np 7 documentation

medical record is aka _

chart

purposes of documentation

• written record of history, treatment, care & response of patient while under care

• guide for reimbursement of costs of care

• may serve as evidence in law

• shows use of np

• provides data for quality studies

• shows progress toward expected outcomes

if you charted on the wrong patient,

one line cross it out & put initial

documentation & nursing process

written nursing care plan / interdisciplinary are plan is framework for documentation

• charting is organize by nursing diagnosis / problem

• implantation of each intervention is documented on flow sheet / nursing notes

the medical record

only hcp directly caring for patient or involved in research or teaching have access to chart

• pt info should not be discussed w anyone not involved

narrative / source charting

organized according to source of info

separate forms for nurses, physicians, dietitians, etc to document

requires documentation of patient care in chronologic order

pros and cons of narrative / source charting

pros: chronologic order. documents baseline condition for each shift. indicates aspects of all steps of np

cons: makes it difficult to separate important from irrelevant. discourages reading of everything. timely

problem-orientated medical record charting

POMR

focuses on patient status rather than medical / nursing care

5 basic parts

• database (assessment)

• problem list (found from database)

• plan

• progress notes

• discharge summary

pros & cons of POMR

pros: focuses on problems, promotes problem-solving approach. relevant data in one place. easy auditing.

cons: loss of chronologic charting. more difficult to track trends in pt’s status. fragments of data bc more flow sheets required.

PIE charting

P: problem identification

I: interventions

E: evaluation

• follows the nursing process and uses nursing diagnoses while placing the plan of care within the nurses’ progress notes

focus charting

directed at nursing diagnosis, patient problem, concern, sign, symptom, or event

 Three components:

 D: data, A: action, R: response (DAR)

 D: data, A: action, E: evaluation

(DAE)

pros & cons of focus charting

pros: shortens charting time

cons: if database insufficient, pt problems are missed

charting by exception

based on the assumption that all standards of care are carried out & met with a normal / expected response. unless otherwise stated

• longhand note only written when standard statement on form isn’t met

pros & cons charting by exception

pros: highlights abnormal data and trend. decreased narrative charting time. eliminated duplication charting

cons: requires detailed protocols & standards. requires staff to use unfamiliar methods.

computer-assisted charting

electronic health record (CHE)

• computerized record of pt history and care across all facilities & admissions

computerized provider order entry (CPOE)

• efficient work flow

• automatically routes orders to appropriate clinical areas

pros of computer-assisted charting

documentation can be done as implementations are preformed

cons of computer-assisted charting

case management system charting

method of organizing pt care through episode of illness

purpose: clinical outcomes achieved within an expected time frame & at a predictable cost

clinical pathway/ interdisciplinary care plan takes place of ncp

accuracy in charting

• be specific & definite in words and phrases

• words w ambiguous meanings / slang should not be used

observed, stated. not seems.

brevity in charting

sentences not necessary

using “pt” omitted. don’t have to use

abbreviations, acronyms, symbols can be used acceptable to agency

guidelines for documentations

• location of s/s

• quality & quantity

• chronology (when it happened)

• setting

• aggravating & alleviating factors

• triggers / manifestations

types of info to chart

• admission note (ex arrived at 8:45 … completed …)

• assessment (ex focused, daily, etc)

• care

• death

• ADL function

• tests & procedures

• I&O

• calls to PMD

• changes in status

the kardex

quick reference for current information ab pt & ordered treatments. outdated

• usually folded card for each pt that can be quickly flipped through pt & pt

• not part of permeant medical record