DOCUMENTATIONDOCUMENTATION Lisa Brock, RN MSN NUR 102 Lab Module D Fall 2006

Definition of Documentation Documentation is defined as “anything written or printed that is relied on as a record or proof for authorized persons” (Perry & Potter, ed 6, pg 45)

Why do we document? Provide a written record of care given to the patient A record is a permanent legal written document IF IT IS NOT CHARTED, IT IS CONSIDERED NOT DONE

Uses for Documentation Provide a record of care for financial reimbursement Clinical research Professional development

What do you chart? Assessment Vital signs Any change in your patient’s condition Verbal orders Procedures PRN medications Intake and output

Military Time Most facilities have gone to military time in documentation in which the clock is read as one 24 hour cycle

Documentation Guidelines Factual Accurate Complete Current Organized

Forms and Formats Admission history form Flow sheets and graphic records Kardex Acuity Standardized care plans Discharge summary forms

Methods of Recording Problem-Oriented Medical Records (POMR)—data organized by problem or diagnosis –Source records –Charting by exception

Standards of Care Use of standardized language –NANDA –NIC –NOC (pg 54) Case management and critical pathways (pg 54)

Home Care Specific guidelines for Medicare and Medicaid reimbursement Accurate assessment skills Multi-disciplinary approach JCAHO requirements

Long-Term Care Called residents, not clients or patients Omnibus Budget Reconciliation Act of 1987 Governed by Department of Health in each state Frequency of assessment

Change of Shift Report Orally, taped, or walking rounds MAINTAIN CONFIDENTIALITY Do not delegate to assistive personnel

Important Information Background Assessment Nursing diagnoses Interventions Outcomes Evaluations Family information Discharge plans Priorities Clarification

Purpose of Records Communication Education Assessment Research Financial billing Auditing Legal documentation

Documentation Formats pg 62, Box 3-4 SOAP –Subjective –Objective –Assessment –Plan PIE –Problem –Intervention –Evaluation

Continued… Focus or DAR –Data –Action –Response –Additionally—Plan Narrative note –Combine subjective and objective data

Incident Reports pg 64, table 3-4 Incident—any event not consistent with the routine Assist in identifying high-risk trends Not a part of the medical record

Complete NCLEX Review Questions, pg 66