1. DOCUMENTATION
NURS116

2. DOCUMENTATION
Anything written or printed on which you rely as a record or proof of patient actions or activities
Retrieve clinical data, maintain continuity of care, track patient outcomes, reflect current standards, provides detailed account of quality of care.

3. PURPOSES OF DOCUMENTATION
Communication
Legal documentation
Reimbursement
Education
Research
Auditing and monitoring

5. CONFIDENTIALITY HIPPA
Records may be used for data gathering, research, continuing education, if permission is granted
View only the information needed to give safe, quality care
As a student, do not use pt identifiers, never print or copy records

6. STANDARDS Frequency of documentation Pt records become legal evidence
Physical, psychosocial, environmental, self- care, knowledge level, and discharge planning needs must all be documented
Minimum standards set by The Joint Commission, Center for Medicare/Medicaid

7. Documentation as Communication
Continuing account of health care status
Available to all health care team
Patient info and demographics
Informed consent
Admission data
Nursing diagnoses and care plan
Record of nursing care
Medical history (H and P)
Medical diagnosis
Orders
Progress notes
Assessment findings
Diagnostic study findings
Pt education
Summary of op procedures
Discharge plan and summary

8. Documenting communication
Shift reports
Telephone reports between departments
Incident reports
Laboratory reports
Consultations
Referrals

9. Guidelines for Quality Documentation
Factual
Accurate
Complete
Current
Organized

10. factual Descriptive, objective information Do not state an opinion
Document patient words in “quotes”

11. accurate Exact measurements Use numbers Avoid abbreviations
Learn to spell!!! Use vocabulary appropriately
Date, time, sign

12. complete Appropriate and essential information
Includes nursing care and patient response
Use narration when flow sheets do not allow enough information

13. current
Don’t delay
VS, pain assessment, medications, treatments, pre op or pre test , provider notification re: changes, deaths should be documented IMMEDIATELY
Use international (“military”) time in charting

14. organized Document in a logical order
Use SOAPIE or the nursing process to guide your thoughts
Think before you write.

15. LEGAL GUIDELINES DO NOT ERASE OR USE WHITE- OUT
DO NOT INCLUDE PERSONAL OPINIONS OR “ATTACKS” ON OTHER PROFESSIONALS
CORRECT ERRORS PROMPTLY
RECORD ALL FACTS
DO NOT LEAVE BLANK SPACES OR LINES
BLACK INK
CHART ONLY FOR YOU
DATE, TIME, SIGNATURE
PROTECT YOUR PASSWORD FOR EMR

16. ELECTRONIC HEALTH RECORDS
AKA EMR
Provides immediate access
Integrates all records
Images
Provides continuity of care

17. Narrative Notes Traditional Tells a story Time consuming, repetitious
Requires reader to “sort”

18. SOAPIE notes Subjective Objective Assessment Plan Intervention
Evaluation
Focuses on ONE problem at a time. Originated from medical records

19. PIE notes Problem Intervention Evaluation
Problems are numbered as identified, then dropped as resolved.

20. DAR (Focus Charting) Data Action Response
Uses the nursing process better, focuses on all concerns, not just “problems”

21. Charting by Exception Identified norms Reduces documentation
Only document when standardized statement on the form is not met
Allows tracking, identifying trends or changes

22. Source records Separate section for each discipline
Caregivers can easily locate section in which to make entries
Physician Notes
Physician’s Orders
Nurses Notes
MAR
Flow Sheets and Graphics
Does not show how care is coordinated or how disciplines are related

23. Flow sheets and Graphics
Quickly and easily enter assessment data
Vital signs, meals, weights, intake/output
Hygiene, ambulation, restraint checks
Allows providers to see trends
Changes should be followed up with narrative

24. HAND-OFF REPORTS Transfer of care to another provider
Provides continuity, individualized treatment
Standardized communication includes:
up to date condition
required care
treatments
medications
recent or anticipated changes
Focus on patient and family (if pertinent to care)

25. INCIDENT REPORTS
Any event that is not consistent with routine operation of a health care unit or routine care of a patient
Falls, needlestick injuries, ill visitor, med errors, omission of treatments
Circumstances that could lead to injury or risk of injury
Analysis of TRUTHFUL reports ID trends that may justify changes, important part of quality improvement

26. INCIDENT REPORTS Always contact the patients HCP
Do not mention the incident report in the patient’s record….document objective findings and follow up, pt response
Goal is to prevent further recurrence
File with risk management department

27. Which documentation is correct?
A patient complains of abdominal pain 9/10.
B. patient states he has pain but I don’t think it’s as bad as he says
C. patient talks about pain all day
D. earlier today, patient said he had bad pain

28. Which statement does not belong in a hand off report
A. “Mrs. Jones is post op day 3 following a CABG”
B. “Mrs. Jones’s daughter has been here during physical therapy, and has demonstrated that she can help Mrs. Jones with ADLs”
C. “Mrs. Jones is very demanding and has been asking for too much medication”
D. “Mrs. Jones is scheduled for a electrocardiogram in the morning”
E. “I started a new IV for Mrs. Jones and used chlorhexidine and lidocaine and accessed the antecubital vein.”