Documentation & Interpersonal Communication

what is ADOPIE

assessment, diagnosis, outcome identification, planning, implementation, evaluation

what can ADOPIE be used for

nursing process for individuals, families, & communities

explain A of ADOPIE

assessment: complete, accurate health data compilation, can be comprehensive or focused

explain D of ADOPIE

diagnosis: clustering data to make a judgement or statement about patients difficulty or condition

explain O of ADOPIE

outcome identification / identify outcomes: formation of measurable, realistic, patient-centered goals

• must be measurable & obtainable

explain P of ADOPIE

planning / plan care: determining resources, targeting nursing interventions, writing the plan of care

• requires analysis of individual patient & their needs

explain I of ADOPIE

implementation: any treatment, based upon clinical judgement & knowledge, that a nurse performs to enhance patient outcomes

• implement strategies

explain E of ADOPIE

judgement of effectiveness of nursing care in meeting patient goals & outcomes based on patient responses to nursing

• requires knowledge of care standards, expected patient responses, conceptual models & theories

• some evaluations aren’t immediate, & can take a while or not work at all

  • Goals can be completely met, partially met, or not met

what is normally top priority

life-threatening situations: ex: airway, cardiac problems

what questions can you ask to focus on patient goals

“what are your goals to reach before you are discharged?”

what are some reasons why charts can be used in criminal or civil courts as evidence

• delay in treatment

• medication issues

• wrong blood product given during transfusion

• surgery in wrong spot

what is a sentinel event

an unexpected occurrence involving death or serious physiological or psychological injury

• “What happened? What caused this? What can we do to prevent this?” less pointing the finger at a specific person & more focused on the system

what can a chart be used for?

• legal document

• communication & care planning

• quality assurance

• financial reimbursement

what are nurses NOT allowed to do?

complete a verbal or phone order

what components are in a nursing chart?

• Nursing admission assessment

• History & physical examination (H&P) by primary healthcare provider

• Advanced directive, power of attorney

• Primary provider’s orders

• Care plan or clinical pathway (kahoot)

• Flow sheets

  • Vital signs; intake & output (I&O)

  • Routine assessments

• Focused assessment sheets

• Medication administration record (MAR)

• Laboratory, diagnostic test results

• Progress notes: members of the healthcare team

• Consultations

• Discharge or transfer summary

what is the one thing that is NOT in chart

handoff

when should urgent assessment be performed?

• Respiratory rate <8 or >28 breaths/min

• Acute change in oxygen saturation <90%

• Threatened airway (patient choking, ex: steak)(anaphalysic shock, airway closing up)

• Acute change in systolic blood pressure (<90 mm Hg) or diastolic blood pressure (>110 mm Hg)

• Acute change in heart rate (<50 or >120 beats/min)

• New-onset chest pain; signs of acute MI

  • Just happened, not that they’ve been consistently something that looks abnormal

• Acutely cold, cyanotic, or pulseless extremity

• Confusion, agitation, or delirium

• Unexplained lethargy or acute altered mental status

• Difficulty speaking or signs of acute stroke

• Acute change in pupillary response

• Temperature >39.0°C (102.2°F)

• Uncontrolled pain (adjusting orders but the pain hasn’t gone away, call the anesthetist perchance)
  Acute change in urine output (<50 ml over 4 hours or <0.5 mL/kg/hr)

• Acute bleeding

• Suspected severe sepsis

what does HIPAA stand for?

the Health Insurance Portability & Accountability Actw

what does HIPAA do?

regulates all areas of information management, including reimbursement, coding, and security of records. The HIPAA Privacy Rule requires an agency to make reasonable efforts to limit the use of, disclosure of, and requests for protected health information to the minimum necessary to accomplish the intended purpose.

how to protect patient confidentiality?

• HIPAA

• log out of computer when you’re done, don’t leave patient info out in the open, turn any papers facing down or stored away

• don’t discuss patient health in public settings

what does accuracy & completeness mean

charting must precisely reflect assessment data

what is subjective data

client’s exact words whenever possible ie. Dialogue

• ex: “I feel like I’ve been hit by a bus” can use quotes in chart

• Subjective = symptoms, something patient describes

what is objective data

what is actually seen or measured ie. VS, auscultation

• ex: weight, temperature, vitals

• Objective = signs, something I measured

what should you try to avoid doing when charting

using abbreviations, use full words

what are narrative notes

unstructured paragraph, based on time (don’t restate vitals bc thats already charted)

what are SOAP (IE) notes?

subjective; objective; analysis; plan; interventions; evaluation

what are PIE notes?

problem; interventions; evaluation

what are DAR notes?

data; action; response

what is charting by exception

• Predetermined standards & norms to record only significant assessment data

• Nurse checks box if client meets designated norms

• Any abnormal assessment findings require additional documentation

what should a discharge note include?

• client status

• received necessary education

  • make sure they know where to pick up meds, any follow ups, etc

• discharge instructions

• time of discharge

when does reporting come

at handoffs, during patient rounds, during patient & family care conferences, when calling or texting provider to report a change in status or provide requested information

what are some barriers when it comes to reporting

• lack of structured format and standards and policies for communication

• uncertainty about who is responsible and should be contacted

• power differences

• cultural background differences

• poor clinical decision making regarding what needs to be reported

• different communication styles

what is the SBAR model

situation, background, assessment, recommendation/request

when is the SBAR model used?

when contacting provider or giving handoff report

explain S in SBAR

situation: State your name, your unit, patient’s name, room number, patient’s problem, when it happened or when it started, & the severity

explain B in SBAR

background: Do not recite the patient’s full history since admission. DO state the date pertinent to this moment’s problem: admitting diagnosis, when admitted, & pertinent background date (e.g., allergies, current medications, IV fluids, laboratory results, pertinent medical history)

• more FOCUSED assessment

explain A in SBAR

assessment: State your assessment findings. This can include what you found & what you may think be wrong (e.g., vital signs, pain, pulse oximetry, change in mental status)

• give actual numbers, not generalizations like “normal” or “abnormal”

explain R in SBAR

recommendation/request: Recommendation or request. State what you want/need to continue caring for the patient

• its what you think is most appropriate

• provider can veto (write provider notified if they do), adjust recommendation, or accept it

what are some ways to report to the primary healthcare provider?

• face to face

• telephone

• text messaging

• fax

what are some things to remember when contacting provider?

• make sure its the actual provider

• have patient information available for reference

• document the call

• CPOE allows remote computer access for entering orders when off-site