FOUNDATIONS OF NURSING Chapter 3: Documentation

the nursing preceptor is preparing to speak with the new licensed practical/vocational nurse (LPN/LVN) regarding documentation. Which statement by the preceptor is correct?

it is important to use only approved medical terms and abbreviations when documenting in the electronic health record (EHR)

The patient asks the LPN/LVN if he can take his chart with him on discharge from the hospital. Which response by the nurse is most accurate?

"the chart is the property of the hospital, but if you need copies of your records, we can arrange that for you."

when reviewing information regarding the problem-oriented medical record (POMR), the LPN/LVN correctly identifies which guideline?

3. the charting format is SOAPE or SOAPIER

the LPN/LVN is using SOAPE method to chart. When documenting the S portion, which entry demonstrates correct documentation? (select all that apply).

2. Patient reports left hip pain 8/10

5. Patient reports nausea after eating

The student nurse is correct when identifying which concept regarding documentation as being correct?

1. chart as soon and as often as necessary

understanding that health care personnel mist respect the confidentiality of patient records, which action by the nurse is appropriate?

3. Reading charts only for a professional reason

following the orientation to the facility's computer system, which statement by the new nurse is most accurate?

1. "I can save on charting time once I am comfortable using the system."

The nurse demonstrates knowledge of correctly completing an incident report with which action?

4. Documenting facts regarding the incident

which statement is correct about formats for documentation? (select all that apply).

3. Charting by exception documents those conditions, interventions, or outcomes outside the norm.

5. EHR systems allow for the patient date to be shared for collaborative care

which statement is a recommended guideline for charting?

4. The patient's name and identification number should be on all documents.

which statement is a safe principle of computerized charting?

4. do not leave patient information displayed on the monitor.

which accreditation agency specifies guidelines for documentation?

1. The Joint Commission (TJC).

What is the primary purpose of Title II of the Health Insurance Portability and Accountability Act (HIPPA)?

2. Maintain privacy and confidentiality of patient information

which statement is correct about the abbreviations? (select all that apply).

1. The nurse should be aware of any abbreviations on the "do not use list"

4. When in doubt the nurse should use the complete word and not the abbreviation.

The nurse documents in the patient record "0830 patient appears to be in severe pain and refuses to ambulate. Blood pressure and pulse are elevated, physician notified, and analgesic administered as ordered with adequate relief. J. Doe RN." Which statement about the documentation is most accurate?

4. The documentation is unacceptable because it is vague, non descriptive data without supportive data.

the nurse works in a facility that uses narrative charting for nurses notes. Identify which documentation is an example of narrative charting. (select all that apply).

1. patient alert and oriented x3, PERRLA, hand grips strong and equal

3. patient ambulated 60 ft in the hall, unassisted with steady gait. Currently resting in chair with no complaints.

5. Patient asking for pain medication for incisional pain 7/10. Hydrocodone 10-325, 2 tablets administered by mouth while patient was eating lunch. Patient resting in bed with side rails up x 2 and call light in reach

in most states patients can gain access to their medical records by which means?

2. submitting a written request to the facility to view the record

the charge nurse in a long-term care facility has been asked by the facility administrator to be sure that the staff documents in a way that will help ensure appropriate reimbursement for services provided. The charge nurse should instruct the staff to chart using what system as a guide?

1. minimum data sets (MDS)

An elderly patient with pneumonia is in an acute care hospital. Medicare will pay for 4 days of care in the facility. What prospective payment system is responsible for determining this reimbursement?

4. Diagnosis- related groups (DRGs)

CBE

Charting by Exception.

focuses on documenting deviations from the norm

DRGs

Diagnosis Related Groups,

disease classification system that relates the type of inpatients a hospital treats (case mix) to the costs incurred by the hospital

EHR

electronic health record.

EHR is shared between one facility to another known as intercommunication

facilitated delivery of patient care and supports the data analysis necessary for coordinating patient care.

increase efficiency, consistency, accuracy and decreases cost.

EMR

electronic medical record

EMR is shared between one unit f a facility to another unit in the same facility known as intracommunication

HIPPA

Health Insurance Portability and Accountability Act. patient information privacy and confidentiality.

MDS (minimum data set)

Resident Assessment protocols in long term care facilities, and utilization guidelines for each state

POC

point of care

Charting that is done at the bedside via computerized system

convenient and quicker allows immediate documentation

DARE

Data, action, response, education

type of focus charting is a modified list of patient problem statements that is used as an index for nursing documentation.

SBARR

Situation, background, assessment, recommendation, read back

method among communication among health care workers.

safety measure for preventing errors from poor communication during interactions between health care personnel (ie day shift to night shift nurse exchange of communication/information).

PIE

plan, intervention, evaluation

problem-solving approach of documentation derived from the nursing process.

SOAPE

subjective, objective, assessment, plan, evaluation

briefer adaptation of the problem oriented medical record (POMR)

which actions by members of the health care team reflect the basic purposes of accurate and complete patient records? select all that apply

1. risk manager uses patient's records to investigate accusations of staff abuse of patient.

2. Nursing instructor directs the student to look at nurses' notes written by expert nurses

3. medicare auditor reviews patient records to observe for evidence of minimum data sets.

4. Nursing student reads the patient's flow sheet to observe for trends in the vital signs

which nurse is most likely to expect a peer review?

1. nurse submits a research article to a nursing journal

in using the hospital's computer information system, where is the nurse most likely to find documentation about the patient's response to the last does of pain medication?

4. Narrative notes

an auditor is randomly reviewing the nurses charts and the nurse manager has agreed that the auditor can ask questions and give feedback as necessary. which example of documentation is the auditor most likely to query?

3. discharge to home accompanied by spouse

the nurse is working on a medical-surgical unit in a large hospital and observes an unfamiliar person looking at a patients' chart. what should the nurse do first?

2. ask for identification to determine if the person can look at the chart.

the nursing student attempts to document am hygiene care, but several computers are broken and the remaining functioning computers are being used. What should the student do?

4. jot down the time that the care was given and document when a computer is available

it is 10:00 am and the nurse needs to give a patient a blood pressure medication but would like to know what the morning vital signs were before administering the medication. The nurse looks at the flow skeet, but the vital signs are not there. Which action should the nurse take first?

3. Check the blood pressure, give the medication as appropriate, and then document both

the nurse phones the provider to report a change in the patients condition using the SBARR (situation, backgroud, assessment, recommendation, readback). Method of communication, however, the provider declines to listen to the "read back" and then hangs up. What should the LPN.LV do first?

2. carry out the orders if they are clear

the LPN/LVN is reading the documentation that was written by a newly graduated RN. There are numerous spelling mistakes and the grammar is terrible. What should the nurse do?

3. Ask te charge nurse to review the documentation

The student nurse sees that it is time to give medication to a patient, but the patient is currently in radiology. The student is aware that there is a 30-minute time window to administer the medication, otherwise it will be considered late. What should the student do?

3. Document that the patient is in radiology, advise the charge nurse, and administer the medication or holding until the next dose is harmful to the patient

a patient is admitted to the hospital for a total hip replacement. Care and documentation are performed according to the facility's clinical (critical) pathway or this condition. What information is likely to appear in this documentation tool?

1. level of activity on day-to-day basis following surgery.

A patient comes to the nurses' station and demands to have his chart because he has decided to leave the hospital and seek care from a different facility. What is the best response?

3. "Sir, please wait and I will call the nurse manager right now."

the nursing student leave a copy of a patient's Kardex in a bedside table. A visitor finds the copy and reads it. What should the nurse do?

4. retrieve the Kardex, contact the instructor, and complete an incident report.

the nurse is documenting with a black pen on the hardcopy nurses' notes about a patient;s response to pain medication. The nurse suddenly realizes that she is writing the note in the wrong chart. What is the best action to take?

1. draw a line through the error and initial it.

an auditor is advising a nurse about possible inadequate or inappropriate documentation that could be involved in a malpractice suite. What type of documentation are likely to cause problems in malpractice cases? Select all that apply.

1. failed documentation of latex allergy

2. documented patient's complaining about care using patient's remarks in quotes

3. Charted medication that the patient claims he did not receive.

4. documented amount of IV fluid but no assessment of IV site.

which nursing action/behavior would be considered a potential Health Insurance Portability and Accountability Act (HIPAA) violation?

leaves the computer monitor display open for easy access

the nurse sees a medication prescription for a patient who has acute postsurgical pain. The prescription reads "3 mg oral MS as needed for pain" What should the nurse do first?

3. Call the prescribing provider and ask for clarification of the abbreviation MS.

the nurse inadvertently gives the patient's 7:00 pm medication at 7:00 am. What should the nurse do first?

2. observe for adverse effects, notify the prescribing provider, and fill out an incident report.

the LPN/LVN arrives for her shift and is assigned to care for a patient who will soon be returned from surgery.: acuity level 1. What should the nurse do first?

4. consult with the charge nurse about the appropriateness of the patient assignment

which nursing students have violated the guidelines for safe computer documentation during clinical rotation? Select all that apply.

1. shares password so that a classmate can collect preclinical information

2. logs on an leaves computer terminal to respond to a call light.

4. positions the monitor display so that it is visible to the patient and visitors.

5. prints and takes a hard copy of patient data to complete case study assignment

chart (health care record)

Legal record that is used to meet many demands of the health accreditation, medical insurance, and legal systems.

charting, recording, or documenting

involves the recording of interventions carries out to meet the patient's needs

type of intervention

time of care

signature and title of provider

this is the proof of activites

Electronic Health Record (EHR)

a computerized lifelong health care record for an individual that incorporates data from providers who treat the individual

also referred to as electronic medical record EMR

Documentation

good documentation reflects the nursing process

Integral part of the implementation phase of the nursing process.

documentation is necessary for the evaluation of the patient.

reimbursement for the cost of care provided

today many people use computerized documentation (EHR/EMR)

Purposes of Patient records

1. documented communication

2. permanent record for accountability

3. legal record of care

4. teaching

5. research and data collection

Chart

provides concise accurate and permanent record of past and current medical and nursing problems, plan of care, care give, and the patient responses to treatment.

facilitates continuity of care.

proper charting covers all aspect of holistic care

auditors

current regulation require chart audits by official auditors or people who are appointed to examine patient charts and health records to access quality of care.

was all ordered care charted?

where the responses to treatment noted?

peer review

An appraisal by professional coworkers of equal status

quality assurance, assessment, and improvemnt

audit in health care that evaluates services provided and the results achieved compared with accepted standards

Diagnostic Related Groups (DRGs)

cost reimbursement rates by the government plans Medicare and Medical) are bases on prospective payment system of DRGs. This system classifies patients by

age

diagnosis

surgical procedure

there are hundreds f different categories to predict the use of hospital resources including

length of stay

fixed payment amount

nursing notes

The form on the patient's chart on which nurses record their observations, care given, and the patient's responses

payers of medical insurance carefully review these notes to determine DRG of the patient and eligibility for Medical Medicare

Legal document

the patient chart of health record is a legal document and used in court proceedings if necessary. it is imperative to chart with as much detail and accuracy as possible to protect those involved with the patient care.

teaching

examples of good charting can be used as teaching for nursing students. Students can also learn from mistakes.

Research and data

effectiveness on new treatment.

length of hospitalization and costs can be researched with charting as a tool of evidence.

nomenclature

naming system or convention used as terminolgy

informatics

the study of information processing. relevant in regards to what software program your facility is using to document

personal health record

extension of the EHR system in which the patient is allowed to input their information into an electronic database for a more comprehensive profile of the patient.

SBAR

Situation

Background

Assessment

Recommendation

safety measure to in preventing errors from poor communication between health care workers

SBARR

Situation: Hello Dr. R, this is nurse Paneda. I am calling about Mr W's predischarge lab results

background: All lab results are within normal range except for his serum potassium level. it is 3.1

assessment: when i spoke to him about home medications he sais he has not been taking his potassium supplement for about 2 weeks. he says he forgot to refill but has continued to take Lasix

recommendation: could we get him a new prescription for K+ and include information on his discharge instructions?

read back: let me read that order back to you to make sure I understood. Prescription for K-tab, 10 mEq p.o B.ID. and include on discharge instructions

readback added by the joint commission nurse reads back order to health care provider to ensure that what the nure heard was accurate

basic guidelines for documentation

quality and accuracy

clear and concise

correct choice of words spelling and grammar

good penmanship

charting is to be complete

notes correlate with medical records, Kardex information and nursing care plan

Charting Rules

correct patient name, ID, DOB and time

avoid general phrases "status unchanged" "had a good day"

Objective information only

timely specific accurate and complete

chart only after care is done

chart all order cared given, or explain the deviation

chart as soon and as often as ncessary

chart fact, avoid judgement and blame

chart only for your own care

describe each item as you see it.

document what you observe, not opinions

fill up all spaces, leaving no blanks

follow the facility policy on documenting

grammar and punctuation needs to be correct

if error is made, put a line through the record, write error and your initials then document correctly

if you question an order record that clarification was sought

note patient response to treatments and response to analgesics

sign each block of charting or entry

use direct quotes whenever appropriate

use only approved abbreviations

use blackpen

when patient leaves a unit note the time and type of transportation

if entry is late not that it is a late entry first and then proceed

write legibly

legal basis of documentation

accurate documentation is one of the best defenses in the event of legal claims

must represent clearly individualized goal-oriented nursing care was provided

exactly what happened and must be updated immediately.

inappropriate documentation can lead to malpractice suite

Common medical abbreviations and terminolgy

use standard terminology only

when in doubt spell out the whole word or phrase

"abbreviations to avoid"

BS = blood sugar, breath sounds ??

traditional (block) chart

Conventional patient chart broken down into sections or blocks; included are admission data, physicians' orders, history and physical examination, nursing care plan, nurses' notes and graphics, progress notes, and test data.

Narrative charting

a descriptive record of client data and nursing interventions, written in sentences and paragraphs in the sequence that care and interaction was taken place. Or organized in a head to toe manner.

can include objective or subjective or both information

Problem oriented medical record

POMR organized according to the specific problem solving system or method.

Database

Problem list

Care Plan

Progress notes

Database

history, physical examination and diagnostic tests are used to identify and prioritize the health problems on the master medical and other problem lists.

problem list

active, inactive, potential, and resolved problems serves as the index for chart documentation. Represent all the disciplines involved with the care.

SOAPIER

SOAPE documentation

Subjective - information that the patient states or feels. Only the patient can provide this information

Objective - information is what the nurse can measure or factually describe

A - Assessment, an analysis or potential diagnosis of the cause of the patient's problem or needs

P - Plan of care to be given or taken place

I - implementation or intervention is specific care given or taken place

E - evaluation appraisal of response and effectiveness fo plan

R - revision is changes that may need to be made to the original plan of care.

SOAPE

Briefer adaptation of the charting format for the POMR

Subjective

Objective

Assessment

Plan

Evaluation

Focus chart formatting

modified list of patient problem statements is used as in index for nursing documentation

uses the nursing process

focused on more positive patient needs rather than teh medical diagnoses and problems

focus is sometimes on current patient behavior

DARE

Data - subjective and objective

A - action, a combination of planning an implementation

Response - response is the same as evaluation

E - education patient teaching

type of focus charting

Charting by exception

CBE

hte nurse charts complete physical assessments, observations, vitals signs, IV site and rate, and other pertinent data at the beginning of each shift.

During the shift the only notes the nurse takes are for additional treatments done or planned treatments withheld, changes in the patient's condition, and new concerns

The nurse uses more detailed flow sheets which enhances the focus on existing concerns

PIE

Problem

Intervention

Evaluation

type of focus format charting

similar to SOAPE

the main difference is that PIE charting arose from the nursing process

Assess problem, if problem remains unresolved, the nurse ensures it is addressed continually until resolution is reached.

Record keeping forms

forms that make medical record documentation quick and easy, yet comprehensive.

eliminate the need to duplicate data

more accessible information

unecessary to chart narrative note each time a medication is given, or a bath, or measurement of vital signs

Kardex (or Rand) system

A system used by some facilities to consolidate patient orders and care needs in a centralized concise way

kept at nursing station for quick reference

is part of the EHR / EMR

nursing care plan

outlines the proposed nursing care based on assessment and identified patient problems to provide continuity of care.

standardized care plans can be used but individualized care plans should be implemented to meet patient's specific needs.

incident report

Form used to document any event not consistent with the routine operation of a health care unit or the routine care of a patient.

necessary in the response to unplanned occurrence within a health care facility.

ie incorrect dose of medication, anything that has the potential to cause injury (fall).

prevent future problems through education and other corrective measures

give only objective information

do not admit liability

report care given in response to the incident and the name of the health care provider notified.

twenty-four-hour patient care records and acuity charting forms

nursing record can be consolidated into a system that accommodates a 24-hour period.

helps eliminate unnecessary record keeping forms

easier to obtain accurate assessment information and documentation of activities of daily living (ADL)

uses flow sheets and check lists to enhance efficiency

Acuity charting

uses a score that rates each patient by severity of illness

i.e. scale of 1-5 (1 being high, and 5 being low). A patient return from surgery with multisystem problems is an acuity level 1.

Patient waiting for discharge after successful surgery is acuity level 5

discharge summary forms

discharge planning begins on admission int facility.

Patient, patient family and caregivers should be included in this process to promote continuity of care after discharge.

Discharge summary forms should include:

information pertinent to patient's continued health care after discharge

concise and instructive

a copy to the patient

managed care

integrate the standards of care from multiple disciplines. Managed care is a sytematic approach to care that provides a framework for the coordination of medical and nursing interventions.

Clinical (critical) pathway

allow staff from all disciplines to develop standardized, integrated care plans for a projected length of stay for patients of a specific case type.

these pathways are usually those that occur in high colume and are predictable ( total hip repair)

Home health documentation

different implications than in other areas of nursing because the primary difference is the mature of the home setting.

indicated a more narrow scope of people involved with care

Long-term health care documentation

specific to residents of facility.

OBRA - Omnibus Budget Reconciliation Act instituted significant medicare and medicaid requirements for long term care provisions and documentation

one of the requirements is Minimum Data Sets MDS

MDS

minimal data sets instituted by OBRA for long term care residents.

regulated standards for resident assessment, individualized care, and qualifications for health care providers

supports a multidisciplinary approach where skilled care units.

Guidelines for safe computer documentation

don't share password (good system requires frequent password changes)

never leave computer unattended after logging in

follow correct protocol for correcting errors.

make sure stored records have backup files

do not leave information of a patient displayed on screen

printouts should also be protected, consider shredding of documents not in use

NCLEX REVIEW QUESTIONS