A factual record contains descriptive, objective Information about what a nurse sees, hears, feels, and smells. . An accurate record uses exact measurements, notations concise data, contains only approved abbreviations, uses correct spelling, and Identifies the date and caregiver. C. A complete record contains all appropriate and essential information. D. Current records contain timely entries with immediate documentation of information as it is collected from the patient. E. Organized records communicate information in a logical order. 3.
Describe methods for multidisciplinary communication within the health care system Case management model of delivering care incorporates an interdisciplinary approach to documenting patient care and critical pathways are interdisciplinary are plans that include patient problems, key Interventions, and expected outcomes within an established time frame unexpected outcomes, unmet goals, and interventions not specified within the critical pathways time frame are called variances Ex: when a patient develops pulmonary complications after surgery, requiring oxygen therapy and monitoring with pulse geometry.
A positive variance occurs when a patient progresses more rapidly than expected (use of Foley catheter is discontinued a day early) 4.
Identify common record-keeping forms. (See Section Below: Page 8) Most charts will Include (Extra Notes):
Patient Identification and demographic data Informed consent for treatment and procedure Admission data Nursing diagnosis or problems and nursing or interdisciplinary care plan Record of Medical history Medical diagnosis Therapeutic orders Medical and health discipline progress notes Physical assessment findings Diagnostic study results Patient education Summary of operative procedures Discharge plan and summary CHI. 6 Lecture Notes Documentation is anything written or printed on which you rely as record or proof of patient actions and activities Information in the patient record provides a detailed account of the level of quality of care delivered to patients.
The quality of care, the standards of regulatory agencies and nursing practice, the reimbursement structure in the healthcare system, and legal guidelines make documentation and reporting extremely important responsibilities of a nurse.
Whether the transfer of a patient info occurs through verbal reports, written documents, or electronically, you need to follow basic principles to maintain confidentiality of information Confidentiality Nurses are legally and ethically obligated to keep information about patients influential Only staffs that are directly involved in a patients care have legitimate access to records. In most cases, patients are required to give written permission for release of medical information.
As a nursing student you must abide to the HIPPO standards of confidentiality and compliance and NEVER share information about patients with classmates or look into medical information about other patients. Standards Standards of documentations differ within a healthcare organization. Institutional standards or policies dictate the frequency of documentation. Ex. How often you record a nursing assessment or a patients level of pain. Patients records can be used as evidence in a court of law if standards of care are not met The National
Committee of Quality Assurance and The Joint Commission maintain institutional accreditation and minimize liability. Current documentation standard require that all patients admitted to a health care facility have an assessment of physical, psychosocial, environmental, self-care, patient education, knowledge level, and discharge planning. Also, evidence of patient and family teaching and discharge planning. Interdisciplinary Communication within the Healthcare Team Patient care requires effective communication among members of the healthcare information relevant to his or her health care.
Reports are given oral, written, or audiotape exchanges of information among caregivers. Common reports given by nurses: change-of-shift reports, telephone reports, hand off reports, and incident reports. Ex. Healthcare provider calls nurses to get a verbal report to receive patient’s conditions. Laboratory submits a written report for results of diagnostic test and verbally notifies nurse if results are critical. Forms of communication Discharge planning conference: involves all members of all disciplines who meet and discuss patient progress towards discharge goals.
Consultations: one reflections caregiver gives formal advice about the care of a patient to another caregiver Ex: a nurse caring for a patent with a chronic wound consults with a wound care specialist Referrals: arrangement for services by another care provider. Purposes of Records Communication Patient’s records are useful for healthcare team members to communicate patient’s needs and progress, individual therapies, content of consultations, patient education, and discharge planning. They also allow healthcare team member to know a patient thoroughly, facilitating safe, effective and timely patient-centered decisions.
Legal accumulation To limit nursing liability documentation must indicate clearly that a patient received individualized, goal-directed nursing care based on the nursing assessment. Common charting mistakes: writing illegibly or incomplete, failure to record pertinent health or drug information, failure to record nursing actions, failure to record that medications have been given, failure to document discontinued medications. Dress are classifications based on patients’ medical diagnosis Your documentation clarifies the type of treatment a patient receives and supports reimbursement to the health care agency Education
Patients records includes many information such as diagnosis, signs and symptoms of a disease, successful and unsuccessful therapies, diagnostic finding, and patient behavior which is why all nurses should read their patients record. With this information and past experience you can learn to anticipate the type of care required for a patient. Research Nurse researchers often use patients records for research studies Also use to investigate nursing interventions or health problems. Ex.
A nurse wants to compare a new method of pain control with a standard pain protocol using two groups of patients. Auditing and Monitoring ETC require quality improvement programs and set standards for the information located in a patients record. Guidelines for Quality Documentation and Reporting Factual Descriptive, objective information about what the nurse sees, hears, feels and smells. Ex: “B/P 80/50, patient diaphragmatic, heart rate 102 and regular” and “the patients pulse rate is elevated 110 beats/min, and the patient reports increased restlessness.
Accurate Use of exact measurements establishes accuracy to determine if a patient’s condition drainage, or edema” All entries in medical records must be dated and end with the receivers name or initials and status (ex: J. Woods, RAN). Complete The information within recorded entry or report must be complete, containing appropriate and essential information Use flow sheets or graphic records when documenting routine activities such as daily hygiene care, vital signs, and patient assessment. Describe in greater detail when they are relevant such as when a change in functional ability or status occurs.
Current Timely entries are essential ongoing care. Delays in documentation lead to unsafe patient care. Document the following activities or finding at the time of occurrence: ITIL signs, pain assessment, administration of medications and treatments, preps for diagnostic testing, admission, transfer, discharge or death of patient etc. USE MILITARY TIME Organized Communication information in a logical order. It is also effective when notes are concise, clear, and to the point. Ex: an organized entry describes the patient’s pain, your assessment and interventions, and the patient’s response.
Methods of Documentation Paper and Electronic Health Records Paper records are episode oriented, with a separate record for each patient visit to a health care agency. EMMER (ELECTRONIC MEDICAL RECORD): contains patients data gathered in a healthcare setting at a specific time and place ERR (ELECTRONIC HEALTH RECORD): an electronic record of patient health information generated whenever a patient accesses medical care in any healthcare delivery setting It integrates all pertinent patient information into one record; regardless of the number of times a patient enters a healthcare system.
In hospital setting it gathers data and performs checks to support regulatory and accreditation requirements and includes tools to guide and critique medication administration Key advantage for urging: provides a means to compare ongoing clinical data about a patient with original baseline information and maintaining ongoing record of a patient’s health education.
Narrative Documentation (the traditional method) Use of a story like format to document information specific to patient conditions and nursing care. Disadvantages: tend to be repetitious and time consuming Problem Oriented Medical Records Method of documentation that emphasized patients’ problems. Data are organized by problem or diagnosis.
SECTIONS INCLUDE: database, problem list, care plan and progress notes Database: notations all available assessment information pertaining to a patient The foundation for identifying patient problems and planning care Problem list After analysis of data, HECK identify problems and make a single problem list (physiological, psychological, social, cultural, spiritual, developmental, and environmental needs) List the problems in chronological order and when a problem is resolved, record the data and highlight it or draw line through the problem or its number.
Care plan Disciplines involved in the patients care develop a care plan or plan of care for each Progress Notes: monitor and record the progress of patient’s problems. SOAP: Subjective Data (fertilization of the patient) Objective data (that which is measured and observed) Assessment (diagnosis based on the data) Plan (what the caregivers plan to do) or COPIES where Intervention and Evaluation.
The nurse numbers each SOAP note and titles it according to the problem on the list Originated from medical records PIE: Problem Intervention Evaluation Nursing origin The narrative does not include assessment information (appears on the flow sheet) Notes are numbered of labeled according to the patient’s problems. Focus Charting: DARK: Data (problem) Action (intervention) Response (evaluation) Addresses patients concern: signs/symptoms, condition, nursing diagnosis, behavior, significant event or change in patients condition.
Incorporates all aspects of the nursing process, highlights a patients concerns, and can be integrated into any clinical setting. Source Records or charts A place in a patients chart that has separate sections for each discipline (I. E. Nursing, medicine, social work, or respiratory data) to record data The method by which source records are organized does not show how information from the disciplines re related or how care is coordinated to meet all of the patient’s needs Charting by Exception Focuses on documenting deviations from established norms.
Reduces documentation time and highlights trends or changes in a patients conditions. Nurses only document significant finding or exceptions to the predefined norms and writes a progress note only when the standardized statement on the form is not met Assumption: all standards are met unless otherwise documented. Case management plan and critical pathways (described above) Common Record Keeping Forms Admission Nursing History Forms: nurses complete a history form when a patient is admitted too nursing unit.
Guides the Nurse through a complete assessment to identify relevant nursing diagnoses or problems Flow Sheets and Graphic Records: allow you to quickly and easily enter assessment data about a patient (including vitals signs, routine repetitive care such as hygiene measures, ambulation, meals, weights and safety and restraint checks. Provide current patient information that is accessible to all HECK Helps team members quickly see patient trends over time and decrease time spent on writing narrative notes.
Patient Care Summary or Carded: computerized systems that provide information in the form of a patient care marry that is often printed for each patient during each shift. Carded: a portable “flip over” file or notebook that is kept at the nurses station Includes an activity and treatment section and a nursing care plan section that organizes information for quick references. Eliminates the need for repeated referral to the chart for routine information A Carded is a written form that contains basic client information.
A Carded contains an activity and treatment section and a nursing care plan section that organizes information for quick reference as nurses give change-of-shift report. It does not include a description of teaching that was provided to the client. Based on the institutional standards of nursing standards of nursing practice, are preprinted, established guidelines used to care for patients who have similar health problems. Useful when conducting quality improvement audits. Discharge Summary Form Interdisciplinary discharge planning ensures that a patient leaves the hospital in a timely manner with the necessary resources.
Discharge documentation includes medications, diets, community resources, follow-up care, and who to contact in case of an emergency or for questions. Acuity records Not part of a patient’s medical record. They are used for determining the hours of care and the staff required for a given group of patients. Home care documentation Documentation in the home care system is different from other areas I nursing Home care documentation systems provide the entire HOC with information needed to enhance teamwork.
Documentation is both the quality of control and the Justification for reimbursement from Medicare, Medicaid, or private insurance companies. Nurses must document all of their services for payment (ex. Direct skilled care, patient instructions, skilled observations, and evaluation visits) Long Term Health Care The Centers for Medicare and Medicaid Services guidelines requires careful documentation for appropriate reimbursement in long term care agencies.
The Resident Assessment Instrument/Minimal Data Set provides standardized protocols for assessment and care planning and a min data set to promote quality improvement within facilities. Reporting Hand off Reporting Happens anytime one healthcare provider transfers care of a patient to another healthcare provider. Purpose is to provide better continuity and individualized care for patients. Ex. Change-of-shift and transfer reports Information during apt. Anodal can be given face to face, in writing, or verbally such as over the telephone or via audio-recording Report elements do not include: normal findings or routine information retrievable from other sources or derogatory or inappropriate comments about a apt. Or family. Telephone Reports and Order Telephone Reports: make a telephone report when significant events or changes in a apt. Condition have occurred. Needs to be clear, accurate, and concise information.
Use SABA: Standardizes telephone communication of significant events or changes in patients and is a communication strategy designed to improve apt. Safety Document EVERY phone call you make to a health care provider and use the “read back” method when receiving information or critical test results. Telephone and Verbal Order Telephone Orders: occurs when a healthcare provider gives an order over the phone to a RAN Verbal Order: involves the healthcare provider giving orders to a nurse while they are standing near each other.
Usually occur at night during emergencies (cause medical errors) Nurse: writes down the complete order or enters it into the computer as it is being given. Then reads back and waits for confirmation from the person who gave the order that it is correct Healthcare Provider: later verifies the TO or VOW by legally signing it within a set time. Incident or Occurrence Reports Any event that is not consistent with the routine operation of a health care unit or systems and unit operations that provide Justification for changes in policies and procedures or for in-services seminars.
DO NOT mention the incidence report in patients medical record Instead you document an objective description of what happened, what you observed, and the follow-up actions taken in the patient’s deiced record. Health Informatics Application of computer and information science for managing health-related data Focused on the patient and the process of care and the goal is to enhance the quality and efficiency of care provided.
Becoming a priority as health care facilities adopt EMMER/HER Nursing Informatics (See Slides 20-24 in Power point) Facilitates the integration of data, information, and knowledge to support patients, nurses, and other providers in decision-making in all roles and settings. Clinical Information Systems CICS: Include monitoring systems (devices that automatically monitor and record metric measurements (vital signs, oxygen saturation, cardiac index, and stroke volume)) order entry systems, and laboratory, radiology, and pharmacy systems in critical care and specialty areas.
Electronically sends measurements directly to the nursing documentation system Computerized provider order entry A process by which a health care provider directly enters orders for patient care into the hospital information system Reduces transcription errors. Potentially speeds up the implementation of ordered diagnostic tests and treatments which improves staff productivity and saves money