Presentation on theme: "PhoneRN TRAINING 2013. Why should we document?! Documentation is the ONLY way that others (physicians, ED/UCC, other triage nurses) know what transpired."— Presentation transcript:
Why should we document?! Documentation is the ONLY way that others (physicians, ED/UCC, other triage nurses) know what transpired between us and the patient. The words you use can either give you credibility or take it all away In a court of law- clear/concise and accurate documentation can make the difference btw winning or loosing the lawsuit!
Your documentation should support the guideline and disposition chosen.
Be sure that a statement in your nursing assessment matches the wording of the disposition you choose.
Incorrect Disposition reason History of Present Illness Pt began to develop pus in both eyes 3 days ago, and eyelids were sealed closed the following morning. Yesterday the amount of pus began to increase in both eyes. The sclera is slightly reddened, and the eyelids are slightly swollen, and he is currently able to open his eyes all the way. Pt is acting normally. Pt has some nasal congestion with some drainage. Fever : afebrile Level : na Duration: N/A PROTOCOL : Eye - Pus Or Discharge – Pediatric DISPOSITION: See Physician within 24 Hours -  Lots of yellow or green nasal discharge AND  present now AND  fever REASON: Nice clear note, good spelling/grammar Correct Protocol but incorrect disposition chosen as the patient does not have a fever
Based on previous note, the correct disposition reason would be: PROTOCOL : Eye - Pus Or Discharge - Pediatric DISPOSITION: Call PCP within 24 Hours -  Eye with yellow/green discharge or eyelashes stuck together AND  no standing order to call in prescription for antibiotic eyedrops (CANADA: Continue with triage)
Incorrect Guideline Choice History of Present Illness Mom reports that child has dry cough and nasal congestion. Mom states she would like to give child medication for it. Child is eating, drinking, voiding, and activity level is wnl per mom. Last bottle of formula 15 minutes ago, he consumed6 oz., and is sleeping on her chest during triage. She states he has been playing and that cough and nasal sound is a concern to her. Denies any other sx of illness. States child is scheduled for 6 months shots 10-19 or 10-20-09. PROTOCOL : Cough - Pediatric DISPOSITION: Home Care - Cough with no complications (all triage questions negative) Note is clear but not complete-no onset of symptoms reported. Unable to determine correct disposition without knowing when symptoms started. Wrong guideline choice-Colds Protocol covers cough/congestion REASON: home care is more specific for child’s symptoms if correct guideline is used
Complete Note History of Present Illness Child woke up this morning with green discharge from left eye and eyelashes stuck together slightly. Throughout day eye has continued to have increasing amounts of green drainage. Mild redness, no swelling. No fever. MAE WNL. No cold symptoms. Feeding WNL.
Complete Note Crying and pulling at right ear onset yesterday, crying and screaming att and mother states `won`t sleep due to pain`-received Infant`s Tylenol 1.6 ml PO last 30 minutes ago, received dose prior 4 hrs ago with relief- no discharge from ear, no redness or swelling behind ear-is mae wnl including head and neck.
The assessment will contain subjective information provided by the parent.
The health history will contain positive findings or the word “healthy”. Correct: Chronic Illness : Healthy Correct: Chronic Illness: Asthma/Diabetes/CP Incorrect: None or blank
The symptoms will be described in detail. Who: Who the patient is, age, gender (if applicable), health concerns, medications he/she takes, allergies, weight etc… What: what symptom/s the parent/care giver calling about Where: which body part/s are affected When: When did it start (use actual date or number of days since onset, NOT day of week) How long: when was the onset (use actual date, NOT day of the week
All follow up calls will be documented 911 follow up calls are documented as addendums on the original note. Urgent Home Care with Follow Up can be documented as addendums on the original note (regardless of improvement or not of symptoms) UNLESS a brand new symptom is presented on callback-then a new note should be opened to triage the brand new symptom.
All OTC medications given should be documented in your note along with dose and time last dose was given. Document chronic/daily meds under the “Medication” section of Past Medical History. Document all OTC or “temporary” meds given in last 24hrs in your nursing note.
The patient registration will include last name, first name, PCP, DOB, sex, phone number, and parent name, all with proper capitalization. Although this information is initially entered by the answering service, we should still confirm Name (spelling if it is unusual)/Caller/DOB and PCP at the beginning of each call.
Any dispositions overridden will have a reason documented Recommended Disposition : See Physician within 24 Hours Over Ride Disposition : Call PCP Now Reason: Nursing judgment.
Reasons to Override “Parent wants to talk to MD” is NOT a reason to override your disposition. If you have triaged a child and the parent is not comfortable with your recommended disposition click on the statement in Global Orders that starts “Parent uncomfortable…”. Then fill in the blank… override for: Nursing Judgment/Level 2 Triage We can NEVER “under ride” our disposition.
When a physician is paged, the note will include name and not just practice. Example: Nurses Comments : MD PAGED: Dr. Smith paged via Triage Logic text/VM at this time. Caregiver advised to call back if they have not heard from the MD on call within 30min.
When a referral is made, the note will include place, mode of transportation, and ETA. Nurses Comments : ED/UCC ETA: Parent will transport pt with private vehicle to ABC ED/UCC; ETA: 1 Hr Parent instructed to call office within 24hrs of the next business day for follow up regarding referral authorization.
Urine output will be documented in all patients <2 years old and any child with hydration concerns. Correct: Hydration status: Last wet diaper 1 hr ago or had 6 wet diapers in last 24hrs-last wet diaper at 0900 or last voided at 0900. Incorrect: Plenty of wet diapers or WNL or “this am”.
Summary As experienced RN’s we are all aware of the # 1 rule of documentation: If it was not written, it is presumed that it was not done” Good documentation will help you defend yourself in a malpractice lawsuit but can also keep you out of court in the first place!