Chapter 17 Documenting, Reporting, and Conferring

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

What is Confidential? All information about patients written on paper, spoken aloud, saved on computer –Name, address, phone, fax, social security –Reason the person is sick –Treatments patient receives –Information about past health conditions

Patient Rights See and copy their health record Update their health record Get a list of disclosures Request a restriction on certain uses or disclosures Choose how to receive health information

Policy for Receiving Verbal Orders in an Emergency Record the orders in patient’s medical record. Read back the order to verify accuracy. Date and note the time orders were issued in emergency. Record V.O., the name of the physician followed by nurse’s name and initials.

Policy for Physician Review of Verbal Orders Review orders for accuracy. Sign orders with name, title, and pager number. Date and note time orders signed.

Duties of RN Receiving a Telephone Order Record the orders in patient’s medical record. Read order back to practitioner to verify accuracy. Date and note the time orders were issued. Record T.O., full name and title of physician or nurse practitioner who issued orders. Sign the orders with name and title.

Purposes of Patient Records Communication with other healthcare professionals Record of diagnostic and therapeutic orders Care planning Quality of care reviewing Research Decision analysis Education Legal and historical documentation Reimbursement

Purposes of Recording Data Facilitate patient care Serve as a financial and legal record Help in clinical research Support decision analysis

Methods of Documentation Source-oriented records Problem-oriented medical records PIE charting Focus charting Charting by exception Case management model Computerized records

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

Medicare Requirements for Home Healthcare Patient is homebound and still needs skilled nursing care. Rehabilitation potential is good (or patient is dying). The patient’s status is not stabilized. The patient is making progress in expected outcomes of care.

Four Basic Components of RAI (Resident Assessment Tool) Minimum data set Triggers Resident assessment protocols Utilization guidelines

Benefits of RAI Residents respond to individualized care Staff communication becomes more effective Resident and family involvement increases Documentation becomes clearer

Change of Shift Report 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) Summary of each newly admitted patient Report on patient transferred or discharged

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

Conferring About Care Consultations and referrals Nursing and interdisciplinary team care conferences Nursing care rounds