DOCUMENTATION PART 1

documentation

 the hallmark of professionalism in nursing.

documentation

It is a written account of patient data, nursing decisions, interventions, and responses.

informatics 

Documentation 

• Must be accurate, comprehensive, and retrievable for continuity of care.

• Achieved through ________(electronic databases).

• Ensures continuity of care, saves time, minimizes errors, and meets legal & regulatory standards.

• Effective communication among health care workers is essential — reports and records link all members of the team.

communication 

legal documentation 

reimbursement 

auditing and monitoring 

research 

education 

6 purposes of Documentation 

Communication 

• Document immediately after providing care to enhance safety.

• Records show assessment findings, decisions, and patient education.
  

Legal Documentation 

• Accurate and timely documentation = legal protection.

• Follow agency standards and record exactly what happened.

• Common errors:

  • Missing data or actions

  • Not documenting meds or reactions

  • Incomplete/illegible entries

  • Failure to note discontinued med

Correct errors promptly ( single line + error + signature) 

Never write retaliatory comments or opinions 

record discussion when clarifying questionable orders 

document only for your self 

avoid vague terms 

always date and time and sign entries 

protect passwords, log out, and secure record 

legal guidelines in documenting 

Reimbursement 

• Used to determine severity of illness, type of service, and quality of care.

PhilHealth and insurers base payments on documentation accuracy.

Auditing and monitoring 

• Quality improvement programs depend on records.

• Accrediting agencies require plans of care, discharge teaching, and patient input documentation.

• Nurses audit to ensure standards are met and identify staff training needs.

Research

•  Records provide statistical data for studies on diseases, outcomes, and effectiveness of interventions.

Education

One way to learn the nature of an illness and an individual's response to it is to read a patient care record Medical  records teach about illness patterns, symptoms, and responses to therapy.

Interprofessional communication

Quality care relies on accurate, timely, and organized documentation.

• Poor communication = fragmented care and delays

Confidentiality

nurses’ Legal & ethical duty to keep patient data private.

• Only those directly involved in care can access records.

• Patients may request copies with written consent.

• Students may review records only for assigned patients.

• Breach = disciplinary action or dismissal.

Handling and disposal of information

• Shred or destroy printouts after use.

• Remove identifiers (name, DOB, address).

• Use locked bins for disposal.

• Maintain confidentiality at all time

Standards 

Follow institutional policies on what to document.

Must show nursing process, teaching, and discharge planning.

Electronic health records 

– lifetime digital record of all encounters.

Electronic medical record

single visit or episode.

Electronic health records Advantages 

• Improves collaboration & safety

• Integrates all patient data

• Accessible anytime, anywhere

Brevity 

• Entries are concise.

• Complete sentences are not required.

• Start each entry with a capital letter and end the entry with a period even if the entry is a single word or phrase.

Use of ink 

Avoid felt pen or pencil for permanence of data, because the client's chart can be used as an evidence in a legal court.

Accuracy 

• Chart objectives facts, not your interpretations or opinions.

• Place complaint of the client in quotation marks to indicate that it is his statement.

• Objective data are also to be charted.

• Describe behaviors rather than feelings to allow other health team member to determine the actual problems of the client.

• Refusal of medications and treatments must be documented.

Appropriateness

• Only information that pertain to the client's health problems and care are recorded.

• Any other personal information that is conveyed to the nurse is inappropriate for the

Completeness and chronology 

• Notes should appear on each succeeding line.

• Continuous charting is done for each entry unless a time change occurs. No need for a new line for each new idea or entry.

• Avoid double chart. If something appears on a particular sheet, it does not need to appear on the nurse's notes, unless there is an alteration from the normal, e.g. body temperature, blood pressure.

• Avoid squeezing information into a space because you forgot to chart it earlier. Add the information on the first available line. Write the time the event occurred, not the time you entered the information.

Use of standards terminology 

Use only those abbreviations and symbols approved by the institution; spell correctly; use proper grammar.

signed 

• Affix signature, place at the end of the charting, at the right hand margin of the nurse's notes.

• Sign each entry with your full name and status, e.g. SN for student nurse, RN for registered nurse.

• Script, not printing is used for the signature.

in case of error 

• Correct errors by drawing a single (horizontal) line through the error. • Write the word error above the line, and then sign your signature. • No ink eradication, erasures or use of occlusive materials.

factual

accurate

complete

current 

organized 

the most important characteristics of quality documentation are

narrative documentation 

problem-oriented medical record 

charting by exception 

case management and use of critical pathway

the 4 methods of documentation

Narrative documentation

 story-like record; detailed but time-consuming.

Problem - oriented medical Record POMR

organized by patient problems.

Sections: Database | problem list | care plan | progress notes

SOAP

SOAPIE 

PIE 

DAR / focus charting

Formats of Problem Oriented medical record

Charting by Exception CBE 

only deviations from normal (WDL within defined limits /WNL within normal limits ).

Case management / critical pathways

interprofessional, outcome-based; tracks variances

database

problem list 

Care plan 

Progress notes 

Sections of POMR

Database

contains all available assessment information pertaining to a patient

• provides the foundation for identifying patient problems and planning care

problem list

After analyzing data, health care team members identify problems and make a single_________

• chronological order 

• add new problems as they arise 

• when problem resolves = text is highlighted and lined out 

Care plan

Disciplines involved in a patient's care

• Nurses document the plan of care in a variety of formats; generally all of these formats include

Progress notes 

Health care team members monitor and record the progress made toward resolving a patient's problems in__________

admission history form

flow sheets / graphics 

patient care summary 

standardized care plan 

discharge summary

Common record Keeping forms

Admission Nursing History form 

A nurse completes a nursing history form when a patient is admitted to a nursing unit.

• base line data 

Flow sheets and Graphic Record 

records to document physiological data and routine care.

• vital signs, hygiene, ambulation, routine care.
  

Patient Care summary

 auto-generated EHR overview.

Standardized care plan

Many computerized documentations systems include _______ or clinical practice guidelines (CPGs) to facilitate the creation and documentation of a nursing and or interprofessional plan of care

• evidence-based guidelines.
  

admission

Ideally discharge planning begins at _________

Discharge summary form

nursing and other health care professionals begin planning for discharge to the appropriate level of care, which sometimes includes support services such as home care and equipment needs.

• meds, diet, follow-up, contacts.

Kardex

• Flip-card system summarizing patient data.

• Used for continuity & endorsement.

• Written in pencil (planning tool, not legal record).

Acuity rating system 

• Determines staffing levels per shift / every 24 hours
  Rates patients from 1 (independent) to 5 (total care).
  

telephone calls 

 record who, when, what discussed.

telephone / verbal orders 

for RNs only; verify & “read back.”
- Must be signed by MD within 24 hours

Incident reports 

1.  for unusual events (falls, errors, injuries).

   • Do NOT mention in patient chart.

   • Used for quality improvement, not punishment.

Health Informatics 

application of computer and information science in all basic and biomedical sciences to facilitate the acquisition, processing, interpretation, optimal use, and communication of health-related data. The focus is the patient and the process of care, and the goal is to enhance the quality and efficiency of care provided

•  integration of computer & info science for health data.
  

Nursing Informatics 

"use of information and computer technology to support all aspects of nursing practice, including direct delivery of care, administration, education, and research,

• use of tech in care, education, admin, research.
  

Clinical Information System CIS 

Used by all professionals; includes monitoring, lab, and order systems.

Nursing Clinical Information System 

• Supports nursing process documentation.

• May use NANDA, NIC, and NOC classifications.

• Two models:
  

  1. Nursing Process Design

  2. Protocol/Critical Pathway Design
     
     

Change of shift reports / endorsement

telephone reports 

telephone orders 

transfer report 

types of Reporting

Change of shift reports / endorsement 

• For continuity of care.

It is based on health care needs of the client. 

It is not mere reciting the content of the Kardex

telephone reports

Provide clear, accurate, and concise information. •

The nurse documents telephone report by including the following information:

a) When the call was made.

b) Who made the call/report.

c) Who was called.

d) To whom information was given.

e) What information was given.

f) What information was received

Telephone orders

Only RN's may receive ____________.

• The order needs to be verified by reporting it clearly and precisely.

• The order should be countersigned by the physician within 24 hr 

Transfer reports

This is done when transferring a client form one unit to another.