9 documentatin & reporting nurses by m.fathoni 2013

8/12/2019 9 Documentatin & Reporting Nurses by M.fathoni 2013

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Documentation and Reporting

Ns. Mukhamad Fathoni, S.Kep., MNS

Jurusan Keperawatan, Fakultas

Kedokteran Universitas Brawijaya

Email : [email protected]
mailto:[email protected]:[email protected]:[email protected]:[email protected]


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INTRODUCTION

A good nurse needs to have great reporting skills.

Since it takes time to develop great reportingskills, you should work on this area if you're

trying to land a job as a clinical nurse or

manager.


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Documentation as

Communication

Communication is a dynamic, continuous,and multidimensional process for sharinginformation.

Reporting and recording are the majorcommunication techniques used by healthcare providers.


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Documentation as

Communication The medical record serves as a legal

document for recording all client activitiesby health care practitioners.

Documentation is defined as writtenevidence of:

The interactions between and among healthprofessionals, clients, their families, and health

care organizationsThe administration of tests, procedures,

treatments, and client education

The results or clients response to these

diagnostic tests and interventions


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Documentation as

Communication Nurses rely on charting, records, and

systems that support the implementation of

the nursing process. Systematic documentation is critical to

presenting the care administered by nursesin a logical fashion.

Critical thinking skills, judgments, and

evaluation must be clearly communicated

through proper documentation


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Purposes of Health Care

Documentation

Professional Responsibility andAccountability

Communication

Education Research

Legal and Practice Standards

Recording provides written evidence ofwhat was done for the client, the clients

response, and any revisions made in the

care plan


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Documentation Recording documents compliance with

professional practice standards and

accreditation criteria.

Written records are a resource for review,

audit, reimbursement, and research.

Documentation provides a written legalrecord to protect the client, institution and

practitioner.


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Documentation Education

Health care students use the medical record as a

tool to learn about disease processes, diagnoses,complications, and interventions.

Clinical rounds and case conferences rely

heavily on information contained in the medical

record.


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Documentation Research

Researchers rely heavily on medical records as

a source of clinical data.

Documentation can validate the need for

research.


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Documentation Legal and Practice Standards

In 80% to 85% of malpractice lawsuits

involving client care, the medical record is thedetermining factor in providing proof of

significant events.


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Informed Consent

Advance Directives

Indonesian National Nurses Association

(INNA) Standards of Care

State Nurse Practice Acts


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Informed consentmeans that the client

understands the reasons and risks of the

proposed intervention.

Witnessing confirms that the person who

signs the consent is competent.


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Principles of Effective

Documentation Nursing notes must be logical, focused, and

relevant to care, and must represent each

phase of the nursing process.

Nursing documentation based on the

nursing process facilitates effective care.


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Elements of Effective

Documentation Use of Common Vocabulary

Legibility

Abbreviations and Symbols

Organization

Accuracy

Documenting a Medication Error

Confidentiality


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Documentation Use of Common Vocabulary

Enhances the quality of documentation.

Supports the efforts of research.

Improves communication and lessens the

chance of misunderstanding between members

of the health team.


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Documentation Legibility

Print if necessary.

Do not erase or obliterate writing.

Draw one line through an erroneous entry.

State the reason for the error.

Sign and date the correction.


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Documentation

Correcting a documentation error


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Documentation Abbreviations and Symbols

Always refer to the facilitys approved listing.

Avoid abbreviations that can be misunderstood.


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Documentation Organization

Start every entry with the date and time.

Chart in chronological order.

Chart in a timely fashion to avoid omissions.

Chart medications immediately after

administration.Sign your name after each entry.


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Documentation

Charting a late entry


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Documentation

Charting a prn

medication


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Documentation Accuracy

Use factual, descriptive terms to chart exactly

what was observed or done.Use correct spelling and grammar.

Write complete sentences.

Maintain continuity of care by recording withrespect to notes made on previous shifts.


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Documentation Documenting a Medication Error

Chart the medication on the MAR.

Document in the nurses progress notes: Name and dosage of the medication

Name of the practitioner who was notified of the

error

Time of the notification

Nursing interventions or medical treatment

Clients response to treatment


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Documentation Confidentiality

The nurse is responsible for protecting the

privacy and confidentiality of clientinteractions, assessments, and care.

The clients significant others, insurance

companies, or other parties not directly

involved in care provided by the health team

may not have access to clients records.


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Methods of Documentation

Narrative Charting

Source-Oriented Charting

Problem-Oriented Charting PIE Charting

Focus Charting

Charting by Exception (CBE)

Computerized Documentation

Case Management with Critical Paths


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Narrative Charting

Describes the clients status, interventions and

treatments; response to treatments is in storyformat.

Narrative charting is now being replaced by

other formats.


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Source-Oriented Charting

Narrative recording by each member (source)

of the health care team on separate records.


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Problem-Oriented Charting (POMR)

Uses a structured, logical format called

S.O.A.P. S: subjective data

O: objective data

A: assessment (conclusion stated in form of

nursing diagnoses or client problems)

P: plan


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Problem-Oriented Charting

(POMR) Uses flow sheets to record routine care.

A discharge summary addresses each

problem.

SOAP entries are usually made at least

every 24 hours on any unresolved problem.

SOAP was developed on a medical model.


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(POMR) SOAPIE and SOAPIER refer to formats that

add:

I: Intervention

E: Evaluation

R: Revision


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.


(POMR)


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PIE Charting

P: Problem

I: Intervention

E: Evaluation

Key components are assessment flow sheets

and the nurses progress notes with anintegrated plan of care.

PIE charting is a nursing model.


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Focus Charting

A method of identifying and organizing the

narrative documentation of all client concerns.Includes data, action, response.

Uses a columnar format within the progress

notes to distinguish the entry from otherrecordings in the narrative notes.


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Charting by Exception (CBE)

The nurse documents only deviations from

preestablished norms.Avoids lengthy, repetitive notes.

Enables the identification of trends in client

status.


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Computerized DocumentationIncreases the quality of documentation and save

time.

Increases legibility and accuracy.

Enhances implementation of the nursing

process. Enhances the systematic approach to

client care.

Provides clear, decisive, and concise key words(standardized nursing terminology).


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Point-of-Care System

A handheld portable computer is used for

inputting and retrieving client data at thebedside.

Provides each health care practitioner with all

pertinent client data to ensure continuity of care

without duplication.

Provides crucial client information in a timely

fashion.


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Case Management Process

A methodology for organizing client care

through an illness, using a critical pathway.A critical pathway is a monitoring and

documentation tool used to ensure that

interventions are performed on time and that

client outcomes are achieved on time.


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Forms for Recording Data

Kardex

Flow Sheets

Nurses Progress Notes

Discharge Summary


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TheKardexis used as a reference

throughout the shift and during change-of-

shift reports.Client data

Medical diagnoses and nursing diagnoses

Medical ordersActivities


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Flow sheetsreduce the redundancy of

charting in the nurses progress notes.

The information on flow sheets can beformatted to meet the specific needs of the

client.


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Nurses progress notesare used to

document the clients condition, problems

and complaints, interventions, responses,achievement of outcomes.

Progress notes can be completely narrative

or incorporated into a standardized flowsheet.


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Discharge Summary

Clients status at admission and discharge

Brief summary of clients care

Interventions and education outcomes

Resolved problems and continuing need

ReferralsClient instructions


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Trends in Documentation

Standardized data bases are required to

ensure accuracy and precision in nursing

information systems.


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Trends in Documentation

Nursing Minimum Data Set (NMDS)

Nursing Diagnoses (Taxonomy II)

Nursing Intervention Classification (NIC)

Nursing Outcomes Classification (NOC)


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Reporting

Report: Is oral, written, or computer- basedcommunication intended to convey

information to others.

Record: Is written or computer based, the

process of making an entry on a clients record

is called recording, charting, or documenting.A clinical record, also called a chart or client

record is a formal, legal document that

provides evidence of a clients care.


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Reporting

Verbal communication of data regarding the

clients health status, needs, treatments,

outcomes, and responses Summary of current critical information to

facilitate clinical decision making and

continuity of client care


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Reporting

Reporting is based on the nursing process,

standards of care, and legal and ethical

principles. Reports require participation from everyone

present.


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Reporting

Summary Reports

Walking Rounds

Telephone Reports and Orders

Incident Reports


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Summary Reports Commonly occur at change of shift (or

when client is transferred).

Assessment data

Primary medical and nursing diagnoses

Recent changes in condition, adjustments in

plan of care, and progress toward expected

outcomesClient or family complaints


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Walking Rounds

Nursing, physician, interdisciplinary

Occur in the clients room and include the

client


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Telephone Reports and Orders

Report transfers, communicate referrals,

obtain client data, solve problems, inform a

physician and/or clients family membersregarding a change in the clients condition.

Telephone orders are documented in the

nurses progress notes and the physicianorder sheet.

D ti T l h


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Documenting a Telephone

Order


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Incident Reports

Used to document any unusual occurrence

or accident in the delivery of client care.

The incident report is not part of themedical record, but it may be used later in

litigation.


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LETS PRACTICE!! Divide your class into 10 small groups Each group must present CASES of patients in different areas

Grup 1 : fractures

Grup 2 : Infectious disease

Grup 3 : Pediatric patient

Grup 4 : Gerontology patient Grup 5 : pregnant woman in labour

Grup 6 : emergency patient in hospital settings

Grup 7 : emergency patient in pre hospital settings

Grup 8 : discharged patient

Grup 9 : mental health patient Grup 10 : dead patient

Each individual of the groups should prepare their own cases ofmaximum 5 minutes reporting


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LETS PRACTICE!!

In the next 2x50, report your work in your

group by role play.

Make a pair in your group. One does thereporting and the other does note taking

Change the turn.

Discuss in pair.


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REFERENCE

Lhynnely. (2012). Nursing Abbreviations

[Electronic Version]. Retrieved June 4,

2012, from http://nursingcrib.com/nursing-notes-reviewer/fundamentals-of-

nursing/nursing-abbreviations/

Kozier, E.2008. Fundamental of Nursing.5th Edition. Lippincott: William Wilkins


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9 documentatin & reporting nurses by m.fathoni 2013

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