Chapter 26 Accountability: Documentation and Reporting Fundamentals of Nursing: Standards & Practices, 2E Chapter 26 Accountability: Documentation and Reporting

Documentation as Communication Communication is a dynamic, continuous, and multidimensional process for sharing information. Reporting and recording are major communication techniques used by health care providers to direct client-based decision-making and continuity of care. Copyright 2002 by Delmar, a division of Thomson Learning

Copyright 2002 by Delmar, a division of Thomson Learning Documentation is defined as written evidence of The interaction between and among health professionals, clients, their families, and health care organizations Copyright 2002 by Delmar, a division of Thomson Learning

Copyright 2002 by Delmar, a division of Thomson Learning The administration of tests, procedures, treatments, and client education The results or client’s response to these diagnostic tests and interventions Copyright 2002 by Delmar, a division of Thomson Learning

Purposes of Health Care Documentation Communication Education Research Legal and Practice Standards Reimbursement Copyright 2002 by Delmar, a division of Thomson Learning

Principles of Effective Documentation Nursing notes must be logical, focused, and relevant to care, and must represent each phase of the nursing process. Charting in accordance with the nursing process ensures thorough documentation in compliance with ANA’s standards of care, practice acts, and reimbursement and accreditation criteria. Copyright 2002 by Delmar, a division of Thomson Learning

Elements of Effective Documentation Use of common vocabulary Legibility Approved abbreviations and symbols Organization Documenting a medication error Confidentiality Copyright 2002 by Delmar, a division of Thomson Learning

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 Copyright 2002 by Delmar, a division of Thomson Learning

Forms for Recording Data Kardex Flow sheets Nurses’ progress notes Discharge summary Copyright 2002 by Delmar, a division of Thomson Learning

Trends in Documentation Nursing minimum data sets (NMDS) Nursing diagnoses Nursing intervention classification (NIC) Nursing outcomes Copyright 2002 by Delmar, a division of Thomson Learning

Copyright 2002 by Delmar, a division of Thomson Learning Reporting The nurse must consider What needs to be said Why it needs to be said How to say it What the expected outcomes are Copyright 2002 by Delmar, a division of Thomson Learning

Copyright 2002 by Delmar, a division of Thomson Learning Types of reporting Summary reports Walking rounds Telephone reports and orders Incident reports Copyright 2002 by Delmar, a division of Thomson Learning