Documentation

legality of documentation

if it wasnt document, it wasnt done

ethicals of documentation

if it wasnt done, dont document it

should you document with “within normal limits” (WNL)?

no, instead use precise values

what is documentation?

anything that is entered into a patient’s chart (EHR, patient record, patient chart)

purpose of the patient record (5)

1. permanent, legal documentation

2. decreases errors

3. collaboration

4. legal evidence

5. evaluation of patient outcomes

measures to maintain confidentiality of patient information (3)

1. maintaining privacy of written patient info

2. paper charts

3. EHR (private log-in, traceable, do not leave patient info pulled up, protect printed items, log-off)

legal and ethical implications of nursing documentation (7)

1. concise

2. facts

3. accurate

4. complete

5. current

6. organized

7. grammer/spelling

charting formats required in nursing (4)

1. charting by exception (EHR)

2. narrative

3. SOAP/SOAPE/SOAPIE

4. PIE

charting by expection

• document only if abnormal

• eliminates redundancy

• checkboxes

• narrative notes used ONLY when there is an exception to the checkbox options

narrative

• story-like format, but concise

• no extraneous words

• approved abbreviations

• can be used as a single way to document or to augment CBE/EHR documentation

narrative is useful in describing ________ and __________ ______ when so much is happening at one time that documenting it in CBE format is not reasonable

procedures and emergency situations

SOAP/SOAPE/SOAPIE

subjective, objective, assessment, plan

PIE

problem, intervention, evaluation

hand written documentation rules (6)

1. no erasing, using white-out, or scratching out

2. black ink, no pencil, no erasing

3. leave no blank line spaces between entries

4. begin entry with date and time

5. end with signature and title

6. indicate late entries

what do you document? (6)

1. assessment findings (subjective and objective)

2. nursing actions

3. patients response to nursing actions

4. additional plans/communication/follow-up

5. evaluation of patient’s progress

6. any changes in the assessment findings

4 types of special documentation

1. routine shift scales

2. against medical advice (AMA)

3. restraint flowsheet

4. incident/adverse event reporting

routine shift scales

routine medical scales for daily checks

against medical advice (AMA)

occurs when a patient chooses to leave a hospital before the treating physician recommends discharge, often due to personal reasons, financial constraints, or long wait times

• thorough documentation of the measures taken

• communication with patient and provider

• patient education

restraint flowsheet

documents in one place care delivered regarding restraints and the concerns that surround it

• alternatives tried before restraints applied

• reason for restraints

• assessments (type of restraint, which extremities, basic human needs assessed every 2 hours as needed)

incident/adverse event reporting

an event outside the normal routine of the unit occurs that could cause or does cause harm to the guest, patient, employee, etc

• actual or potential injury/harm (error, fall, injury, accident)

adverse event reports are for the …

facility quality improvement (QI)

are adverse event reports completed with or separate from the patient chart

separate

document what occurred, the patient status, and what you did then …

separately complete an incident report and submit to QI department