Foundations of Nursing - Documentation

Documentation Chapter 3: Foundations of Nursing

Objectives

  • List the five purposes for patient records.
  • Describe the electronic health record (EHR) and the personal health record (PHR).
  • Determine when the use of Situation, Background, Assessment, and Recommendation is beneficial.
  • State important legal aspects of chart ownership, access, confidentiality, and patient care documentation.
  • Describe differences between traditional and problem-oriented medical records.
  • Describe the basic guidelines for and the mechanics of charting.
  • Describe the differences in documenting care with activities of daily living and physical assessment forms, narrative, SOAPIE, and focus formats.
  • Discuss documentation and clinical (critical) pathways.
  • Discuss home health care documentation.
  • Discuss long-term health care documentation.
  • Discuss issues related to computerization in documentation.

Key Terms

  • Health Care Record (Chart): A legal record used to meet health, accreditation, medical insurance, and legal system demands.
  • Charting: The process of adding information to the chart, including recording interventions carried out to meet patient needs.
  • EHR (Electronic Health Record) / EMR (Electronic Medical Record): Systems used by most healthcare facilities.

Purposes of Patient Records

  • Five basic purposes:
    • Documented communication
    • Permanent record for accountability
    • Legal record of care
    • Teaching
    • Research and data collection
  • Legal Owner: The institution owns the client’s medical record.
  • Auditors: Review records to improve quality of care and verify ordered care and treatments were carried out and noted.
  • Peer Review: Appraisal by professional coworkers of equal status.
  • QAPI (Quality Assurance Performance Improvement): Evaluates services provided and results achieved against accepted standards.
  • Diagnosis-Related Groups (DRGs):
    • Classifies patients by age, diagnosis, and surgical procedure.
    • Produces approximately 300 categories for predicting hospital resource use, including length of stay, resulting in fixed payments.
    • Forms the basis for reimbursement rates for Medicare and Medicaid.
    • Many private insurance companies use similar systems for reimbursement.
  • Nursing Notes:
    • Nurses record observations, care given, and patient responses.
    • Institutions are reimbursed by insurance companies or government programs only for documented care.
    • Patient charts/health records are used for teaching.

Electronic Health Record (EHR) and Personal Health Record (PHR)

  • Use of the Record: Focus on ease of use and documentation.
  • Point-of-Care: Utilizing computers on wheels (COWS).
  • Security: Maintaining information security within the PHR.
  • Input Information: Entering data into the system.
  • Patient Access: Patients can access their records by following facility rules.
  • I-S-B-A-R (Identification, Situation, Background, Assessment, Recommendation):
    • Used for communication between providers and nurses.
    • The Joint Commission states it meets the National Patient Safety Goals.
    • An additional "R" can be added, read back.

Basic Guidelines for Documentation

  • Quality and accuracy of nurse’s notes are extremely important.
  • Correct spelling, grammar, and punctuation, along with good penmanship and writing skills, are important.
  • Information recorded should be clear, concise, complete, and accurate.
  • The Registered Nurse (RN) is responsible for the initial admission nursing history, physical assessment, and development of the care plan.

Charting Rules

  • All sheets should have the correct patient name, identification number, date of birth, date, and time if appropriate.
  • Use only approved abbreviations and medical terms.
  • Be timely, specific, accurate, and complete.
  • Write legibly.
  • Follow rules for grammar and punctuation.
  • Leave no empty lines; chart consecutively.
  • Chart only for yourself after care is given.
  • Chart as soon and as often as possible.
  • Use direct quotes as appropriate.
  • Be objective in charting; describe each item as you see it.
  • Avoid judgmental terms and placing blame.
  • Sign each entry so the person who signed did the work & interventions were carried out
  • Chart all ordered care as given.
  • Note patient responses to treatments and/or medications.
  • When a patient leaves the unit, chart the time and method of transportation on departure and return.
  • Use only hard-pointed, permanent, black ink pens; no erasures or correcting fluids are allowed on charts.
  • If a charting error is made, identify the error according to facility policy and make the correct entry.
  • When making a late entry, note it as a late entry and proceed with the entry.
  • Follow each institution’s policies and procedures for charting.
  • Avoid general, empty phrases such as "status unchanged" or "had a good day."
  • If you question an order, record that clarification was sought.

Legal Basis of Documentation

  • Accurate documentation confirms individualized, goal-directed nursing care was provided based on nursing assessment.
  • Update chart immediately after providing care - if it is not written, it was not done.
  • Indicate all assessments, interventions, patient responses, instructions, and referrals in the medical record.
  • Avoid inappropriate documentation.
Medical Abbreviations and Terminology
  • Use standard medical abbreviations and terminology.
  • Most facilities have a published list of generally accepted medical abbreviations and terms.
  • Use complete words if unsure of the proper abbreviation.

Methods of Recording

  • Traditional Chart:
    • Divided into specific sections.
    • Emphasis placed on specific information sheets.
    • Typical sections include admission sheet, physician’s orders, progress notes, history and physical, nurse’s admission notes, care plan, nurse’s notes, graphics, and laboratory and X-ray reports.
  • Narrative:
    • Care given is descriptive.
    • Written in abbreviated story form.
    • Includes: patient need or problem data, whether someone was contacted, care and treatments provided, and response to treatment.
  • Problem-Oriented Medical Record (POMR):
    • Scientific problem-solving system or method.
    • Principal sections: database, problem list, care plan, and progress notes.
    • Database: History and physical, diagnostic tests. Identify and prioritize the health problems on the medical and other problem lists.
    • Problem list: Active, inactive, potential, and resolved problems.
    • Care plan with nursing diagnosis is developed for each problem by disciplines involved in care.
  • SOAPIER:
    • S – Subjective
    • O – Objective
    • A – Assessment
    • P – Plan
    • I – Intervention
    • E – Evaluation
    • R - Revision
  • Focus Charting:
    • Modified lists of nursing diagnoses.
    • Nursing process used with a focus on patient needs.
  • Charting by Exception (CBE):
    • Complete physical assessments, observations, vital signs, IV site and rate, and other pertinent data charted at the beginning of each shift.
    • During the shift, only additional treatments given or withheld, changes in patient condition, and new concerns are charted.
    • More detailed flow sheets, which reduce time needed to chart, are used.

Alternative Recordkeeping Forms

  • Make medical documentation easy and quick.
  • Eliminate duplication of data; unnecessary to document each time medication is given.
  • Kardex/Rand:
    • Consolidate orders and care needs in a centralized, concise way.
    • Concise centralized source of information on current treatment
  • Nursing Care Plans:
    • Preprinted guidelines are used to care for patients with similar health problems.
    • Developed to meet nursing needs, based on nursing assessment and nursing diagnoses.

Other Documentation Forms

  • Incident Reports:
    • Used for any event not consistent with routine patient care.
    • Give only objective information.
    • Do not admit liability or give unnecessary details.
    • Do not mention the incident report in nurse’s notes.
  • 24-Hour Patient Care Reports and Acuity Forms:
    • Accurate assessment information and documentation of activities of daily living.
    • Use flow sheets and checklists.
    • Acuity charting rates each patient’s severity of illness and determines efficient staffing patterns.
  • Discharge Summary:
    • Pertains to patient’s continued health care after discharge.
    • Concise and instructive form.
  • Clinical Pathways:
    • Coordinates medical and nursing interventions.
    • All disciplines develop integrated care plans for projected length of stay for specific case types.
    • Monitors patient’s progress and documentation tool.

Home Health Care Documentation

  • Documentation provides quality control and reimbursement from Medicare, Medicaid, and private insurance companies.
  • Must note patient education and demonstration of learning.
  • Coordination of services and compliance of regulation reflected by all members of the health care team.

Long-Term Health Care Documentation

  • Omnibus Budget Reconciliation Act (OBRA) of 1987 regulates standards for resident assessment, individualized care plans, and qualifications for health care providers.
  • The Department of Health (DOH) for each state governs the frequency of written nursing records of residents.
  • Supports a multidisciplinary approach in assessment and planning processes of patient care.

Special Issues in Documentation

  • Record Ownership and Access:
    • Property of the institution or health care provider.
    • Patients usually do not have immediate access to the full record.
    • To gain access, need to follow the established policy of the facility.
    • Lawyers can gain access to the chart with the patient’s written consent.
  • Confidentiality:
    • The Patient’s Bill of Rights and the law guarantee that the patient’s medical information will be kept private unless the information is needed to provide care, or the patient gives permission for others to use it.
    • Nurses should not read a record unless there is a clinical reason and should hold the information regarding the patient in confidence.
  • Electronic Documentation Safeguards:
    • Institutions have mainframe computers for data processing tasks.
    • Progressive hospitals’ computers handle provider orders, pharmacy, laboratory, diagnostic imaging orders, central supply requests, care planning, documentation, and billing.
    • Most efficient computer systems have bedside or handheld terminals for data entry.
    • Do not share passwords used to log into the computer.
    • Do not leave a computer terminal unattended without logging off.
    • Follow the correct protocol for correcting errors.
    • Be sure stored records have backup files.
    • Do not leave information about a patient displayed on a monitor where others can see it.
  • Use of Fax Machines: Transmit information between offices, hospitals, and other facilities – vital for rapid information transmission and as important as computers for documentation and data handling.