documentation pn 103. introduction the “chart” = health care record – legal record the process...
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Documentation
PN 103
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Introduction
• The “chart” = health care record – LEGAL record
• The process of adding written information to the chart is called:– Charting– Recording– Documenting
• 24 hr record-keeping system• To consolidate nursing records
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Introduction
• Good documentation reflects the nursing process
• Documentation is an integral part of the implementation phase of the nursing process
• It is necessary for the evaluation of patient care and reimbursement from payor sources
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Purposes of Patient Records
• 1. Provides written communication• 2. Permanent record for accountability• 3. Legal record of care• 4. Teaching• 5. Research and data collection
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Basic Guidelines for Documentation
• Hand-out: FON Box 7-1
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Legal Guidelines for Documentation
• Hand-out: FON, Table 7-2
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Methods of Recording
• The Traditional Chart– Divided into sections - eg. Admission sheet,
physician orders, progress notes, etc.– Nurses use: flow sheets, graphics, and narrative
charting• Narrative Charting – the recording of patient care in
descriptive form to chart observations, care, and responses– Abbreviated story form– Information obtained from nursing assessment is clustered
and organized in a head-to-toe manner
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Methods of Recording
• Problem-oriented Medical Record (POMR)– Database: accumulated information from the
medical history, physical exam, and diagnostic tests
– Problem list: of active, inactive, potential, and resolved problems
– SOAPE documentation
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Methods of Recording• SOAPE format: – S = subjective information
• What the patient states or feels
– O = objective Information• What the nurse can measure or factually describes
– A = Assessment• A potential diagnosis of the cause of the patient’s problem
or need
– P = Plan• Of care to be given or action to be taken
– E = Evaluation• And appraisal of the the response and effectiveness of the
plan
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Methods of Recording• Focus Charting Format• “DARE”: – D = data
• Subjective and objective
– A = Action• Combination of planning and implementation
– R = Response and evaluation• Of the patient; evaluating the effectiveness of the actions
– E = Education and patient teaching• As needed
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Methods of Recording
• Charting by Exception = CBE– Will chart per usual at the beginning of each shift : • complete physical assessments• Observations• VS• IV site and rate• other pertinent data
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Methods of Charting
• Charting by Exception cont.– The only other notes the nurse will make will be:• Additional treatments done• Planned treatments withheld• Changes in patient condition• New concerns• Notations re: progress or revisions for all active nsg. dx.
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Case Study Exercise
• Index Cards• Progress Notes
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Record-Keeping Forms
• P. 146-148 FON
• “Kardex” – term for a card or paper system used to consolidate patient orders and care needs in a centralized and concise way– Usually kept in the nurse’s station for quick
reference
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Incident Reports
• An “incident” refers to:– An event not consistent with the routine
operation of a health care unit or the routine care of a patient, or
– Other hospital / facility notification form when the patient care delivered is not consistent with the facility or national standards of expected care• Eg. Giving an incorrect dosage of a drug or a wrong
drug
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Incident Reports
– Also completed for any unusual event in the hospital or facility:• Needle stick• Patient/visitor/hospital personnel injury
– This information helps the facility risk manager and unit manager prevent future problems through education and other corrective measures
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Incident Reports
• FON P. 150, Fig. 7-9/Table 7-3• When filling out:– Give only objective, observed information– Do not admit liability or give unnecessary
information– Do list time, date, care given to the person and
name of physician notified (if it was a pt.)– When charting in the progress notes, do not
mention that an incident report was made
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Acuity Charting
• 24 hr scoring system• Rates each patient by the severity of their
illness• Helps to determine staffing patterns
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Home Health Care Documentation
• Box 7-4 Documentation Forms Used• 50% of nursing time!• Documentation has different implications in the
home health system:– Fewer witness to the majority of care– Accurate communication to all team members
• Some forms left in the home; others at the agency
– Quality control and justification for reimbursement• Computer influence
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Computer Influence
• Communication and assessment via modem linkage– Phone and visual visits– Promotes integration of chart• some parts of the chart left in the home; some in the
chart• Various healthcare disciplines need access
• Box 7-5 p. 155 FON “Guidelines for Safe Computer Documentation
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Long-Term Health Care Documentation
• MDS – Minimum Data Set– Dictated by Medicare and Medicaid • OBRA 1987
– Regulated standards for resident assessment, individualized care plans, and qualifications for healthcare providers
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Practice
• P. 156, 157 FON Practice NCLEX questions
• SG – Ch. 6 and 7