2 Purpose of Records Communication tool for healthcare team Legal documentFinancial billingEducationAssessmentResearchAuditing and monitoring
3 Common Forms of Documentation Admission nursing assessmentClient care planKardex or clinical worksheetFlowsheetProgress notesNursing discharge or referral summaries
4 Guidelines for Legal Documentation Avoid words with unclear meaningsOnly include facts and observations not your interpretationComplete: assessment, interventions, client outcomes, client response, progress toward goals, care that was omitted & why, & who was notified, any communication with other disciplinesCurrent: done when care is provided, late entries must be noted
5 Guidelines for Legal Documentation OrganizedAppropriate: only include info relevant to current healthcare status and care being deliveredAgency policies: each entry contains date and time, legible, permanent (black) ink, correct spelling, proper terminology, contain signature
6 Pitfalls of Documentation Writing illegibly: could lead to errors, misunderstandingLeaving blank lines: someone could insert info at a later dateAltering someone else’s notesBack-dating recordsCorrecting errors incorrectly: only draw single line through error and write “error” above it with nurse’s initialsInserting info between lines: big no no
7 Pitfalls of Documentation Documenting for someone else: each nurse should only document their own care and observationsExpressing opinionsUsing unmeasurable terms: each entry should reflect clarity and brevity (use as few words as possible)Failing to document communication with other healthcare members regarding client care: REMEMBER: “IF IT WAS NOT DOCUMENTED, IT WAS NOT DONE”
8 Methods of RecordingNarrative charting: normal assessment findings integrated with the documentation about the problemProblem oriented medical record: 4 basic components; database, problem list, plan of care, and progress notesCharting by exception: only the exception to the rule is charted: Problem (P), Intervention (I) and Evaluation (E)
9 Methods of RecordingFocus charting: clients needs that deviate from the normal; data (D), action (A) and response (R)Critical pathways: Guidelines for client outcomes within certain groups; Ex. Clients with Pneumonia or Post-MastectomyComputerized charting: becoming more popular, legible records, easy to transfer client records
10 ReportingTransfer of info from one nurse to another at shift change, or from nurse to another healthcare memberCan be written, or verbal (in person or recorded)Change of shift report should include: Client name, age, room # & physician. Diagnosis, general condition, diet, activities permitted, scheduled diagnostic test, new orders, teaching needs, safety needs, any procedures such as dressing change, etc.Must be careful with tape recording report; follow proper procedure to maintain confidentiality
18 Documentation assignment You are taking care of the patient in the above pictures. He is a debilitated CHF/ Cor Pulmonale patient in the last stages. All of the pictures depict his physical status. Document the findings from the pictures on assessment sheets provided Continued on next slide.
19 Assignment continued This patient is on 4 Liters of Nasal O2. His lungs sounds are crackles in lower lobes, diminished throughout. He has a productive cough at times of frothy pink sputum. Heart rate irregular and 120 bpm.Bowel sounds present in all quadrants, hypoactive in lower quadrants.The sacral wound measures 10cmX 8cm.
20 Assignment con’tThe sacral wound has a fetid odor, with a scant amount of green drainage. The dressing is a normal saline soak. Dressing changed at 1025.Initial shift assessment completed at 0730.