Documentation in Nursing

Documentation

• Documentation:
  • Recording pertinent medical information in a patient’s medical record.
  • Can be handwritten or electronic.
  • Chart or Electronic Health Record (EHR).

Purposes of Documentation

• Continuity of care:
  • Nurses document ongoing patient data 24/7.
  • Provides a complete patient picture to the healthcare team.
• Permanent record of care.
• Accountability:
  • Motivates continual internal assessment and evaluation.
• Legal record.
• "Not charted, not done":
  • Belief that undocumented actions were not performed.
  • Documentation is written evidence.

Ownership and Access to Medical Records

• The original medical record (written or computerized) belongs to the facility.
• However, the information belongs to the patient.
• HIPAA guarantees the patient's right to view and obtain a copy of their medical record.

Confidentiality of Documentation

• Confidentiality:
  • Maintaining privacy by not sharing privileged information with a third party.
  • Violation can lead to litigation and hardship for the patient.
• Medical records must be protected from unauthorized access, available only to healthcare providers directly involved in the patient’s care.

Uses of Documentation Forms

• Report form:
  • "Pocket brains."
  • Used to document reports received at the beginning of a shift.
  • Includes additional notes throughout the shift.
• Incident report:
  • Documents out-of-the-ordinary occurrences.
  • Should be objective, including the incident and actions taken.
• Reasons for incident reports:
  • Medication error, patient/visitor/employee injury.
  • Safety hazards.
  • Failure of healthcare provider to respond or perform ordered care.
  • Loss of patient belongings.
  • Lack of vital supplies or equipment.
• Care plan:
  • Includes patient’s problems, interventions, and their effectiveness.
  • Revisions/modifications are documented as the patient's condition changes.
• Patient chart/medical record:
  • Avoid shortcuts.
  • Use only approved abbreviations.
  • Be accurate and objective.

Types of Medical Records

• Source-oriented:
  • Organized by data source (nurse’s notes, lab results, etc.).
  • Includes: Nurse’s notes, healthcare provider’s progress notes, vital signs, rehabilitation therapy, medication administration record, laboratory and X-ray results
• Problem-oriented:
  • Organized around patient’s problems.
  • Includes: Database, problem list, plan of care, progress notes
  • Encourages collaboration.

Data to Document

• Physical and emotional assessment.
• Nutrition, hygiene, activity level.
• Physician’s visits.
• Elimination.
• All nursing care and interventions.
  • Patient teaching, discharge teaching.
• Patient’s response to each intervention.
• All patient complaints.
• Safety issues.
• Laboratory tests, X-rays, and other diagnostic tests.

Methods of Recording Patient Information

• Narrative charting:
  • Tells the patient’s story during their hospital stay.
  • Written in chronological order.
  • Provides a continuous description of the patient’s condition including:
    • Complaints, problems, assessment findings
    • Activities, treatments, nursing care provided
    • Evaluations of effectiveness for each nursing intervention

Documenting Patient Care

• Important to document:
  • The teaching needs of the patient.
  • Specific information taught and methods used.
  • Effectiveness of teaching.

Electronic Health Record (EHR)

• Record of an individual’s lifetime health information.
• Easily updated and transferable.
• Improves quality of patient care by:
  • Reducing errors.
  • Emphasizing patient needs and problems.
  • Providing communication for healthcare staff.
• Includes documentation of:
  • Patient’s interactions with the healthcare system.
  • Record of tests, appointments, medications.
  • Signs and symptoms, diseases, immunizations, allergies.
• Protecting confidentiality:
  • Requires ID and password.
  • Subject to civil and criminal penalties.
• Additional uses:
  • Research to determine causes.
  • Information for the healthcare community and continuing education.

Long-term Care Documentation

• Documentation frequency differs from acute care.
• Many use paper charts.
• The Kardex is used.

Guidelines for Paper Documentation

• Use black or blue ink.
• Write neatly and legibly.
• Sign each entry.
• Include date and time with each entry
• Follow chronological order.
• Make entries in a timely manner.
• Be succinct, use punctuation, do not leave blank lines.
• Use continued notes.
• Correct mistaken entries.
• Keep medical record intact.

Long-term Care Admission Documentation and Required Assessments

• To meet Medicare and Medicaid requirements, the facility must complete an admission assessment document.
• Minimum data set (MDS) for resident assessment and care screening.
  • Omnibus Budget Reconciliation Act (OBRA).
• Weekly assessment data.
• Medication administration records (MAR).

Home Health Documentation

• Certain criteria must be met to admit a patient to home healthcare.
• Outcome and Assessment Information Set (OASIS) is used.
• Documentation is regulated and audited by both the state health department and Medicare.

Documentation Mistakes Leading to Malpractice Risk

• Failure to document assessment findings.
• Failure to document medications administered.
• Failure to document pertinent health history.
• Documenting on the wrong chart or MAR.
• Failure to accurately document physician’s orders.