3 Learning outcomeBy the end of this lesson the student participant will be able to:Explain the purposes of documentation in health care.Discuss the principles of effective documentation.
4 Learning outcome cont’d Describe various methods of documentation.Describe various types of documentation records.Describe the latest advances in computerized documentation
5 Definitions of documentation Documentation in nursing practice is any thing written or electronically generated that describes the status of client on the care or services given to that client.
6 Definitions of documentation cont’d Written evidence of:The interactions between & among health professionals, clients, their families, and health care organizationsThe administration of tests, procedures, treatments, & client educationThe results or client’s response to these diagnostic tests & interventions
7 purposes Communication. Education. Research Planning client care. legal professional standerReimbursement.( for a facility to obtain payment)Health care analysis
8 Elements of Effective Documentation Correcting a documentation error
10 The importance of using Proper spelling & grammar of documentation in nursing practiceNursing documentation and progress notes that are filled with misspelled words & poor grammar create a negative impression.(lawyer (may infer that a person with poor spelling and grammar is uneducated &care less.
11 Example of common errors on nursing flow Fecal heart tone heard.Patient observed to be seeping quietly.The pelvic exam was done on the floor.Vaginal packing out doctor in
12 Methods of Documentation Problem-Oriented Charting (POMR)Uses a structured, logical format called S.O.A.P.S: subjective dataO: objective dataA: assessmentP: plan
13 Methods of Documentation cont’d Uses flow sheets to record routine care.A discharge summary addresses each problem.SOAP entries are usually made at least every 24 hours on any unresolved problem.SOAP was developed on a medical model.
14 Methods of Documentation cont’d SOAPIE and SOAPIER refer to formats that add:I: InterventionE: EvaluationR: Revision
16 Methods of Documentation cont’d PIE Charting:1) PIE charting is a nursing model.P: ProblemI: InterventionE: Evaluation2) Assessment flow sheets3) Nurses’ progress notes with an integrated plan of care.
17 Methods of Documentation cont’d 4) Computerized DocumentationIncreases the quality of documentation and save time.Increases legibility and accuracy.Enhances implementation of the nursing process.Enhances the systematic approach to client care.Provides standardized nursing terminology).
18 Forms for Recording Data KardexFlow SheetsNurses’ Progress NotesDischarge Summary
19 Forms for Recording Data cont’d Discharge SummaryClient’s status at admission & dischargeBrief summary of client’s careInterventions & education outcomesResolved problems & continuing needReferralsClient instructions
20 ReportingVerbal communication of data regarding the client’s health status ,needs, treatmentsoutcomes, and responsesSummary of current critical information to facilitate clinical decision making and continuity of client care
21 ReportingReporting is based on the nursing process, standards of care & legal, ethical principles.Reports require participation from everyone present.
23 Summary Reports Commonly occur at change of shift When client is transferred).Assessment dataPrimary medical & nursing diagnosesRecent changes in condition, adjustments in plan of care, & progress toward expected outcomesClient or family complaints
24 Incident ReportsUsed to document any unusual occurrence or accident in the delivery of client care.The incident report is not part of the medical record, but it may be used later in litigation.