FUNDAMENTALS OF NURSING LESSON 11 DOCUMENTATION

VOCABULARY TERMS KNOW YOUR VOCAB!!!!!

MEDICAL RECORDS Definition A legal record Purpose Written communication Record for accountability & reimbursement Legal record of patient care Teaching tool Used for research

MEDICAL RECORDS AUDITING: Federal, state, & local regulations Auditors QA Determine whether standards of care are being met CQI Peer review 4

MEDICAL RECORDS DRGs NURSE’S NOTES Document observations Document care given Document pt response THE CHART: Legal document Must meet quality standards Used as teaching tools Used for research 5

MEDICAL RECORDS Label ALL paperwork in chart Objective charting 8. RULES OF CHARTING Label ALL paperwork in chart Objective charting Subjective charting Chart timely Sign your charting Know when to document 6

TYPES OF PATIENT RECORDS TRADITIONAL PATIENT RECORD Traditional chart: divided into specific sections nursing document Flow sheets Graphics Narrative charting 7

TYPES OF PATIENT RECORDS PROBLEM ORIENTED MEDICAL RECORD POMR: Based on scientific problem solving Rarely used See pg 104 in Fund. book 8

THE NURSING PROCESS A: ASSESS needs D: DIAGNOSE needs that involve nursing P: PLAN pt care I: IMPLEMENT pt care E: EVALUATE success of care THE NURSING PROCESS CENTERS ON…… HUMAN RESPONSE!!!!! 9

THE NURSING PROCESS REMEMBER ADPIE…… ASSESS DIAGNOSE PLAN IMPLEMENT EVALUATE

THE NURSING PROCESS REMEMBER ADPIE…… ASSESS the gathering of data or information Where do you obtain information? What is the purpose of the assessment?

THE NURSING PROCESS REMEMBER ADPIE…… ASSESS Where do you obtain information? 1. interview the pt 2. examine the pt 3. search through previous records 4. other health care providers 5. family and friends

THE NURSING PROCESS REMEMBER ADPIE…… ASSESS What is the purpose of the assessment? Provides info needed to identify problems Provides baseline needed to make changes

THE NURSING PROCESS REMEMBER ADPIE…… DIAGNOSE Analyze the data and establish the client’s problems The NURSING diagnoses…impaired skin integrity NOT psoriasis, which is “medical”

THE NURSING PROCESS REMEMBER ADPIE…… PLAN 1. Goals or outcomes: must be client centered, measurable, realistic, time limited 2. Nursing orders: part of plan of care

THE NURSING PROCESS REMEMBER ADPIE…… PLAN 1. Goals or outcomes 2. Nursing orders: part of plan of care Example: Dr. orders PT encourage to be OOB X3 assist with use of cane

If it wasn’t charted….it wasn’t done…. THE NURSING PROCESS REMEMBER ADPIE…… IMPLEMENT the “doing” part of the nursing process If it wasn’t charted….it wasn’t done….

THE NURSING PROCESS REMEMBER ADPIE…… EVALUATE Nurse evaluates client’s progress towards meeting goal Final step if goal is met But if not…reevaluate to determine whether to change or extend plan of care

THE NURSING PROCESS QUIZ! REMEMBER ADPIE…… ASSESS DIAGNOSE PLAN IMPLEMENT EVALUATE

THE NURSING PROCESS QUIZ! Performing a physical exam Conducting an interview Giving a pt a bed bath Using client data to determine if goals are met Writing nursing orders on care plan Charting care given to pt

THE NURSING PROCESS QUIZ! Assess Implement Evaluate Plan

POMR FORMATS 2 TYPES: SOAPE SOAPIER (pg. 106, Fund.) 22

SOAP NOTE….. 23

FOCUSED CHARTING Uses nursing diagnosis: Indication for documentation Gives direction to nursing care Indication for documentation Current pt or behavior Significant change in pt status Significant change in pt’s therapy Decreases charting time 25

FOCUSED CHARTING FORMAT: D: Data from assessment A: Action or implementation taken R: Response by pt E: Education (pg. 105, Fund.) 26

FOCUSED CHARTING KARDEX/RAND: For quick reference NURSING CARE PLAN: Communication tool for all providers of implemented care of patient INCIDENT REPORTS: NOT a part of the medical record 27

CHART OWNERSHIP Who owns pt records? Confidentiality Pt bill of rights Ethical code of practice Computers 28

EFFECTIVE DOCUMENTATION MUST BE APPROPRIATE MUST BE FREQUENT MUST BE AFTER CARE IS GIVEN MUST BE AS OFTEN AS NECESSARY DOCUMENTATION IS A CYA TOOL….. USE IT!!!! 29

EFFECTIVE DOCUMENTATION CHANGE OF SHIFT HOME HEALTH 30

THE END!!!