Landmark Medical Center Licensed Nurse Documentation In-Service March 8, 2010 Presented by Lizeth Flores, RHIT Anderson Health Information Systems, Inc.

Objectives Participants will review: Regulatory guidelines relating to weekly summaries Weekly summary documentation guidelines Weekly summary content How to review the medical record when writing a weekly summary

Why do I have to write a progress note every week?

State of CA Regulations Title XXII Section § A facility shall maintain for each patient a health record which shall include (5) Nurses’ notes which shall be signed and dated. Nurses’ notes shall include: (A) 2. narrative notes of observation of how the patient looks, feels, eats, drinks, reacts, interacts and the degree of dependency and motivation toward improved health.

Title XXII Section § (B) Meaningful and informative nurses’ progress notes written by licensed nurses as often as the patient’s condition warrants. However, weekly nurses’ progress notes shall be written by licensed nurses on each patient and shall be specific to the patient’s needs, the patient care plan and the patient’s response to care and treatments.

Required Documentation Body Assessment – Body evaluation including head to toe skin check Nail / toenails condition Hair / Scalp Condition

NEW SKIN CONDITIONS

Regulations Title XXII §72315(f) states: Each Patient shall be given care to prevent the formation and progression of decubiti, contractures and deformities A proper body assessment and documentation of skin condition will help you stay in compliance with this requirement

New skin Conditions Indicate whether or not there is a new condition Was a care plan developed for the new skin condition? Was the physician notified?

NUTRITIONAL ASSESSMENT & WEIGHT RECORDS

Regulation Title XXII §72311 (a) Nursing service shall include, but not be limited to, the following: (3) Notifying the attending physician promptly of: (D) A change in weight of five pounds or more within a 30-day period unless a different stipulation has been stated in writing by the patient’s physician.

Nutritional Assessment Document the current diet order Review meal intake records and document the average intake over the last 7 days Review the chart and document meal refusals over the last 7 days and reason why If > 6 meals have been refused, was the physician notified?

Weight Review the weight record Document the latest weight Has there been a weight fluctuation over the last week? If 3lbs in a week or 5lbs in one month, was the physician notified?

REVIEW OF PHYSICIAN’S ORDERS

Regulation Title XXII §72547 (a) A facility shall maintain for each patient a health record which shall include: (7) Laboratory reports of all tests prescribed and completed (8) Reports of all X-rays prescribed and completed

Regulation Title XXII § ( C ) Name, dosage and time of administration of drugs, the route of administration or site of injection, if other than oral. If the scheduled time is indicated on the record, the initial of the person administering the dose shall be recorded….. Medication and treatment records shall contain the name and professional title of staff signing by initials.

Title XXII § (D) Justification for the results of the administration of all PRN medications and the withholding of scheduled medications.

Medication Assessment Check physician’s orders for any new orders written since the last weekly summary What is the reason for the new order, is it an order change? An order related to a COC? Check to see if a new care plan was developed or an existing care plan was updated as applicable

Labs Check lab orders Make sure that any labs that were due were requested and carried out Review the final lab reports and make sure the physician was notified of lab results

Medication Administration Review the medical record and the MAR Are there any side effects to medications documented? If so, was physician notified?

PRN Medications Review the Medication Administration Record (MAR) for PRN medications given during the last 7 days make sure the documentation on the back of the MAR justifies the administration and documents effectiveness Were there more than 5 administrations in one week?

PRN Medications Continued… If more than 5 administrations of the same medication, was psychiatrist/MD notified? Is the physician response documented in the nurses’ notes?

Care Plans

Regulation Title XXII §72311 (a) Nursing service shall include, but not be limited to, the following: (B) Development of an individual, written patient care plan which indicates the care to be given, the objectives to be accomplished and the professional discipline responsible for each element of care. Objectives shall be measurable and time limited.

Regulation Title XXII §72311 (C) Reviewing, evaluating and updating of the patient care plan as necessary by the nursing staff and other professional personnel involved in the care of the patient at least quarterly, and more often if there is a change in the patient’s condition

Care Plan Review all care plans Are there any short term care plans i.e. cough, UTI etc. Is the condition still present? Is the care plan current? Address all care plans and document progress or lack of progress towards goals.

Pain Assessment Complete the pain assessment If there is pain, document the location, and whether or not it is relieved by medication or other interventions

Authenticate

Sign & Date your weekly summary This is not only a standard of practice but a legal requirement under California Title XXII regulations §72543 (f) Patient’s health records shall be current and kept in detail consistent with good medical and professional practice based on the service provided to each patient…… All entries in the health record shall be authenticated with the date, name and title of the person making the entry.

Q&A

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