DOCUMENTATION

Documentation

If it is not charted,

it wasn’t done!!!

The written or printed legal record of all pertinent interactions with the client.It reflects quality of care and accountability in providing care.Health personal communicate through: • Discussion• Reports• Records

Documentation

DocumentationA discussion: informal oral consideration of a subject by 2 or more health care personnel to ID problem or establish strategies to resolve a problemA report: is oral, written or computer based communication intended to convey information to others (endorsement).A record (chart or client record): is a formal, legal document that provides evidence of a client’s care. Can be written or computer based. The process of making entry on a client record is called recording, charting, or documenting.

Documentation Purposes

CommunicationPlanning client care: uses data from the client records to plan careAuditing heath agencies: review of client records for quality assurance purpose Research: data can be valuable resource for researchEducation: Students often use client records as educational tools

Legal Documentation: used in the court as evidence

Reimbursement: for obtaining payment through medicare, the client’s record must contain the correct diagnosis-related group codes and reveal that the appropriate care has been given

Health care analysis: to ID health care agency needs, ID services that cost money and those that generate revenue

Documentation Systems

I. SOURCE ORIENTED RECORDThe traditional client record and organized by disciplineEach person or department makes notations in a separate section or sections of the client’s chart (Admission departments have their own sheet, physicians have their own sheets, nurses have their own sheets…etc)

Advantage: easy to locate discipline specific information

Disadvantage: not organized by client problem, therefore difficult to track; fragmented and have repetition in the information which decreases communication among health care team, an incomplete picture of the client’s care, and lack of coordination of care

Narrative Charting: A traditional part of the source oriented record

Consists of written notes that include routine care, normal findings, and client problems

There is no right or wrong order to the information (may used in emergency situations), chronological order is used frequently

…..

II. PROBLEM ORIENTED MEDICAL RECORDS (POMR):

Documentation organized around client problems rather than the source of informationall disciplines record on same form

Advantage: encourages collaboration, and the problem list in the front of the chart alerts care givers to the client’s needs and makes it easier to track the status of each problem

Disadvantages: caregivers differ in their ability to use the required charting format, it takes constant awareness to maintain an up to date problem list, and it is somewhat inefficient because assessments and interventions that apply to more than one problem must be repeated.

Components: Database, problem list, Plan of care, and progress note

Data base: contains all information known about client when the client 1st enters the health care agency, updated according to change in health status Problem list: derived from the data base, problems are listed in order in which they are identified, redefined as patient condition changed or more data obtainedPlan of care: made with reference to active problem list, it generated by the person who lists the problem, listed under each problem in progress note

Progress notes:Is a chart entry made by all heath professionals involved in a client’s care

All use same type of sheet for notes

Numbered to correspond to the problems on the problem list

SOAP format is frequently used.

SOAP/SOAPIE/SOAPIER / APIE/ APIERformat:Subjective dataObjective dataAssessmentPlan InterventionEvaluationRevision

III. PIE: Groups information into three categories

Consist of flow sheet (assessment) and progress note.

Acronym for:Problem:

Intervention

Evaluation

NANDA used to word the problem

The problem statement, intervention and evaluation where numbered the same

Advantage: eliminate traditional CP and incorporates an ongoing care plan

Disadvantage: all nursing note should be reviewed before giving care to determine which problems are current and which intervention were effective.

IV. Focus Charting: It intended to make the client and client concerns and strengths the focus of care.Three columns for recording are usually used: date and time, focus, and progress noteFocus may be a condition, nursing diagnosis, a behavior, or S/S, client strength The progress notes are organized into:

DAR

D: Data: assessment phaseA: Action: planning and implementationR: Response: evaluation phase

Summary of focus charting

Date\time Focus progress note

- Condition - Data: S&O data

- Nsg Dx - Action: P&I

- S&S - Response: E

21/10

9:00 pain D: abd. Incision, facial grimacing. Rates pain at 8 on scale 0-10

A: administer morphine sulfate 4 mg IV

R: Rates pain at 1. states welling to ambulate

V. Charting by Exception (CBE):Is a documentation system in which only abnormal or significant findings or exceptions to norms are recorded

1. Flow sheets: as graphic records, fluid balance records, daily nursing assessment record, skin assessment record

2. Standards of nursing care: eliminates much of the repetitive charting of routine care.

3. Bedside access to chart form: all flow sheets are kept at the client’s bed side to allow immediate recording and to eliminate the need to transcribe data from the nurse’s worksheet to the permanent record.

• Advantage: is the elimination of lengthy, repetitive notes and it makes client changes in condition more obvious.

VI. Computerized Documentation:

Used to store clients database, add data, create and revise CP, and document client progress

It make care planning and documentation easy

It made transmission of information from one care setting to another possible.

VII. Case Management:

Uses multidisciplinary approach to planning and documenting client care, using critical pathway

Id the outcome that certain groups of client are expected to achieve on each day of care

It uses critical pathway, graphics and flow sheet

Promote collaboration and teamwork among caregiver, helps decrease length of stay, make efficient use of time

Work for client with one or two diagnosis and few needs.

Client with multiple diagnosis difficult to document on critical pathway.

Documenting Nursing Activities

Admission Nursing Assessment

Nursing Care Plans

Kardexes

Flow Sheets

Progress Notes

Nursing Discharge\referral

General Guideline for Recording

Date and Time

Timing

Legibility

Permanence

Accepted Terminology

Correct Spelling

Signature

Accuracy

Sequence

Appropriateness

Completeness

Conciseness

Legal prudence

Documentation

Correcting errors in charting:

Single line through error

Write “error” above entry

Date, time and initial “errored” entry

Reporting

Purpose: to communicate specific information to a person or group of people.Should be concise, include pertinent information no extraneous detailsInclude change of shift report, telephone report, care plan conference, and nursing round.

Change of shift report

Is a report given to all nurses on the next shiftPurpose: provide continuity of care for ptMay be written or given orally (face to face or by audiotape record) Sometimes given at the bedside, where client and nurse participate in information change.

Telephone ReportThe nurse receive telephone report should document the date &time, the person name giving the information, the subject of information, then sign the notation.information should repeated back to the sender to ensure accuracyBe concise and accurate, begin with name and relationship to the clientIt include (pt name, medical diagnosis, V\S, significant lab data), keep the pt record available to give Dr any additional informationAfter reporting, the nurse document the date and time, call content.

Telephone OrdersPhysician states prescribed therapy over the phone to the registered nurse

TO transcribe to the physician order sheet, indicate as VO or TO

Then the order should be signed by the physician in a period of time (24hr’s)

Include the following information: Date & time orders accepted Stated order Signature & credentials of the nurse Name of the ordering physician

Care Plan Conference: Meeting of a group of nurses to discuss possible solutions to certain problems of a client

Nursing Round: procedure in which 2 or more nurses visit selected clients at bedside to :

- Obtain information that help in Nsg CP- Provide chance for the client to discuss their

care- Evaluate nursing care received to pt