Documentation and Reporting NUR 212-NUR211 Legal Aspects of Nursing Documentation and Reporting Concepts of Nursing-NUR 123

Concepts of Nursing-NUR 123 Documentation Reporting and recording are the major communication techniques used by health care providers. Concepts of Nursing-NUR 123

Documentation as Communication Documentation is defined as written evidence of: The interactions between and among health professionals, clients, their families, and health care organizations. The administration of tests, procedures, treatments, and client education. The results or client’s response to these diagnostic tests and interventions. Concepts of Nursing-NUR 123

Purposes of Health Care Documentation Professional Responsibility and Accountability Communication Education Research Legal and Practice Standards Concepts of Nursing-NUR 123

Legal and Practice Standards Informed consent means that the client understands the reasons and risks of the proposed intervention. Witnessing confirms that the person who signs the consent is competent. Concepts of Nursing-NUR 123

Elements of Effective Documentation Use of Common Vocabulary Legibility Abbreviations and Symbols Organization Accuracy Documenting a Medication Error Confidentiality Concepts of Nursing-NUR 123

Elements of Effective Documentation Use of Common Vocabulary Improves communication and lessens the chance of misunderstanding between members of the health team. Concepts of Nursing-NUR 123

Elements of Effective Documentation Legibility Print if necessary. Do not erase or obliterate writing. State the reason for the error. Sign and date the correction.

Elements of Effective Documentation Concepts of Nursing-NUR 123 Correcting a documentation error

Elements of Effective Documentation Abbreviations and Symbols Always refer to the facility’s approved listing. Avoid abbreviations that can be misunderstood. Concepts of Nursing-NUR 123

Elements of Effective Documentation Organization Start every entry with the date and time. Chart in chronological order. Chart medications immediately after administration. Sign your name after each entry.

Elements of Effective Documentation Accuracy Use descriptive terms to chart exactly what was observed or done. Use correct spelling and grammar. Write complete sentences.

Elements of Effective Documentation Documenting a Medication Error Document in the nurses’ progress notes: Name and dosage of the medication Name of the practitioner who was notified of the error Time of the notification Nursing interventions or medical treatment Client’s response to treatment

Elements of Effective Documentation Confidentiality The nurse is responsible for protecting the privacy and confidentiality of client interactions, assessments, and care.

Methods of Documentation Narrative Charting Source-Oriented Charting Problem-Oriented Charting PIE Charting Focus Charting Charting by Exception (CBE) Computerized Documentation Case Management with Critical Paths

Methods of Documentation Narrative Charting Describes the client’s status, interventions and treatments; response to treatments is in story format. Narrative charting is now being replaced by other formats.

Methods of Documentation Source-Oriented Charting Narrative recording by each member (source) of the health care team on separate records. For example the admission department has an admission sheet, nurses use the nurses’ notes, physicians have a physician notes, etc….

Methods of Documentation Problem-Oriented Charting Uses a structured, logical format called S.O.A.P. S: subjective data O: objective data A: assessment (conclusion stated in a form of nursing diagnoses or client problems) P: plan Uses flow sheets to record routine care. SOAP entries are usually made at least every 24 hours on any unresolved problem. Concepts of Nursing-NUR 123

Methods of Documentation PIE Charting P: Problem statement I: Intervention E: Evaluation Example: P: Patient reports pain at surgical incision as 7/10 on 0 to 10 scale I : Given morphine 1mg IV at 2335. E : Patient reports pain as 1/10 at 2355. Concepts of Nursing-NUR 123

Methods of Documentation Focus Charting A method of identifying and organizing the narrative documentation of all client concerns. Uses a columnar format within the progress notes to distinguish the entry from other recordings in the narrative notes (Date & Time, Focus, Progress note) The progress notes are organized into: Data (D), Action (A), Response (R). Concepts of Nursing-NUR 123

Example of focus charting Date & Time Focus: Progress notes: 05.Jan.2011 Acute pain related to surgical incision D: Patient reports pain as 7/10 on 0 to 10 scale. A: Given morphine 1mg IV at 2335. R: Patient reports pain as 1/10 at 2355. Concepts of Nursing-NUR 123

Methods of Documentation Charting by Exception (CBE) The nurse documents only deviations from pre-established norms (document only abnormal or significant findings). Avoids lengthy, repetitive notes. Concepts of Nursing-NUR 123

Methods of Documentation Computerized Documentation Increases the quality of documentation and save time. Increases legibility and accuracy. Facilitates statistical analysis of data. Concepts of Nursing-NUR 123

Methods of Documentation Case Management Process A methodology for organizing client care through an illness, using a critical pathway. A critical pathway is a multidisciplinary plan or tool that specifies assessments, interventions, treatments and outcomes of health related problems a cross a time line. Concepts of Nursing-NUR 123

Forms for Recording Data Kardex Flow Sheets Nurses’ Progress Notes Discharge Summary Concepts of Nursing-NUR 123

Forms for Recording Data The Kardex is used as a reference throughout the shift and during change-of-shift reports. Client data (e.g name, age, admission date, allergy) Medical diagnoses and nursing diagnoses Medical orders, list of medications Activities, diagnostic tests, or specific data on the pt. Concepts of Nursing-NUR 123

Forms for Recording Data Flow Sheets The information on flow sheets can be formatted to meet the specific needs of the client. (e.g.: graphic sheets for vital signs, intake & output record, MAR, skin assessment record). Nurses’ Progress Notes Used to document the client’s condition, problems and complaints, interventions, responses, achievement of outcomes. Concepts of Nursing-NUR 123

Forms for Recording Data Discharge Summary Client’s status at admission and discharge. Brief summary of client’s care. Interventions and education outcomes. Resolved problems and continuing need. Referrals. Client instructions. Concepts of Nursing-NUR 123

Concepts of Nursing-NUR 123 Reporting Verbal communication of data regarding the client’s health status, needs, treatments, outcomes, and responses Reporting is based on the nursing process. Concepts of Nursing-NUR 123

Concepts of Nursing-NUR 123 Reporting Summary Reports Walking Rounds Incident Reports Telephone Reports and Orders Concepts of Nursing-NUR 123

Reporting Summary Reports Walking Rounds Incident Reports Commonly occur at change of shift (or when client is transferred). Walking Rounds Occur in the client’s room Include Nursing, physician, interdisciplinary team. Incident Reports Used to document any unusual occurrence or accident in the delivery of client care.

Concepts of Nursing-NUR 123 Reporting Telephone Reports and Orders Report transfers, communicate referrals, obtain client data, solve problems, inform a physician and/or client’s family members regarding a change in the client’s condition. Telephone orders are documented in the nurses’ progress notes and the physician order sheet. Concepts of Nursing-NUR 123

Documenting a Telephone Order Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.