documentation 101 - bmh/tele
TRANSCRIPT
Documentation Documentation 101101
Natalie Bermudez, RN, BSN, MSNatalie Bermudez, RN, BSN, MS
Clinical Educator for TelemetryClinical Educator for Telemetry
For Novice and For Novice and Experienced Nurses New Experienced Nurses New
to Bethesda Memorial to Bethesda Memorial HospitalHospital
Nursing DocumentationNursing Documentation
“Documenting your patient’s care has
always been important. But with health care growing increasingly
complex, expert documentation skills
have become indispensable.”(Seeber-Combs, 2006, p. 1)
Nursing DocumentationNursing Documentation
Cost constraints, sicker patients, and nurses’ growing roles further emphasize the need
for a properly documented medical
record.
(Seeber-Combs, 2006, p. 1)
Nursing DocumentationNursing Documentation
“When you document effectively, your patient’s medical
record reflects your professionalism.”
(Seeber-Combs, 2006, p. 1)
Reasons for DocumentationReasons for Documentation
Continuity-of-Care Tool
Patient Protection Device
Quality Management Aid
Legal Safety Net
(Seeber-Combs, 2006, p. 1)
Documentation SystemsDocumentation Systems
Source-Oriented
Problem-Oriented
Narrative Notes
Focus Charting (DAR)
PIE Documentation
Charting By Exception
(Seeber-Combs, 2006)
Charting By ExceptionCharting By Exception
When you use CBE, you document only
abnormal or significant findings or deviations from established norms.
(Seeber-Combs, 2006, p. 7)
Charting By ExceptionCharting By Exception
This system eliminates lengthy, repetitive notes and
makes trends or changes in the
patient’s condition more obvious.
(Seeber-Combs, 2006, p. 7)
Documentation Made EasyDocumentation Made Easy
1. Document what the patient tells you
2. Document what you assess
3. Document what you do
4. Document outcomes of what you do
5. Document what you teach
BMH Tools for DocumentationBMH Tools for Documentation
PCAR (Patient Care Activity Record)PCAR (Patient Care Activity Record)
Patient LogisticsMedical Diagnosis/Diagnoses
Medication ListRecent Vital Signs & Lab ResultsPending Procedures/Labs/Tests
Diet/Activity/Code StatusNursing Interventions
IVFs & Cardiac Rhtyhm
Tools for DocumentationTools for Documentation
Problem ListProblem List• Nursing Diagnoses
• Specific Goals and Interventions
Nurses NotesNurses Notes• CBE documentation
• Narrative-style documentation
Tools for DocumentationTools for Documentation
Shift AssessmentShift Assessment• Documentation of initial multi-system
assessment
• Charting By Exception
Cardiac Monitoring StripsCardiac Monitoring Strips• Provides important assessment data
• Remains part of permanent health record
Tools for DocumentationTools for Documentation
Flow Sheets and ChecklistsFlow Sheets and Checklists
IV Site
Neuro-checks
PCA Pumps
Post-Cardiac Catheterization
Incident ReportsIncident Reports
Medication errors or harm to clients, staff, or visitors
Risk management tool
Use to track trends and patterns
For Quality Assurance
Not for punitive measures
Kept separately of health record
Legal AspectsLegal Aspects
A patient chart is a legal document
Any documentation on the patient’s chart is permanent
Assure that only pertinent information is entered
Telephone OrdersTelephone OrdersOnly registered nurses may obtain a
telephone order
A telephone order may only be taken via the telephone
All telephone orders must have the date and time the order is received
Must also include name of RN and physician
EXAMPLESEXAMPLES
Nurses’ Notes:Nurses’ Notes:
• Pertinent Information
• Precise and concise
• Descriptive words
• Quotation marks when necessary
• Avoid words like “appears to be” or “seems to be”
EXAMPLESEXAMPLES
Nurses’ Notes:Nurses’ Notes: 826/10 – 08:00
Patient received in bed awake. Alert and oriented x 3. Patient c/o nausea. Medicated with Phenergan 25 mg IM – left deltoid. Will continue to monitor for medication effectiveness and/or adverse reactions. No other complaints or concerns verbalized at this time.
EXAMPLESEXAMPLES
Nurses’ Notes:Nurses’ Notes: 8/26/10 – 17:30Patient stated “I have pain in my chest. It feels like
an elephant is sitting on me”. Patient is pale, diaphoretic, and has SOB. Vital signs: B/P 130/70, HR 120, O2 Sat 92% on RA. Nitro-stat SL x 2 tabs administered with complete relief of chest pain. Stat call placed to physician. Stat EKG done and faxed to physician’s office as requested. Patient started on a Nitro drip @ 20 mcg/min per physician orders and will be transferred to ICU when bed available.
EXAMPLESEXAMPLES
Shift Assessment:Shift Assessment: 8/26/10 – 08:00
Neuro: WNL
Resp: WNL
If WITHIN NORMAL LIMITS is documented there is no need to write in “Comments” that “Patient is
AAO x 3” or “Lungs are clear”.
EXAMPLESEXAMPLES
Shift Assessment:Shift Assessment: 8/26/10 – 08:00
If you documented the shift assessment @ 0800, then it is not necessary to document
a narrative assessment in the Nurse’s Notes for the same time.
EXAMPLESEXAMPLES
Shift Assessment is done:Shift Assessment is done: 8/26/10 – 08:00
AAO x 3. No neuro deficits. Lungs are clear/diminished at bases bilaterally. O2 sat with 2L NC is 100%. Oral mucosa and nailbeds are
pink with adequate CR. Heart sounds are regular; no murmurs. Rhythm is sinus 70’s.
Abdomen soft, non-tender. Bowel sounds are positive x 4; last BM 9/29/07. Foley catheter in
place draining clear, yellow urine. MAE. Ambulates to bathroom independently; steady gait. 0/9% NaCL @ 50 ml/hr infusing to LFA IV
site; no redness or swelling at insertion site.
EXAMPLESEXAMPLES
Admission AssessmentAdmission Assessment
&&
Nursing Admission HistoryNursing Admission History
EXAMPLESEXAMPLES
Nursing Admission Nursing Admission History/AssessmentHistory/Assessment
• Needs to be completed ASAP
• Includes Home Meds
• Immunization & TB History
• Past Medical/Surgical History
• Social History
• Assessment Needs to be Thorough
EXAMPLESEXAMPLES
Problem List:Problem List:
Documentation needs to be completed for each problem on the list once per shift
If problem goals have been met, problem may be removed from the list (Resolved)
Problem list may be updated to include new problems
EXAMPLESEXAMPLES
PCAR:PCAR:
Needs to be initiated on admission and updated by nursing on an as needed basis
Communication tool for nurses!!!!!!!!!!!!
EXAMPLESEXAMPLES
PCAR:PCAR:
Routine Activities…
Conditioning Parameters…
Call Physician If…
EXAMPLESEXAMPLESTelephone Orders:Telephone Orders:
All telephone orders should be verified by repeating the orders to the physician
Label verbal orders with RBTORBTO = Read Back Telephone Order
All telephone orders need to be signed by physician with date and time within 48 hours!!!
EXAMPLESEXAMPLES
Verbal Orders:Verbal Orders:8/26/10 19:008/26/10 19:001) Start IV Nitro drip @ 20 mcg/min and
titrate for chest pain relief.2) Stat EKG3) Cardiac enzymes every 6 hours x 3, first
set stat4) O2 2L NC, titrate to keep O2 sat > 92%RBTO: Dr. Von Sohsten/N. Bermudez, RN
Incident ReportsIncident Reports
What is an incident report?
What info do I include in an incident report?
Do I document the event/occurrence in the nurses’ notes?
How should I document the occurrence … what should I say?
Documentation in a NutshellDocumentation in a Nutshell
Documentation should tell a story without making it sound like a novel!!!
Parts of documentation are like pieces of a puzzle
Document facts
• Avoid judgments or suggestive comments
Documentation in a NutshellDocumentation in a Nutshell
Be sure to TIME and DATE all entries
Change TIME and DATE to the actual time of occurrences
Incident Reports should not be documented as such
• Document details of incident only
Documentation in a NutshellDocumentation in a Nutshell
Remember that the patient chart is a LEGALLEGAL document
ReferenceReference
Seeber-Combs, C. (2006). Mosby’s surefire documentation: How, what, and when nurses need to document, (2nd ed. ). St. Louis, MO: Mosby Elsevier.