1. Reporting, Documenting, Conferring and Using Informatics

2. Objectives List guidelines for giving an effective report
Understand 24-hr clock
Identify common abbreviations used in charting
Describe the purposes of patient records
Compare and contrast the different methods of documentation
Describe the nurse’s role in communicating with other members of the health care team
Understand the rationale for documentation guidelines

3. Objectives Understand the purpose of each of the following:
Nursing assessment
Nursing Care Plan
Progress notes
Flow sheets
Discharge summary
Critical/collaborative pathways
Homecare documentation

4. Reporting
Def: the oral, written or computer-based communication of patient data to others.
Purpose of report: to communicate something that has been seen, heard, done or considered.
It can be written, oral, audio taped, computerized
Ex:
Lab reports
Procedure reports (x-ray, biopsies)

5. Nursing Reports Use SBAR format:
Situation: Patient identification, diagnosis, MD’s name, vital signs
Background: Assessment findings, lab values
Assessment: Your assessment of patient’s current condition
Recommendation: Do you think any changes are necessary?

6. Types of nursing reports
End of shift report: Off-going nurse gives necessary information about patient/patients to On-coming nurse
May be written, face to face orally, audio taped, or videotaped
Telephone report: To or from other departments, to or from MD’s
Transfer and Discharge Reports: To other departments/ nurses who will be caring for the patient
To family members and significant others: to inform about the patient’s condition
Incident Reports: documents anything out of the ordinary that has the potential to harm the patient

7. Morning Report

8. Nurse to nurse report

9. Group Report

10. Nurse’s worksheet - or “Brain”

11. Report Form

12. End of Shift Report Occurs at: (for 8 hr. shifts)
0700: night shift to day shift
1500: day shift to evening shift
2300: evening shift to night shift
OR: at 0700 and 1900 for 12 hr. shifts

13. 24 Hour Time

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

15. Bedside End-of-Shift Report at the Patient’s bedside

16. Change of Shift Report: Include
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) and unfilled orders
Summary of each newly admitted patient
Report on patient transferred or discharged

17. End of Shift Report: Guidelines
Be professional
Be courteous
Be concise
Ensure that you have all the necessary data at hand
Keep report focused on the patient
No gossip, rumor
Students: Tell the RN/LPN all of the patient care that you delivered; also anything not done
Do not speak disrespectfully about the patient or family

18. Documentation

19. Documentation
Def: the written or typed legal record of all pertinent interactions with the patient: assessing, diagnosing, planning, implementing, and evaluating.
Patient record: compilation of the patient’s health information
Everything contained in the medical record is confidential information and protected by HIPPA law

20. Documentation Purposes for the medical record
Communication: means by which health care team members communicate client needs and progress, therapies, client education and discharge planning
Legal documentation: to limit nursing liability nursing documentation must clearly indicate that individualized, goal-directed nursing care was provided to the client based on the nursing assessment. Nurses need to indicate all assessments, interventions, client responses, instructions, and referrals in the medical record

21. Documentation: Purposes for the medical record
Diagnostic and Therapeutic Orders
Verbal orders/Telephone orders: repeat back to MD to verify; write on chart; must be signed by ordering MD within 24 hours
written or computerized orders: must contain MD’s name, patient name, date and time, medication name or treatment, amount, frequency, route
Care Planning: Outlining Nursing or interdisciplinary goals for the patient’s care

22. Purposes of the Medical Record
Financial Billing: Reimbursement from insurance companies and Medicare and Medicaid (DRG’s)
Education
Research (Requires consent from the patient)
Auditing/Monitoring (Quality Improvement)
Historical Documentation: because entries are by date and time, can give a history of patient’s condition
Decision Analysis: Organizational strategic planning about treatment methods, patient services

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

24. Documentation Guidelines
See attached p. 326 from textbook
Also documentation should be:
Factual - be objective not subjective; quote the patient, if necessary
Accurate - use exact measurements: “Midline abd. incision measure 5” in length and 1” in depth with no obvious drainage or odor”; not “Incision healing well”.
Complete - If it wasn’t charted, it wasn’t done
Current - vital signs, medications, treatments, changes in condition, test preps
Organized - should be in a logical, time sequential order, written in 3rd person, not 1st person, and in passive tense

25. Documentation
Ex:
“Patient medicated for pain with Morphine 2 mg. IV for a complaint of pain of 8:45.”
Not:
“I gave the patient 2 mg. of Morphine because he said he was in sever pain”
“Patient prepped for colonoscopy per order with 1 Liter Golytely prep.”
“ I prepped the patient for the colonoscopy like the order said to.”

27. Documentation These are actual excerpts from medical records:
“Patient has chest pain if she lies on her left side for over a year”
“On the second day the knee was better, and on the third day it disappeared.”
“The patient is tearful and crying constantly. She also appears to be depressed”
“The patient has been depressed since she began seeing me in 1993”
“Discharge status: Alive but without my permission”
“Healthy appearing decrepit 69year old male, mentally alert but forgetful”

28. Documentation “The patient refused autopsy”
“The patient has no previous history of suicides”
“Patient has left white blood cells at another hospital”
“She is numb from her toes down”
“While in ER, she was examined, X rated, and sent home”
“Patient stated she has been constipated most of her life, until she got a divorce”
“I saw your patient today, who is still under our car until she is seen by physical therapy”

29. Documentation
“Patient was seen today by Dr. Blank, who felt we should sit on the abdomen, and I agree.”
“Rectal exam revealed a normal sized thyroid”
“I saw your patient today, who is still under our car until she is seen by physical therapy”

30. Methods of Documentation
Source-oriented records
Problem-oriented medical records
PIE charting
Focus charting
Charting by exception
Case management model
Computerized documentation
Electronic medical records (EMRs)

31. Methods of Documentation
Source-Oriented Records: each healthcare discipline has its own section of the chart; sections for MD’s, nursing, laboratory, social services, physical therapy, procedure reports; use progress and narrative notes
Problem-Oriented Medical Records: all healthcare disciplines use the same forms referencing patient problems; uses SOAP or SOAPIE or SOAPIER (subjective, objective, assessment, plan, intervention, evaluation, response

33. Patient Chart

34. Electronic Medical Record

35. Computerized Bedside Charting

36. Methods of Documentation
PIE: Problem, Intervention, Evaluation; problems are identified by number and addressed in the documentation used flow sheets; no formal care plan

37. Sample PIE Patient Care Note

38. Sample Focus Patient Care Notes

39. Case Management Models
Collaborative pathways
Variance charting

40. Major Components of POMR
Defined database
Problem list
Care plans
Progress notes

41. 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

42. Types of Flow Sheets Graphic record 24-hour fluid balance record
Medication record
24-hour patient care records and acuity charting forms

43. Incident Reports- Include
Complete name of person and names of witnesses
Factual account of incident
Date, time, and place of incident
Pertinent characteristics of person involved
Any equipment or resources being used
Any other important variables
Documentation by physician of medical examination of person involved