documentation and reporting

documentation

written or electrical legal record of all patient interactions

purpose of patient records

communication

diagnostic and therapeutic orders

care planning

quality process and performance improvement

research; decision analysis

education

credentialing, regulation, and legislation

reimbursement

legal and historical documentation

characteristics of effective documentation

do not chart in advance

consistent with professional and agency standards

complete

accurate

concise

factual

organized and timely

legally prudent

confidential

elements of documentation

use military time

content

timing

format

accountability

confidentiality

confidentiality

all information about patients written on paper, spoken aloud, or saved on computer

breaches in confidentiality

displaying information on a public screen

sharing confidential emails via public networks

sharing printers among units with differing functions

discarding copies of patient information in trash cans

holding conversations that can be overheard

faxing confidential information to unauthorized persons

sending confidential messages overheard on pagers

patient rights

see and copy their health record

update their health record

get a list of disclosures

request a restriction on certain uses or disclosures

choose how to receive health information

verbal orders

given during an emergency

1. record orders exactly as said

2. read back

3. date and time

4. who gave the order

5. nurse’s name/title

source oriented records

paper format in which each healthcare group keeps its own forms

problem oriented medical records

paper charting oriented around patient’s problem. all healthcare charts on one document

defined database

problem list

care plans

progress notes

SOAP format

PIE charting

problem, intervention, evaluation

paper charting with no separate care plan

focus charting

focus on strengths, problems, needs

case management model

collab among team members

charting by exception

electronic shorthand documentation

uses clear standards of practice- normal parameters

only exceptions are documented in narrative notes

less time spent charting and more time for patient care

more difficult to prove high quality safe care if negligence claim is made

nursing documentation

initial nursing assessment

care plan

patient care summary

progress notes

flow sheets and graphic records

medication record (MAR)

acuity record

discharge and transfer summary

medication record (MAR)

all medications that have been and will be given to patient

acuity record

how much staff was needed for patient

flow sheets

graphic record

24 hour fluid balance record

medication administration record (MAR)

24 hour patient care record

acuity records

ISBARR

widely used way of communicating information about a patient to other health care providers quickly and efficiently

identity/introduction

situation

background

assessment

recommendation

read back of orders

hand off reports

basic identifying information about each patient

current appraisal of each patient’s health status

current or newly changed orders

abnormal occurrences during your shift

any unfilled orders that need to be continued onto the next shift

patient/family concerns, questions, or needs

report transfers/discharges

telephone reports

identify yourself and the patient and state your relationship to the patient

report concisely and accurately the change in the patient’s condition that is of concern and what has already been done in response to this condition

report the patient’s current vital signs and clinical manifestations

have the patient’s record at hand to make knowledgeable responses to any physician’s inquiries

concisely record time and date of the call, what was communicated, and physician’s response

incidence reports

aka a variance report

used to document the occurrence of anything out of the ordinary that results in, or has the potential to harm a patient, employee, or visitor

used for quality improvement

collect facts about an incident case of litigation

report to family members

only give report to approved family member or friend

in an emergency situation, use judgement to decide whether to share information with family

do not inform family of results

explain what results mean

be honest, respectful, and compassionate

communicate so family can understand

ethical and legal concerns

be aware of laws, regulations, policies, and procedures regarding data security and confidentiality of patient information

always log out before walking away from computer

only access charts that are needed for direct patient care

always be completely truthful when charting

do not use others’ computer resources without authorization to do so

eight behaviors of purposeful rounding

accomplish scheduled tasks

address 4 Ps. (pain, personal, position, prevention of falls)

address additional personal needs, questions

conduct environmental assessment

ask “is there anything else I can do for you”

tell the patient when you will return

document the round