Reporting, Documenting, Conferring and Using Informatics

Objectives List guidelines for giving an effective report Understand 24-hr clock Identify common abbreviations used in charting Describe the purposes of patient records Compare and contrast the different methods of documentation Describe the nurse’s role in communicating with other members of the health care team Understand the rationale for documentation guidelines

Objectives Understand the purpose of each of the following: Nursing assessment Nursing Care Plan Progress notes Flow sheets Discharge summary Critical/collaborative pathways Homecare documentation

Reporting Def: the oral, written or computer-based communication of patient data to others. Purpose of report: to communicate something that has been seen, heard, done or considered. It can be written, oral, audio taped, computerized Ex: Lab reports Procedure reports (x-ray, biopsies)

Nursing Reports Use SBAR format: Situation: Patient identification, diagnosis, MD’s name, vital signs Background: Assessment findings, lab values Assessment: Your assessment of patient’s current condition Recommendation: Do you think any changes are necessary?

Types of nursing reports End of shift report: Off-going nurse gives necessary information about patient/patients to On-coming nurse May be written, face to face orally, audio taped, or videotaped Telephone report: To or from other departments, to or from MD’s Transfer and Discharge Reports: To other departments/ nurses who will be caring for the patient To family members and significant others: to inform about the patient’s condition Incident Reports: documents anything out of the ordinary that has the potential to harm the patient

Morning Report

Nurse to nurse report

Group Report

Nurse’s worksheet - or “Brain”

Report Form

End of Shift Report Occurs at: (for 8 hr. shifts) 0700: night shift to day shift 1500: day shift to evening shift 2300: evening shift to night shift OR: at 0700 and 1900 for 12 hr. shifts

24 Hour Time

Methods of Reporting Face-to-face meetings Telephone conversations Written messages Audio-taped messages Computer messages

Bedside End-of-Shift Report at the Patient’s bedside

Change of Shift Report: Include Basic identifying information about each patient Current appraisal of each patient’s health status Changes in medical conditions and patient response to therapy Where patient stands in relation to identified diagnoses and goals Current orders (nurse and physician) and unfilled orders Summary of each newly admitted patient Report on patient transferred or discharged

End of Shift Report: Guidelines Be professional Be courteous Be concise Ensure that you have all the necessary data at hand Keep report focused on the patient No gossip, rumor Students: Tell the RN/LPN all of the patient care that you delivered; also anything not done Do not speak disrespectfully about the patient or family

Documentation

Documentation Def: the written or typed legal record of all pertinent interactions with the patient: assessing, diagnosing, planning, implementing, and evaluating. Patient record: compilation of the patient’s health information Everything contained in the medical record is confidential information and protected by HIPPA law

Documentation Purposes for the medical record Communication: means by which health care team members communicate client needs and progress, therapies, client education and discharge planning Legal documentation: to limit nursing liability nursing documentation must clearly indicate that individualized, goal-directed nursing care was provided to the client based on the nursing assessment. Nurses need to indicate all assessments, interventions, client responses, instructions, and referrals in the medical record

Documentation: Purposes for the medical record Diagnostic and Therapeutic Orders Verbal orders/Telephone orders: repeat back to MD to verify; write on chart; must be signed by ordering MD within 24 hours written or computerized orders: must contain MD’s name, patient name, date and time, medication name or treatment, amount, frequency, route Care Planning: Outlining Nursing or interdisciplinary goals for the patient’s care

Purposes of the Medical Record Financial Billing: Reimbursement from insurance companies and Medicare and Medicaid (DRG’s) Education Research (Requires consent from the patient) Auditing/Monitoring (Quality Improvement) Historical Documentation: because entries are by date and time, can give a history of patient’s condition Decision Analysis: Organizational strategic planning about treatment methods, patient services

Characteristics of Effective Documentation Consistent with professional and agency standards Complete Accurate Concise Factual Organized and timely Legally prudent Confidential

Documentation Guidelines See attached p. 326 from textbook Also documentation should be: Factual - be objective not subjective; quote the patient, if necessary Accurate - use exact measurements: “Midline abd. incision measure 5” in length and 1” in depth with no obvious drainage or odor”; not “Incision healing well”. Complete - If it wasn’t charted, it wasn’t done Current - vital signs, medications, treatments, changes in condition, test preps Organized - should be in a logical, time sequential order, written in 3rd person, not 1st person, and in passive tense

Documentation Ex: “Patient medicated for pain with Morphine 2 mg. IV for a complaint of pain of 8/10 @ 8:45.” Not: “I gave the patient 2 mg. of Morphine because he said he was in sever pain” “Patient prepped for colonoscopy per order with 1 Liter Golytely prep.” “ I prepped the patient for the colonoscopy like the order said to.”

Documentation These are actual excerpts from medical records: “Patient has chest pain if she lies on her left side for over a year” “On the second day the knee was better, and on the third day it disappeared.” “The patient is tearful and crying constantly. She also appears to be depressed” “The patient has been depressed since she began seeing me in 1993” “Discharge status: Alive but without my permission” “Healthy appearing decrepit 69year old male, mentally alert but forgetful”

Documentation “The patient refused autopsy” “The patient has no previous history of suicides” “Patient has left white blood cells at another hospital” “She is numb from her toes down” “While in ER, she was examined, X rated, and sent home” “Patient stated she has been constipated most of her life, until she got a divorce” “I saw your patient today, who is still under our car until she is seen by physical therapy”

Documentation “Patient was seen today by Dr. Blank, who felt we should sit on the abdomen, and I agree.” “Rectal exam revealed a normal sized thyroid” “I saw your patient today, who is still under our car until she is seen by physical therapy”

Methods of Documentation Source-oriented records Problem-oriented medical records PIE charting Focus charting Charting by exception Case management model Computerized documentation Electronic medical records (EMRs)

Methods of Documentation Source-Oriented Records: each healthcare discipline has its own section of the chart; sections for MD’s, nursing, laboratory, social services, physical therapy, procedure reports; use progress and narrative notes Problem-Oriented Medical Records: all healthcare disciplines use the same forms referencing patient problems; uses SOAP or SOAPIE or SOAPIER (subjective, objective, assessment, plan, intervention, evaluation, response

Patient Chart

Electronic Medical Record

Computerized Bedside Charting

Methods of Documentation PIE: Problem, Intervention, Evaluation; problems are identified by number and addressed in the documentation used flow sheets; no formal care plan

Sample PIE Patient Care Note

Sample Focus Patient Care Notes

Case Management Models Collaborative pathways Variance charting

Major Components of POMR Defined database Problem list Care plans Progress notes

Formats for Nursing Documentation Initial nursing assessment Kardex and patient care summary Plan of nursing care Critical collaborative pathways Progress notes Flow sheets Discharge and transfer summary Home healthcare documentation Long-term care documentation

Types of Flow Sheets Graphic record 24-hour fluid balance record Medication record 24-hour patient care records and acuity charting forms

Incident Reports- Include Complete name of person and names of witnesses Factual account of incident Date, time, and place of incident Pertinent characteristics of person involved Any equipment or resources being used Any other important variables Documentation by physician of medical examination of person involved