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Chapter 2Nursing Documentation Overview

© 2012 The McGraw-Hill Companies, Inc. All rights reserved.McGraw-Hill

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Chapter 2 Content

2.1 Role of documentation in nursing practice

2.2 Purposes of documentation

2.3 Documentation methods

2.4 Medication administration using an electronic Medication Administration Record (eMAR)

2.5 Nursing diagnoses, NOC, and NIC

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LO 2.1 Role of Documentation in Nursing Practice

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LO 2.1 Role of Documentation in Nursing Practice

• Communication

• Key to preventing medical errors

• Promoted by documentation by all disciplines– Assessments

– Treatments

– Diagnostic testing

– Preparation for discharge

• Trend toward use of EHR to enhance communication

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LO 2.1 Role of Documentation in Nursing Practice

• Advantages of EHRs– Enhanced quality of documentation– Promotion of safe, effective patient care– Readily accessible information– Elimination of illegible handwriting– Automatic alerts– Decision support– Reduction in duplication of diagnostic testing

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LO 2.1 Role of Documentation in Nursing Practice

• Concerns with Use of EHRs– Confidentiality/HIPAA– Power outages– Computer “crashes”– Computer viruses altering data

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LO 2.2 Purposes of Documentation

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LO 2.2.Purposes of Documentation

• Prevention of medical errors• Communication with other healthcare

providers• Demonstrate the delivery of care • Ensure appropriate reimbursement• Demonstrate adherence to accreditation

standards• Provide evidence in legal proceedings• Promote knowledge development through

research

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LO 2.2.Purposes of Documentation

• Three ‘Cs’ of Documentation– Comprehensive

– Concise

– Clear

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LO 2.2.Purposes of Documentation

• Characteristics of Good Documentation– Factual– Accurate– Complete– Current– Organized– Legible– Secure

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LO 2.2.Purposes of Documentation

• Types of Documentation Errors– Errors of omission– Inaccurate documentation– Incomplete documentation

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LO 2.3 Documentation Methods

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LO 2.3 Documentation Methods

• Documentation Methods– Narrative– Charting by exception (CBE)– Source oriented– Focus charting (DAR)– Critical pathway / caremap– Problem-oriented

• PIE• SOAP• SOAPIER

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LO 2.3 Documentation Methods

• PIE– Problem– Intervention– Evaluation

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LO 2.3 Documentation Methods

• SOAP– Subjective– Objective– Assessment– Plan

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LO 2.3 Documentation Methods

• SOAPIER– Subjective – patient verbalization– Objective – measurable data– Assessment – nursing diagnosis – Plan – desired outcomes – Intervention – nursing actions– Evaluation – patient response– Revision/resolution – modifications of plan

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SOAPIER Nursing ProcessSubjective DataObjective Data

Assessment

Assessment Nursing Diagnosis

Plan Nursing Outcomes

Intervention Nursing Intervention

Evaluation Evaluation

Revision Revision

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LO 2.4 Electronic Medication Administration Record (eMAR)

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LO 2.4 Electronic Medication Administration Record (eMAR)

• Medication Administration = Key nursing function

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LO 2.4 Electronic Medication Administration Record (eMAR)

Rights of Medication Administration• Right patient• Right medication• Right time• Right dose• Right route

• Right assessment• Right education• Right evaluation• Patient’s right to • Right

documentation

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LO 2.4 Electronic Medication Administration Record (eMAR)

• Documenting Medication Administration– Medication name– Medication dosage– Medication route– Medication frequency– Date and time of administration– Signature of nurse who administers

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LO 2.4 Electronic Medication Administration Record (eMAR)

• Withholding Medications– Reasons for withholding

• Patient NPO• Patient nauseated/vomiting• Patient condition contraindicates• Patient refusal

• Document when held– Prevents appearance of error of omission– Indicates reason for withholding

• Follow facility policy

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LO 2.4 Electronic Medication Administration Record (eMAR)

• Benefits of eMars– Reduction in medication errors– Efficient tracking of medications– User-friendly– Interface with bar code systems where

available

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2.5 Nursing Diagnoses, NOC, and NIC

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2.5 Nursing Diagnoses, NOC, and NIC

• Standardized Nursing Language– Unified language for documenting care

• Allows comparison of care across settings

– Communicates• Quality • Effectiveness• Value of nursing care

– Purpose – accurate, legal, reimbursable documentation

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2.5 Nursing Diagnoses, NOC, and NIC

• Nursing Diagnoses– North American Nursing Diagnosis

Association-International (NANDA-I)– Nursing diagnosis classifications

• Reflect nursing needs of individuals• Guide nursing decisions• Guide nursing plans of care• Used in variety of settings• Based on assessment data

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2.5 Nursing Diagnoses, NOC, and NIC

• Nursing Outcome Classifications (NOC)– Reflect desired outcomes of nursing care– Linked to nursing diagnoses

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2.5 Nursing Diagnoses, NOC, and NIC

• Nursing Intervention Classifications (NIC)– Reflect nursing actions designed to help meet

nursing outcomes– Linked to nursing diagnoses