Documenting and Reporting Med/Surg I Lisa Osborne

Documentation Why do we document? Gives an idea of the account of events that occurred during a healthcare treatment Characteristics: Chronological Systematic Record of health Past and current problems Diagnostic tests Treatments Responses to treatment Discharge planning

Purposes of the Health Record Communication—the entire healthcare team knows the plan of care—not just nursing—can include care paths or other items—can be a means of knowing a health history when no one is with you and you cannot speak for yourself Accountability—Documented evidence that the healthcare facility and team have acted responsibly and effectively Legal requirements—fulfills the legal requirement that all businesses have to keep records—IT IS A LEGAL DOCUMENT Regulatory requirements—Healthcare agencies must meet a standard of care established by the government or regulatory agencies—chart helps prove the standards have been met Financial Accountability—receipt listing the items you selected or were used for your care or benefit—think of it like a grocery store receipt—procedures, surgeries, equipment, supplies—also provides the third-party payers with the information they need for reimbursement

Purposes of the Health Record Research and Education—allows for the study of experimental health treatments and their effectiveness, also as a means to educate others

Documentation Electronic documents—Medical information systems—housed in computer networks—usually connected to a central server with a backup for system failure purposes—many facilities have system backups at least every 24 h or more often What are some benefits and some drawbacks to electronic health records Manual documents—collection of various forms of paper or the like type of documents—needs a large amount of storage space—some facilities have some manual documents as well as electronic What are some benefits and some drawbacks of manual records?

Contents of the Health Record Four general categories of information Assessment documents—history and physical documents LTC facilities sometimes utilize MDS or minimum data set, or RAP resident assessment protocol—designated by state and regulatory agencies Plans of care and treatment—nursing care plan, clinical pathway Used to ensure everyone utilizes the same care guidelines—everyone is on the same page Progress notes—usually utilized by physicians and other ancillary departments—MARs are included in progress notes Gives time, date, route, amount, patient identifiers, medication type and generic and trade names SOAP charting: S stands for subjective data O stands for objective data A stands for analysis or assessment P stands for plan It can continue to contain other acronyms such as in table 3-2 Plans for continuity of care—discharge planning documents, client discharge disposition Case managers notes, discharge summaries, discharge teaching materials

Guidelines for Documentation Document what you see—be specific—describe it to minimize misinterpretation Be specific—do not chart vague or ambiguous information or generalizations Use direct quotes—directly quote the patient’s statements to allow for specific episodes Be prompt—the more timely your charting the less that time can be used against you—late entries are acceptable but can sometimes throw up a red flag—DO NOT BACKTIME OR DATE YOUR ENTRIES—TO DO SO IS FRAUD Be clear and consistent—correct spelling, punctuation, and sentence structure are important—otherwise when the chart is taken to court, you could be portrayed as incompetent by your use of grammar—but remember normal rules of grammar do not always apply to nursing—spelling and clarity of though is more important—USE ONLY APPROVED ABBREVIATIONS

Reporting Several times a day the nurse must report off to another to provide continuity of care and for effective communication Change of shift—gives an overall summary of the patient and the changes that have occurred over that period of time Must be efficient and accurate to provide the oncoming staff with a complete picture of the patient status Communicates specific findings and some events to be mindful of while caring for the patient Walking rounds—go from room to room with oncoming shift to give report

Reporting You must know the abbreviations and symbols commonly used in medicine to be able to decipher the charting, physician orders, others notes, and reports given Know commonly used abbreviations and symbols

Guidelines for Documentation Respect confidentiality—conversations with clients are to be shared only with those who have a need-to-know basis—never share charting or confidential matters with anyone other than those who have a need to know—not other units, departments, or friends—the exception is education and this must be used in a non-identifying manner Record document errors—NO WHITE OUT, NO ERASEABLE PENS, BLACK INK ONLY, NO COMPLETE MARKING OUT YOUR ERRORS—explain the error, i.e. wrong chart, time, etc—single line through the error and no more with your initials above it—some facilities provide specific means of correcting errors, be sure to know your facilities policy—special note: electronic charting usually has specific means to correct errors, depending upon the system

Other Stuff Be conscious of charting liability Avoid a, an and the Not always in keeping with standard grammar, more important to have spelling correct, concise thought, and easily understood Charting by exception: Documentation of only the significant information or changes in condition

Other Stuff Narrative charting: tell a story from start to finish—just writing a description as you see it with assessment findings—with interventions and the evaluation of such interventions Alert and oriented to person, place and time. Skin pink, warm and dry. Repirations regular and unlabored. (Or, crackles ascultated in RLL with deep breath--productive coughing of green colored sputum upon deep inspiration) No cough noted. Continuous O2 at 2L/min by nasal cannula. Abdomen rounded and soft with active bowel sounds ausculated in all four abdominal quadrants. No pain to mild palpation of abdomen. (Or, no bowel sounds auscultated in any quadrant of abdomen after one full minute of listening at each quadrant.) Foley catheter patent with clear yellow urine draining. IV intact and patent in anterior aspect of left lower forearm with 1000cc D5W infusing at 100cc/hr by gravity drip (we didn't use pumps in those days, but if we did I always mentioned that a pump was in use). No pain, redness, or swelling at or above IV site. No calf tenderness. No pedal edema. Knee high TED hose in place bilaterally. Side rails up. Call light in reach. Flow sheets or check sheets—see the examples I will give you to look at Not always in keeping with standard grammar, more important to have spelling correct, concise thought, and easily understood Charting by exception: Documentation of only the significant information or changes in condition

Example 10/4/96 2100. 86 y.o. male admitted 10/3/96 for L CVA. V/S 99.2 T, 100, 20, 140/76. Vital signs assessed q 2 hrs, Nursing Assessments every 4 hours, Neuro Checks q 4 hrs. Alert and oriented x 3. Responds appropriately to verbal stimuli. PERL, 2-3 mm bilateral. No slurring of speech. At risk for injury related to dysphagia, on soft-thick dysphagia diet, feeds self with assistance. No JVD. Grips unequal, strong on right, weak on left. Left arm has limited mobility due to weakness secondary to CVA. At risk for injury (falls) related to limited mobility, side rails up x 4, call light in reach, patient needs assessed q 2 hours. Has a saline lock R forearm, flush q 8 hours, patent and intact, site free from redness or drainage. (If your patient has an infusing IV, make sure you record the fluid and rate in your assessment). Lung sounds clear in all lung fields. (If your patient is on O2, make sure you record the O2 rate and delivery system here, along with pulse ox readings). Heart sounds clear and regular, patient has a history of heart disease and has an implanted pacemaker (If your patient is on a heart monitor, record the rhythm here - such as normal sinus rhythm, A-fib ect.). Bowel sounds active in all 4 quads, abd non-tender to palpation. (If your patient has an abdominal incision, record the condition of it here). Last BM 17:15 today, brown, soft formed. Has a history of constipation. Urine clear yellow. Uses urinal, has occasional episodes of incontinence. Peri-area skin currently clear and intact, with no areas of redness. At risk for skin breakdown related to limited mobility and incontinence, at risk for pneumostatic pneumonia due to limited mobility, TCDB q 2 hr, up in chair TID with assist of 2 people. Limited mobility L leg, weakness due to CVA. At risk of DVT due to immobility, TEDS on bilateral, Active ROM Right leg, Passive ROM left leg, q 4 hours. Calf pumps x 5 bilateral encouraged every 2 hours while awake. Homan’s sign negative bilateral. Pedal pulses palpable bilateral. Feet cool, dry, intact, with thick toenails bilateral. Capillary refill toes < 2 Sec. Shift Intake 850, Output 750 cc  Fluid balance Positive 100 cc for this shift. ----------------------------------------------------M. Bennett RN