Lesson 4 Validating and Documenting Data

Reporting

It can be written or verbalized

Recording

It can only be written documentation

Never events, death, serious physical injury

¾ of Sentinel Events

Adverse Events

-unusual occurrences

-it don't usually happen

For legal document

For communication

For care planning

Quality assurance

Financial Reimbursement

Education

Research

Purpose of having medical record

Nursing Admission assessment

History and physical examination

Advance directive

Primary care provider

Plan of care

Flow sheets

Focused assessment sheets

Medication administration record

Laboratory and diagnostic test results

Progress notes

Consultations

Discharge/ transfer summary

Components of the medical record

Nursing Admission Assessment

It is Initial assessment

GCS sheet

It is the sheet of level of consciousness

Electronic Medical Record

Computerized software program

Confidentiality

Accuracy and completeness

Logical organization

Timeliness

Conciseness

Principles in Documentation

Confidentiality

-it is legally and ethically to keep all information confidential

-means keeping information private

-health care professional is directly involved

Accuracy and Completeness

-patients record must be accurately reflect on what you observe, hear, palpate, or percuss

-subjective data

Logical Organization

-it must be in chronological order

-focus

Timeliness

- assessment data in timely manner

-it must be specific time

-point of care documentation

Conciseness

-complete yet concise

-document all vs

-approved abbreviations

Vital signs

Intake and output

Example of flow sheets

Nurse’s progress notes

-can be narrative

-implement soapie,pie, dar

Charting by exception

-abnormal assessments require a note rather than signing off

-predetermined standards to record

Reporting

-handoff/summary report (endorsing it to the next shift)

-telephone report

-walking rounds

-incident repor

SBAR

Use what pnemonic for reporing?

Situation

State concisely (purpose of communication)

Background

Describe the circumtances

Assessment

Subjective and objective data

Recommendation

Suggestions for what needs to be done to manage the difficulty