Chapter 10 Documentation

Standard for Documentation

Health care organization’s policies/procedures. The Joint Commission

The Joint Commission

Requires accurate, timely, and complete documentation. Having a medical record that is only accessed by authorized personnel

Principles of Documentation

Centers for Medicare and Medicaid services. American Nurses Association

Centers for Medicare & Medicaid Services (CMS)

reimbursement tied to documentation accuracy

American Nurses Association (ANA):

emphasizes accountability and ethical recordkeeping.

Electronic health record documentation

Computer competency, Computer support and maintenance, Passwords and verification codes

Aspects of documentation

Standardized nursing terminologies and Do-Not-Use abbreviations

PIE

problem, intervention, evaluation

APIE

assessment, problem, intervention, evaluation

SOAP

subjective data, objective data, assessment, and plan

SOAPIER – adds interventions, evaluation, revision

subjective data, objective data, assessment, plan, interventions, evaluation, revision

Charting by exception

only chart abnormal or significant data

Confidentiality

Nurses have a professional and legal obligation to protect patient information.

Privacy

Patient controling access to personal information

Health Insurance Portability and Accountability Act (HIPAA)

Standards for the protection of personal health information, whether conveyed orally or recorded in any form or medium

Hand-Off Reports

Passing patient-specific information from one caregiver to another. May be oral, written, recorded, or printed Promotes continuity of care and collaborative problem solving

SBAR

Situation, Background, Assessment, Recommendations

RN responsibilities during Verbal/Telephone Orders

Repeat the order verbatim, enters order in the EMR, document it as a verbal/phone order, includes date, time, physician’s name, and RN signature

Incident report

Generated when unusual and unexpected event involving a patient, visitor, or staff member occurs.

Types of Medical Record (EHR)

Written record. EMR (real-time, electronic access). CPOE Computerized Provider Order Entry (reduces transcription errors)

Nurse’s responsibility

Maintain computer competency, keep passwords private, log off after use, report system downtime or issue

Essential qualities of nursing documentation

Factual, accurate, timely, complete, current, organized, standardized