Nursing Documentation Overview Chapter 2 Nursing Documentation Overview McGraw-Hill © 2012 The McGraw-Hill Companies, Inc. All rights reserved.

Chapter 2 Content 2.1 Role of documentation in nursing practice 2.2 Purposes of documentation 2.3 Documentation methods 2.4 Medication administration using an electronic Medication Administration Record (eMAR) 2.5 Nursing diagnoses, NOC, and NIC

LO 2.1 Role of Documentation in Nursing Practice

LO 2.1 Role of Documentation in Nursing Practice Communication Key to preventing medical errors Promoted by documentation by all disciplines Assessments Treatments Diagnostic testing Preparation for discharge Trend toward use of EHR to enhance communication

LO 2.1 Role of Documentation in Nursing Practice Advantages of EHRs Enhanced quality of documentation Promotion of safe, effective patient care Readily accessible information Elimination of illegible handwriting Automatic alerts Decision support Reduction in duplication of diagnostic testing

LO 2.1 Role of Documentation in Nursing Practice Concerns with Use of EHRs Confidentiality/HIPAA Power outages Computer “crashes” Computer viruses altering data

LO 2.2 Purposes of Documentation

LO 2.2.Purposes of Documentation Prevention of medical errors Communication with other healthcare providers Demonstrate the delivery of care Ensure appropriate reimbursement Demonstrate adherence to accreditation standards Provide evidence in legal proceedings Promote knowledge development through research

LO 2.2.Purposes of Documentation Three ‘Cs’ of Documentation Comprehensive Concise Clear

LO 2.2.Purposes of Documentation Characteristics of Good Documentation Factual Accurate Complete Current Organized Legible Secure

LO 2.2.Purposes of Documentation Types of Documentation Errors Errors of omission Inaccurate documentation Incomplete documentation

LO 2.3 Documentation Methods

LO 2.3 Documentation Methods Narrative Charting by exception (CBE) Source oriented Focus charting (DAR) Critical pathway / caremap Problem-oriented PIE SOAP SOAPIER

LO 2.3 Documentation Methods PIE Problem Intervention Evaluation

LO 2.3 Documentation Methods SOAP Subjective Objective Assessment Plan

LO 2.3 Documentation Methods SOAPIER Subjective – patient verbalization Objective – measurable data Assessment – nursing diagnosis Plan – desired outcomes Intervention – nursing actions Evaluation – patient response Revision/resolution – modifications of plan

Nursing Process SOAPIER Subjective Data Objective Data Assessment Nursing Diagnosis Plan Nursing Outcomes Intervention Nursing Intervention Evaluation Revision

LO 2.4 Electronic Medication Administration Record (eMAR)

LO 2.4 Electronic Medication Administration Record (eMAR) Medication Administration = Key nursing function

LO 2.4 Electronic Medication Administration Record (eMAR) Rights of Medication Administration Right patient Right medication Right time Right dose Right route Right assessment Right education Right evaluation Patient’s right to Right documentation

LO 2.4 Electronic Medication Administration Record (eMAR) Documenting Medication Administration Medication name Medication dosage Medication route Medication frequency Date and time of administration Signature of nurse who administers

LO 2.4 Electronic Medication Administration Record (eMAR) Withholding Medications Reasons for withholding Patient NPO Patient nauseated/vomiting Patient condition contraindicates Patient refusal Document when held Prevents appearance of error of omission Indicates reason for withholding Follow facility policy

LO 2.4 Electronic Medication Administration Record (eMAR) Benefits of eMars Reduction in medication errors Efficient tracking of medications User-friendly Interface with bar code systems where available

2.5 Nursing Diagnoses, NOC, and NIC

2.5 Nursing Diagnoses, NOC, and NIC Standardized Nursing Language Unified language for documenting care Allows comparison of care across settings Communicates Quality Effectiveness Value of nursing care Purpose – accurate, legal, reimbursable documentation

2.5 Nursing Diagnoses, NOC, and NIC North American Nursing Diagnosis Association-International (NANDA-I) Nursing diagnosis classifications Reflect nursing needs of individuals Guide nursing decisions Guide nursing plans of care Used in variety of settings Based on assessment data

2.5 Nursing Diagnoses, NOC, and NIC Nursing Outcome Classifications (NOC) Reflect desired outcomes of nursing care Linked to nursing diagnoses

2.5 Nursing Diagnoses, NOC, and NIC Nursing Intervention Classifications (NIC) Reflect nursing actions designed to help meet nursing outcomes Linked to nursing diagnoses