Foundations chapter 20: documenting and reporting

documentation

the written or electronic legal record of all pertinent interactions with the patient: assessing, diagnosing, planning, implementing, and evaluating. “if it wasn’t charted it wasn't done”

patient record

a compilation of a patient’s health information (PHI)

what information if confidential?

all information about patients is considered private or confidential, whether written on paper, saved on a computer, or spoken aloud. This includes patient names and all identifiers such as address, telephone and fax number, social security number, and any other personal information

potential breaches in patient confidentiality

• displaying information on a public screen or failing to log off a computer

• sharing passwords

• discarding copies of patient information in trashcans

• leaving the hospital with patient information sheets

• improperly assessing, reviewing, or releasing patient records

• holding conversations that can be overheard in a public area

• sending confidential messages unintended recipients or unprotected devices

• giving out information over a phone to unauthorized individuals

  • sharing information with a professional not involved in the patients care

patients have the right to

• see and copy their health record

• update their health records

• get a list of disclosures

• request a restriction on certain uses or disclosures

  • choose how to receive health information

protect =

protect PHI

access =

only access patient records with permissiona and only those to which your are assigned

Use =

never use a patient’s name when preparing writtwn or oral reports for school

leave =

leave any patient report sheet at the facility

do not have =

do not have your phone out in the clinical areas. they should not be on your person

do not post =

do not post anything on social media about your clinical experiences. No uniformed pictures without faculty permission

Communication

to help health care professionals from different discipplines (who interact with the patient at different times) communicate with one another

Communicationa and documentation

• follows facility’s protocols for patient records

• only document the assessments and interventions you perform

• as a nurse, inform assisstive personel of what they should chart in the medical record and supervise

• communication in the medical record fosters continuity of care and collaboration with other disciplines

• other healthcare professionals will judge a nurse’s work based in what is documented ( or not documented) in the patient record

diagnostic and therapeutic orders

anyone reviewing the chart can find all the diagnostic studies ordered for the patient since admission, the results of these studies, and related orders for care

verbal orders (VOs)

must be given directly by the physician or nurse practitioner to a registered nurse or registered professional pharmacist, who receives, read back, documents and executes the order

policy for recieving verbal order

• must be given directly by the physician or nurse practitioner to a registered nurse or registered professional pharmacist - READ BACK the order to verify accuracy

• record the orders in patient’s medical record with the initials VO

• read back the order to verify accuracy

• date and note the time orders were issued

• record verbal order and name of the physician or NP issuing the order, followed by nurse’s neame and initials. VO should be signed by provider at earliest possible time

• should be limited to urgen situations

quality process and performance improvement

records may be reviewed to evaluate the quality of care patients have received and the competence of the nurses providing that care. r

research

researcher may study patient records, hoping to learn how best to recognize or treat identified health problems from the study of similiar cases

decision analysis

information from record review often provides the data needed by administrative strategic planers to identify needs as well as the means and strategies most likely to address these needs

education

health care professionals and students reading a patient’s record can learn a great deal about the clinical manifestations of particular health problems, effective treatment modalities, and factors that affect patient goal achievement

credentialing, regulation, and legislation

patient records are legal documents that might be used as evidence in court proceedings. One in four malpractice suits are decided on the basis of the patient’s record

reimbursement

patient records are used to demonstrate to payers that patients received the intensity and quality of care for which reimbursement is being sought

historical documentation

because all entires on records are dated, the record has value as a historical document. years later, information concerning a patient’s past health care may be perminent

computerized documentation and electronic health records

computer systems are used for nursing documentation in the patient record. data can distributeed amoung many caregivers in a standardized format, allowing them to compare and uniformly evaluate patient progress easily

source oriented records

a paper format in which each health care gorup keeps data on its own seperate form. secotions of the record are designated for nurses, health care providers, laboratory, x-ray personnel, etc.

progress notes

notes written to inform caregivers of the progress a patient is making toward achiveing expected outcomes

narrative notes

porgress notes written by nurses in a source-oriented record and address routine care, patient data, and patient problems identified in the care plan

problem-oriented medical records

organized around a patient’s problems rather than around sources of information. all health care professionals record information on the same forms

SOAP format notes

(subjective data, Objective data, assessment, plan) used to organize entires in the progress notes of the POMR

PIE charting: Problem, intervention, evaluation

in thsi documentation system, a patient assessment is performed and documented at the beginning of each shift using preprinted fill-in-the-blank assessment forms

focus charting

to bring the focus of care back to the patient and the patient’s concerns. Instead of a problem list or list of nursing or medical diagnoses, a focus column is used that incorporates many aspects of a patient and patient care

charting by exception

a shorthand method of documenting normal finding, based on standardized normals, stards of practice, and predetermined criteria for assessments and interventions

initail nursing assessment

a typical electronic form used to record the initial database obtained from the nursing history and physical assessment. accurate documentation of these data is important to provide a baseline for later comparisons as the patient’s condition changes

care plan

patient records must communicate the patient’s problems or diagnoses; related goals, outcomes, and interventions; and progress or resolution of the problems.

patient care summary

contains an overview of valuable patient information such as documentation, lab and test reuslts, orders, and medications

critical collaborative pathways

the case management plan is detailed, standardized care plan that is developed for a patient population with a designated diagnosis and procedure.

flow sheets

are documentation tools used to efficiently record routine aspects of nursing care

graphic record

is a form used to record specific patient variables such as pulse, respiratory rate, blood pressure readings, body temperature, weight, fluid intake and output, bowel movements, and other patient characteristics

medication administration record

must include documentation of all the medications administered to the patient (drug, does, route, time) the nurse administering the drug, and, for some medications, the reason the drug was administered and its effectiveness

acuity record

24 hour reports are increasingly used in conjunction with acuity reports, with which nurses rank patients as high-to-low acuity in realtion to both the patient’s condition and need for nursing assistance and intervention

discharge and transfer summary

when a patient is discharged from care or transfered from one unit, institution, or facility to another, a discharge summary should be written that concisley summarizes the reason for treatment, significant findings, and procedure performed and treatment rendered

home health care documentation

documentation of home health care visits that reports the patient’s progress serves multiple purposes. sent to the atrending health care provider with a request for signed medical orders to continue treatment, these records ensure continuity of care

long-term documentatiion

documentation in long term care settings is specified by the resident assessment instrument, which helps staff gather definitive information on a residents strength and needs and addresses these in an individualized care plan

Medication requirements for home health care

• patient is homebound and still needs skilled nursing care

• the patient’s status is not stabilized

• rehabilitation potential is good (or patient is dying)

  • the pateint is making progress in expected outcomes of care

Benefits of Resident assessment instrument (RAI)

• residents repsond to individualized care

• staff cmmunication becomes more effective

• resident and family involvement increases

  • documentation becomes clearer

ISBARR

• Identity/introduction = state NAME, TITLE, and UNIT

• Situation = I am calling about: (patient name and room number) The PROBLEM i am calling baout is:

• Backgroud = State admission diagnosis and admission date, state pertinent medical history, brief synopsis of treatment if pertinent, most recent vital signs, changes in VS or assessment from prior assessment

• Assessment = give your analysis and conclusions about the present situation. Words like “might be” or “could be” are helpful. A diagnosis is not necessary. if the situation is unclear, at least try to indicate what body system might be involved. state how severe the problem seems to be. if appropriate state that the problem could be life threatenign

• Recommendation = say what you think would be healpful or needs to be done

• Read- back = ask about any changes in order, restate order you have been given. clarify how often you do vital signs. Under what circumstances to call back

change of shift/handoff report

is given by a promary nurse to the nurse replacing them, or by the charge nurse to the nurse who assumes responsibility for continuing care of the patient. may be given in written form or orally in a meeting

telephone/telemedicine reports

can link health care professionals immediately and enable nurses to recieve and give critical information about patients in a timely fashion.

incident and variance reports

a tool used by health care facilities to document unexpected events that result in or have the potential to result in, or have the potential to result in, harm to a patient or person or damage property

conferring about care

to confer is to consult with someone to exchange ideas or to seek information, advice, or instructions. A nurse may confer with another nurse, such as when a primary care nurse consults with a nurse clinical specialist about a particular patient’s care

consultations and referrals

when nurses detect problems they cannot resolve because the problems are outside the scope of independent nursing practice or the nurses’ expertise, they consult with or make referrals to other professionals

nursing and interdisciplinary team care conferences

nurses and other health care professionals frequently confer in groups to plan and coordinate patient care.