Social and Legal

• Actions taken in response to the resident’s status or change in condition.

• Individuals notified about concerns and issues (doctors, family member, pharmacist, psychologist, etc.)

• All telephone calls! And Be Specific!

• Fax Information (lab results, radiology reports, etc.)

– Document the time , date and contents of the faxes not retained in the medical record.

Communication logs

important information communicated about the resident’s condition or interventions & response must also be reflected in the medical record.

CHART OUTCOMES

• Resident’s response to the intervention, including unexpected responses.

This shows that you were following up on a concern and demonstrates how the resident responded to your intervention.

.

– DOCUMENT PLANS FOR CONTINUED FOLLOW UP AND ADDITIONAL COMMUNICATION WITH PHYSICIANS, FAMILY, ETC!

Document Client & Family Education & Instructions

Document the education provided and the client/family response.

Incorporate direct “quotations” and non-verbal responses from the resident, family or visitor.

Document referrals to Community Resources.

Document phone calls thoroughly including actions you took as a result of the telephone call.

Family Member

date and time

caller’s name

caller’s request or complaint

advice/information given

follow-up requested.

PHYSICIAN’S CALL

– DATE AND TIME

– PHYSICIANS NAME

T/O AND WDRB • T/O: TELEPHONE ORDER

• WDRB: WROTE DOWN READ BACK

NOTE AND TRANSCRIBED ACCORDING TO POLICY

SIGN YOUR NAME AND CREDENTIALS

SIGN YOUR NOTE AND INCLUDE CREDENTIALS

• Record your full name, credentials and job title in the appropriate section on forms.

• Your signature must be in cursive.

• Take time to sign your name legibly.

If You Make An Error

• Make one single line through what is written incorrectly, and initial. Then write error next to it.

Different Formats For Charting

• Each facility uses their own format.

• You will be oriented to their way of doing things.

• The type of charting will be documented in the policy and procedure manual;

Documentation Formats

• POMR (Problem Oriented Medical Record)• SOMR (Source Oriented Medical Record)• Narrative• APIE• PIE• FOCUS• SOAP(IER) CHARTING/NOTES• CBE• FLOWSHEETS AND CHECKLISTS• EMR

Source Oriented Medical Records.

• Each health care discipline will have a section in the chart.

– Nurses notes

– MD progress notes

– Therapy

– Nutritional Service

– Etc.

APIE and PIE

• APIE CHARTING

– ASSESMENT

– PLANNING

– IMPLEMENTATION

– EVALUATION

• PIE CHARTING

– PLANNING

– IMPLEMENTATION

– EVALUATION

Focus Charting: Focuses on the pts need from a variety of perspectives.

DAR

DATA

ACTION

RESPONSE

• DAE

DATA

ACTION

EVALUATION

Narrative Charting

• Narration of care provided.

• Chronological Order.

Cons

Time Consuming To Write

Difficulty tracking progressand outcomes

Information regarding a specific problem found in multiple places.

Problem Oriented Medical Record

• Information corresponds to the Nursing Process.

• Data is organized by presenting issue or diagnosis

• Each health care team member contributes to a single list of client problems.

• Each recording includes a database, problem list, care plan and progress note

• Each discipline make their problem list specific to their emphasis.

SOAPIER

• SUBJECTIVE

• OBJECTIVE

• ASSESSMENT

• PLANNING

• IMPLEMENTATION

• EVALUATION

• REVISION

ADVANTAGES! DISADVANTAGES

UNIFORM PROBLEM LIST LACK OF FLEXIBILITY WITH EVERYTHING DIRECTED TO A SPECIFIC PROBLEM

CBE

• Chart By Exception

– Uses flow sheets

– You only chart exceptions to the norm

– Uses checklists

– This is a time when narrative notes are beneficial.

Electronic Medical Charts

• These contain information identical to CBE

• Nurses run through a series of flow sheets with check boxes and mark those boxes when their status is WNL after initial assessments.

• You only make notations when there is a variance.

8 Biggies to Avoid!!1) Failing to record pertinent health or drug

information2) Failing to record nursing actions3) Failing to record that medications have been

given4) Recording on the wrong chart5) Failing to document a discontinued

medication6) Failing to record drug reactions or changes in

condition7) Transcribing orders improperly or

transcribing improper dosages8) Writing illegible or incomplete records

Practice Charting Scenario

• How do you document your assessment and interventionm?

– No matter what the facility will use from checklists to full narrative notes, you need to be sure to include the most important details.

– Include the 5 w’s and an h

• Who , What, Where, Why and How.

Patient Handoffs/ Shift Reports

• Critical that all information is communicated between caregivers.

• Communication breakdown are a leading cause of medical errors

• The key to stopping these problems is a clearly defined communication process

What Is A Handoff?

• Handoffs occur anytime there is a transfer of responsibility for a patient from one caregiver to another. The goal of the handoff is to provide timely, accurate information about a patients care plan, treatment, current condition and any recent or anticipated changes.

3 Widely Accepted Methods

• 1) The Five P’s

• 2) I PASS the B ATON

• 3) SBAR + 2

The Five P’s

PATIENT Name, Identifiers, Age, Sex, Location

Plan Patient Diagnosis, treatment plan, next steps

Purpose Provide a rationale for the care plan

Problems Explain what’s different or unusual about this specific patient

Precautions Explain what’s expected to be different or usual about the patient

I PASS the BATON

I Introduction Individuals involved in the handoff identity themselves, their roles and jobs

P Patient Name, identifiers, age, sex, location

A Assessment Present chief complaint, vital signs, symptoms & diagnosis

S Situation Current status and circumstances, including code status, level of certainty or uncertainty, recent changes and response to the treatments

S Safety Concerns Critical lab values and reports, socioeconomic factors , allergies and alerts (i.e. at risk for falls)

the

B Background Comorbidities, previous episodes, current meds and family history

A Actions Detail what actions were taken or are required and provide a brief rationale for those actions

T Timing Level of urgency and explicit timing, prioritization of actions

O Ownership Who is responsible (nurse/doctor/team) inclu8ding patient and family responsibilities

N Next What will happen next? Any anticipated changes? What is the plan? Any contingency plans?

SBAR + 2

I Introduction Individuals involved in the handoff identify themselves, their roles and jobs

S Situation Complaint, diagnosis, treatment plan and patients wants and needs

B Background Vital Signs, mental and code status, list of meds and lab results

A Assessment Current providers assessment of the situation

R Recommendation Identify pending lab results and what needs to be done over the next few hours and other recommendations for care

Q Question & Answer An opportunity for questions and answers is builty into this process.

Types of Handoffs

• The difinition of “handoff is purposefully broad to encompass the huge assortment of handoffs that occur across the healthcare setting.

• In Hospitals:– Nurse shift change

– Dr’s transferring responsibility for a patient

– Temporary relief of coverage (BreakTime!)

– Anesthesiologist report to PACU nurse

– Nursing and physician handoff from the ED to inpatient units.

More Instances for Handoffs

• Primary Care physician to hospital admission department

• Patient transfer from one hospital to another

• Patient transfer to a SNF

• Relay of lab and radiology reports to the PCP after discharge

• Patient Information to Home Health Care

• Educating the patient and family upon discharge to home

• Discharge summary information from hospital to PCP

10 Barriers to effective Handoffs

1. Lack of education at nursing and medical schools2. Health care system that historically has supported individual autonomy and

performance3. Lack of engagement of patients and families in the care process4. Resistance of change among staff5. Lack of time for providers to devote to handoffs6. Problems in the physical setting, including background noise and interruptions7. Language barriers between clinicians and between the clinician and the patient.

It is also important for clinicians to avoid abbreviations and ambiguous terminology

8. Failures in mode of communication, such as fax machine, email or inability to locate the patient record

9. Lack of definitive scientific research and data to identify accepted handoff best practices

10. Lack of financial resources to implement standardized handoff proccesses

10 Tips for effective handoffs

1. Allow for face-to-face handoffs whenever possible2. Ensure two-way communication during the handoff process3. Allow as much time as necessary for handoffs4. Use both verbal and written means of communication5. Conduct handoffs at the patient bedside wheneve3r possible. Involve patients

and families in the handoff process. Provide clear information at discharge6. Involve staff in the development of handoff standards7. Incorporate communication techniques like SBAR in the handoff process.

Require a verification process to ensure that information is both received and understood

8. In addition to information exchange, handoffs should clearly outline the transfer of patient responsibilities from one provider to another

9. Use available technology, like EMR to streamline the exchange of timely accurate information

10. Monitor use and effectiveness of the hand off. Help streamline what works and doesn’t with management.