NUR 2270 exam 2

Documentation

• Purpose of Documentation

  • Legal document

  • Communication

  • Services and care

    • Reimbursement

    • Auditing/Evaluation

    • Research

    • Education

  • What the nurse is doing to the patient

  • Importance of documentation: "if you didn’t document it, you didn’t do it"

    • Rules:

      • Factual

      • Accurate

      • Complete

      • Current

      • Organized

      • Include date and time

      • Document after care is provided

      • Use only accepted terminology

• Purpose of the Medical Record

  • EMR (Electronic Medical Record)

    • Legal record for a single patient healthcare encounter

  • EHR (Electronic Health Record)

    • Longitudinal record of all healthcare encounters for a patient

  • Benefits:

    • Promotes ease of access to information

      • Improves continuity of care

    • Improves healthcare quality and safety

    • Reduces healthcare costs

• Legal and Ethical Considerations of Documentation

  • HIPAA

    • Health Insurance Portability and Accountability Act

    • Patients can access their own records

Security Measures Using Electronic Documentation

• Digital Security

  • Firewalls

• Physical Security

  • Computer placement guidelines

  • Importance of logging out of computers

• Handling and Disposal of Information

• Deidentification of Patient Data

  • Restrictions on accessing patient information

  • Never share login credentials

Guidelines for Quality Documentation

• Factual

• Accurate

• Complete

• Current

• Organized

• Do’s and Don’ts of Documentation

Documentation Forms

• Flowsheets

  • Intake and output

  • Vital signs

  • Weights

• Progress Notes

  • Undated condition

General Guidelines for Documentation

• Confidentiality

• Concise and Complete

• Document care only after providing care

• Use accepted abbreviations and terminology only

• Correct spelling

• Correct sequence of information

• Must include date/time/signature

Methods of Documentation

• Narrative

  • Sections with varied input

• Problem-Oriented Medical Record (POMR)

  • More organized; outlines plan

• Progress Notes: tracking patient improvement

  • SOAP (Subjective, Objective, Assessment, Plan)

  • SOAPIE (Subjective, Objective, Assessment, Plan, Intervention, Evaluation)

  • PIE (Problem, Intervention, Evaluation)

  • Focus Charting [DAR] (Data, Action, Response)

  • Charting by Exception

• Change of Shift Report

  • Ensures continuity of care

• Handoff Report

  • Verbal or written exchange of information

• iSBAR

  • Introduce, Situation, Background, Assessment, Recommendation

• Telephone Orders: Writing protocol

  • Know board position and agency policy

  • Speak slowly and clearly; spell medication names

  • Verify unusual medications/doses

  • Document order and read back for confirmation

• Graphic Record/Flow Sheet

  • Document and compare vital signs

• Discharge Summary

  • Follow-Up Appointment, Activity Restrictions, At-Home Medications, Reportable Complications

• Acuity Rating Systems

• Clinical Pathways

  • Assist in decisions and interventions for specific health problems

• Nursing Informatics

  • CPOE (Computerized Provider Order Entry)

Medication Administration

• Role of the Nurse in Medication Administration

  • Verify correct medication, educate patient, evaluate safety, check administration routes, assess for interactions

• Types of Medication Orders

  • Oral: slow onset, prolonged effect

    • Includes: Caplet, Capsule, Tablet, Enteric coated, Elixir, Syrup

  • Injections: Risks include infection and discomfort

  • Skin/Topical: Care with skin breakdown, documentation of transdermal patches

  • Mucous Membranes: Buccal and sublingual methods

  • Inhalation

• Components of a Medication Order

  • Patient’s full name, date and time, medication name, dosage, route, frequency, provider signature

• The Rights of Medication Administration

  • Right patient, medication, dose, route, time

• Medication Reconciliation

  • Compare current medications with orders to avoid duplications and evaluate interactions

• Medication Errors

  • Defined as preventable events affecting medication safety

  • Report all errors, document incidents, notify relevant parties

Medication Half-Life

• Therapeutic Range: Concentration levels defined

• Half-Life: Time for serum concentration to decrease by half

• Onset, Peak, Duration

  • Onset: when medication effects start

  • Peak: highest concentration and effectiveness

  • Duration: period during which drug is effective

Medication Routes

• Oral Medications: Restrictions on crushing certain formulations

• Topical Medications: Differences in paste, ointment, transdermal patches

• Rectal Instillation: Techniques and precautions

• Eye Instillation: Technique to avoid cornea

• Ear Instillation: Administration according to age

• Enteral Medication: Flushing protocols for NG/G tubes

• Inhalation Medications: Techniques to improve administration effectiveness

Injections

• Injection Techniques: IM, intradermal, subcutaneous, considerations for needle length and gauge depending on size/age

• Volume for Injections: Maximum volumes according to site and age

  • Deltoid: 1 mL; Vastus lateralis: 3 mL; Ventrogluteal: 3 mL

Concepts Related to Tissue Integrity

• Factors Affecting Tissue Integrity:

  • Internal: age, genetics, underlying health

  • External: environment, activity

• Pressure Injury Risk Factors:

  • Patient age, mobility, nutrition, body heat

• Staging Pressure Ulcers

• Wound Assessment and Documentation

  • Assess skin breakdown, document details

Wound Healing Complications

• Types: Hemorrhage, infection, dehiscence, evisceration

• Nursing Actions for Wound Care

• Documentation Needs: Size, condition, drainage type

Interventions to Promote Healing

• Regular repositioning and skin inspections

• Wound Care Guidelines: Differ by stages of pressure ulcers

Concepts Related to Mobility / Safe Patient Handling

• Complications of Immobility:

  • Musculoskeletal, cardiovascular, respiratory, gastrointestinal, urinary

  • Psychosocial effects

• Lifespan Considerations: Impacts on development and health

Responding to Falls

• Nursing Actions: Prevent complications of immobility through education and interventions