Documentation and interprofessional communication

Nursing process acronym

ADOPIE

ADOPIE

Asses

Diagnose

Outcome identification

Plan care

Implement

Evaluate

Asses

complete, accurate health data compilation

Diagnose

clustering data to make a judgment or statement about patients difficulty or condition

Outcome identification

formation of measurable, realistic, patient-centered goals

Plan Care

Determining resources, targeting nursing interventions, writing the plan of care

Implement

Any treatment, based upon clinical

judgment and knowledge, that a nurse performs

to enhance patient outcomes

Evaluate outcomes

Judgment of the effectiveness of nursing care in meeting patient goals and outcomes based on patient responses to nursing interventions

Prioritization within the nursing process

Among all the patient's problems, identify the problem that is most urgent/important and address it first.

Purposes of the Medical Record

Legal document

Communication and care planning

Quality assurance

Financial reimbursement

Medical record as a legal document

Used in civil or criminal courts for evidence

Sentinel event

An unexpected occurrence involving death or serious physiological or psychological injury

serious, often life-threatening errors in healthcare: what is involved in most of them?

Almost 3/4s of these are from failures in communication

EMR

An electronic patient record that uses computer systems to store, organize, and sometimes automatically process/flag patient information

Computerized provider order entry(CPOE)

Direct entry of all orders by healthcare providers to laboratory, pharmacy, nursing personnel

Patient medical record components

Nurses Have All Primary Care Flowing, Focused Meds, Labs, Progress, Consults, Discharge

Nursing admission assessment

History and physical examination (H&P) by primary provider

Advance directive, power of attorney

Primary provider’s orders

Care plan or clinical pathway

Flow sheets

Focused assessment sheets

Medication administration record (MAR)

Laboratory, diagnostic test results

Progress notes: members of the healthcare team

Consultations

Discharge or transfer summary

Things that Warrant immediate attention and interventions

Rats always think about a nasty ass crap AND Unknown dogs are new threats until an amazing sandwich

Respiratory rate <8 or >28 breaths/min

Acute change in oxygen saturation <90%

Threatened airway

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

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

New seizure

Temperature >39.0°C (102.2°F)

Uncontrolled pain

Acute change in urine output (<50 ml over 4 hours or <0.5 mL/kg/hr)

Acute bleeding

Suspected severe sepsis

Respiratory rate danger zone

<8 or >28 breaths/min

Oxygen saturation danger zone

<90%

Acute change in blood pressure

(<90 mm Hg) or diastolic blood pressure (>110 mm Hg)

Acute change in heart rate

(<50 or >120 beats/min)

Acute change in urine output

(<50 ml over 4 hours or <0.5 mL/kg/hr)

Health Insurance Portability and Accountability Act

A federal law that protects patients’ private health information (PHI) and controls how it can be used and disclosed.

Subjective data

client’s exact words

Objective data

What is actually seen or measured. ie. VS, auscultation

Progress Notes

Most are check boxes

Other formats include
Narrative notes

SOAP(IE) notes

PIE notes

DAR note

Narrative notes

unstructured paragraph, based on time

SOAP(IE) notes

subjective; objective; analysis; plan; interventions; evaluation

PIE notes

problem; interventions; evaluation

DAR

Data action response

Charting by exception

Nurse checks box if client meets designated norms

abnormal findings then require additonal documentation

Discharge note

Indicates

client’s status

received necessary education

discharge instructions

condition and time of discharge

When does nursing reporting occur?

During

handoffs

rounds

care conferences

communication with providers about patient status or requested information

What can interfere with nursing reporting?

Unclear roles

poor structure

cultural/power differences

poor judgment

different communication styles

Hand offs

When responsibility for a patient is transferred from one healthcare provider/nurse to another

SBAR Model

Used for handoffs

Situation

Background

Assessment

Reccomendation/Request

Situation

State

your name
your unit
patient’s name

room number

patient’s problem

when it happened or when it started

and the severity

Background

State the data pertinent to this moment’s problem

admitting diagnosis

when admitted

and pertinent background data

Assessment

State your assessment findings

Recommendation or request

State what you want/need to continue caring for the patient

What are ways nurses can report information to the primary healthcare provider?

Face-to-face, telephone, text messaging, or fax.

What should you ensure before contacting a healthcare provider?

ensure the correct provider is being contacted

What should you have available when making a phone call or urgent communication to a provider?

The patient's relevant information for reference.

What should you do after communicating with a provider by phone?

Document the call.

What is CPOE useful for when a provider is off-site?

It allows the provider to remotely enter patient orders into the computer system.

What is "read back" in provider communication?

Repeating the order/information back to the provider to confirm it was heard and understood correctly.