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Documentation of Nursing Care Theory 1)Identify three purposes of documentation. 2)Correlate the nursing process with the process of charting. 3)Discuss.

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Presentation on theme: "Documentation of Nursing Care Theory 1)Identify three purposes of documentation. 2)Correlate the nursing process with the process of charting. 3)Discuss."— Presentation transcript:


2 Documentation of Nursing Care


4 Theory 1)Identify three purposes of documentation. 2)Correlate the nursing process with the process of charting. 3)Discuss maintaining confidentiality and privacy of paper or electronic medical records. 4)Compare and contrast the five main methods of written documentation. LEARNING OBJECTIVES

5 Provides a written record of the history, treatment, care, and response of the patient while under the care of a health care provider Is a guide for reimbursement of costs of care May serve as evidence of care in a court of law Shows the use of the nursing process Provides data for quality assurance studies PURPOSES OF DOCUMENTATION

6 Is a legal record that can be used as evidence of events that occurred or treatments given Contains observations by the nurses about the patient’s condition, care, and treatment delivered Shows progress toward expected outcomes PURPOSES OF DOCUMENTATION

7 Written nursing care plan or interdisciplinary care plan is framework for documentation Charting organized by nursing diagnosis or problem Implementation of each intervention documented on flow sheet or in nursing notes Evaluation statements placed in nurse’s notes and indicate progress toward the stated expected outcomes and goals DOCUMENTATION AND THE NURSING PROCESS

8 Contains data about patient’s stay in a facility Only health care professionals directly caring for the patient, or those involved in research or teaching, should have access to the chart Patient information should not be discussed with anyone not directly involved in the patient’s care THE MEDICAL RECORD

9 Source-oriented (narrative) charting Problem-oriented medical record (POMR) charting Focus charting Charting by exception Computer-assisted charting Case management system charting METHODS OF DOCUMENTATION (CHARTING)

10 Organized according to source of information Separate forms for nurses, physicians, dietitians, and other health care professionals to document assessment findings and plan the patient’s care Narrative charting requires documentation of patient care in chronologic order SOURCE-ORIENTED OR NARRATIVE CHARTING

11 Advantages Information in chronologic order Documents patient’s baseline condition for each shift Indicates aspects of all steps of the nursing process Disadvantages Documents all findings: makes it difficult to separate pertinent from irrelevant information Requires extensive charting time by the staff Discourages physicians and other health team members from reading all parts of the chart SOURCE-ORIENTED OR NARRATIVE CHARTING (CONT’D)


13 Focuses on patient status rather than on medical or nursing care Five basic parts: database, problem list, plan, progress notes, and discharge summary Page 85 Table 7-2 PROBLEM-ORIENTED MEDICAL RECORD CHARTING (POMR)

14 Advantages Documents care by focusing on patients’ problems Promotes problem-solving approach to care Improves continuity of care and communication by keeping relevant data all in one place Allows easy auditing of patient records in evaluating staff performance or quality of patient care PROBLEM-ORIENTED MEDICAL RECORD CHARTING (POMR) (CONT’D)

15 Disadvantages Results in loss of chronologic charting More difficult to track trends in patient status Fragments data because more flow sheets required PROBLEM-ORIENTED MEDICAL RECORD CHARTING (POMR) (CONT’D)

16 P—problem identification I—interventions E—evaluation Follows the nursing process and uses nursing diagnoses while placing the plan of care within the nurses’ progress notes PIE CHARTING


18 Directed at nursing diagnosis, patient problem, concern, sign, symptom, or event Three components: D: data, A: action, R: response (DAR) OR D: data, A: action, E: evaluation (DAE) FOCUS CHARTING

19 Advantages Compatible with the use of the nursing process Shortens charting time: many flow sheets, checklists Disadvantages If database insufficient, patient problems missed Doesn’t adhere to charting with the focus on nursing diagnoses and expected outcomes FOCUS CHARTING (CONT’D)


21 Based on the assumption that all standards of practice are carried out and met with a normal or expected response unless otherwise documented A longhand note is written only when the standardized statement on the form is not met CHARTING BY EXCEPTION

22 Advantages Highlights abnormal data and patient trends Decreases narrative charting time Eliminates duplication of charting Disadvantages Requires detailed protocols and standards Requires staff to use unfamiliar methods of recordkeeping and recording Nurses so used to not charting that important data is sometimes omitted CHARTING BY EXCEPTION (CONT’D)

23 Electronic health record (EHR) Computerized record of patient’s history and care across all facilities and admissions Computerized provider order entry (CPOE) Provides efficient work flow Automatically routes orders to appropriate clinical areas COMPUTER-ASSISTED CHARTING

24 Documentation done as interventions are performed using bedside computers Variations depending on the system Some produce flow sheets with nursing interventions and expected outcomes Others use a POMR format to produce a prioritized problem list Never leave the terminal while part of the patients chart is on the screen Never share you password with ANYONE Deferent levels of security dependent on your job title COMPUTER-ASSISTED CHARTING (CONT’D )

25 Advantages Date and time of the notation automatically recorded Notes always legible and easy to read Quick communication among departments about patient needs Many providers have access to patient’s information at one time Can reduce documentation time Reimbursement for services rendered is faster and complete Can reduce errors COMPUTER-ASSISTED CHARTING (CONT’D)

26 Disadvantages Sophisticated security system needed to prevent unauthorized personnel from accessing records Initial costs are considerable Implementation can take a long time Significant cost and time to train staff to use the system Computer down time can cause problems Page 90 Tips for computer Charting Box 7-1 COMPUTER-ASSISTED CHARTING (CONT’D)

27 A method of organizing patient care through an episode of illness so clinical outcomes are achieved within an expected time frame and at a predictable cost A clinical pathway or interdisciplinary care plan takes the place of the nursing care plan CASE MANAGEMENT SYSTEM CHARTING

28 Be specific and definite in using words or phrases that convey the meaning you wish expressed Words that have ambiguous meanings and slang should not be used in charting Appears to be……. Large among…… Ate well………. Good……. ACCURACY IN CHARTING

29 Sentences not necessary Articles (a, an, the) may be omitted The word “patient” omitted when subject of sentence Abbreviations, acronyms, symbols acceptable to the agency used to save time and space (policy and procedure) Choose which behaviors and observations are noteworthy A rule of thumb is that is the behavior or finding is abnormal or a change from previous behavior or data, chart it. BREVITY IN CHARTING

30 If writing not legible, misperceptions can occur Be sure to include as much information as needed What constitutes complete charting may vary among hospitals and health care agency's LEGIBILITY AND COMPLETENESS IN CHARTING

31 Box 7-3 page 95 Box 7-2 – page 95- Guidelines for Charting about a Sign or a Symptom TYPES OF INFORMATION TO BE DOCUMENTED

32 Not a part of the permanent medical record A quick reference for current information about the patient and ordered treatments Usually consists of a folded card for each patient in a holder that can be quickly flipped from one patient to another THE KARDEX

33 Room number, patient name, age, sex, admitting diagnosis, physician’s name Date of surgery Type of diet ordered Scheduled tests or procedures Level of activity permitted Notations on tubes, machines, other equipment in use Nursing orders for assistive or comfort measures List of medications prescribed by name IV fluids ordered INFORMATION ON THE KARDEX


35 These are actual entries made in medical charts: 1. She has no rigors or shaking chills, but her husband states she was very hot in bed last night. 2. Patient has chest pain if she lies on her left side for over a year. 3. On the second day the knee was better, and on the third day it disappeared. 4. The patient is tearful and crying constantly. She also appears to be depressed. 5. The patient has been depressed since she began seeing me in 1993. 6. Discharge status: Alive but without my permission. 8. The patient refused autopsy. 9. The patient has no previous history of suicides. 10. Patient has left white blood cells at another hospital. 11. Patient's medical history has been remarkably insignificant with only a 40-pound weight gain in the past three days.

36 12. Patient had waffles for breakfast and anorexia for lunch. 13. She is numb from her toes down. 14. While in ER, she was examined, x-rated and sent home. 15. The skin was moist and dry. 16. Occasional constant infrequent headaches. 17. Patient was alert and unresponsive. 18. Rectal examination revealed a normal-size thyroid. 19. She stated that she had been constipated for most of her life, until she got a divorce. 20. I saw your patient today, who is still under our car for physical therapy. 21. Both breasts are equal and reactive to light and accommodation. 22. Examination of genitalia reveals that he is circus sized. 23. The lab test indicated abnormal lover function. 24. The patient was to have a bowel resection. However, he took a job as a stockbroker instead. 25. Skin: somewhat pale but present.

37 26. The pelvic exam will be done later on the floor. 27. Patient was seen in consultation by Dr. Blank, who felt we should sit on the abdomen, and I agree. 28. Large brown stool ambulating in the hall. 29. Patient has two teenage children but no other abnormalities.

38 “unresponsive and in no distress” “nonverbal, noncommunicative and offers no complaints” “irregular heart failure” “his Hct is stable but dropping” “I don’t want to be incubated again” “pulses are fixed and dilated” in asking about code status – “do you want your wife to receive artificial insemination” “Findings compatible with ileus. Bladder is still in colon” “be sure to check eyes and nose” (Is and Os) Reason for leaving AMA – “pt wants to live” “I had a kiwi on my chest” (keloid) “dictated home O2, transcribed homo too” “that bacterial virus is a doozy” “noncompliant smoker” “denies any rectal breeding”

39 “fireballs in the uterus” Reason for office visit – “F\U chest rumbles” “partial TAH” Nursing notes in the ICU – “MD @ bedside attempted to urinate” Indication for flex sig – “blood when whipping himself” “chicken pops” “if she wants children, think about recommending birth control pills” “holy systolic murmur” “pt expired and was dc’d home” “She diuresed pretty well. I gave her 40 of Lasix and she put out 2000 liters.” “My back has been hurting ever since they gave me that cauterizer.” (Foley catheter) discharge dx=nephrolithiasis; discharge instructions=”drink plenty of urine” “She did not lose control of her rectum” Plan – “gently dehydrate” “allergic to Sulpher” “platelets 1889 – dx thrombocytopenia” chief complaint – “bazaar behavior” “depakote shot for pain” “albeauty inhaler”

40 “I follow him for his paranoia” “We will watch her diarrhea closely” NH order – “check pulse everyday” “They took a 50 cent piece out of my colon” (hemicolectomy) “She has encephalitis of her right leg.” “I need a colectomy because I have pollen in my colon.” “This is a 981 YO female with a host of medical problems.” “The patient is actually a fairly reliable historian.” “hyperglycemia toe” “brachycardia” “pt was given a banana bath” “Will hold glyburide for now because of reverse hypoglycemia.” “pneumonia left femur” “2-4 packs of whiskey QD”

41 “This is a 75 YO type 2 hypertensive” Order “Please feed patient only when awake.” “Check orthostasis while on the floor” “She is to wear STD stockings” “nonaudible wheezing noted” When asked if she had a discharge, the patient said “No, but I have Blue Cross Blue Shield.” “Yes, I just met the Infectious Waste doctor.” Nurse to doctor: “I just want to let you know that this lady has had decreased urinary intake.” (Doctor aware) “He is allergic to wives.” “No clubbing, cyanois, or extremities.” order: “Incentive spriometry Q 1 hour until awake.” “fibromyalgia rheumatica” “Pleasant man lying comfortably in bed. Appears somewhat uncomfortable” “Her stomach showed 3+ edema up to the knees.”

42 The End

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