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8/17/2019 Documentation SLP

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Documentation Guidelines

Greater Baltimore Medical Center


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General Documentation

Information• Most nursing documentation is completed on thecomputer using Meditech PCS

• Agency nurses will be reuired to ta!e an " hour

Meditech course taught by GBMC before

beginning to wor! at the hospital

• #his class will co$er order entry% documentation%

and barcoding medication deli$ery & using theelectronic medication administration record


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Patient Care System 'PCS(

) PCS is the system for documentation that

reflects the nursing process% encourages clear

and concise charting% is legally sound% and

focuses on patient inter$entions to support

patient outcomes

) All information entered through PCS can be

$iewed in the *M+ '*nterprise Medical+ecord(


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,ith PCS% you are able to-

• .ill out the Admission Database

• +ecord $ital signs and I/0s

• Document the patient1s Past Medical 2istory

• Document your head3to3toe assessment 'using System.lowsheets(

• *nter nursing notes

• Add Care Plans and record outcomes

• 4iew and print 5arde6es and patient reports

• *nter lab% radiology% respiratory% diet% and nursing orders throughorder entry

• Document medication administration through the electronic MA+


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Shift

) A shift is defined as 78 hours

) Documentation that is reuired shift is to bedocumented once e$ery 78 hours% unless physician orders or unit specific policies dictateotherwise

) Change in patient status or change of care pro$ider necessitates a repeat of the shiftdocumentation 'i9e9 Patient System .lowsheets(


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+eal #ime Documentation

• Documentation completed at the time the inter$ention is performed

• In the e$ent that :real3time; documentation is not possible%documentation that occurs within one hour of the

inter$ention is acceptable% e6cept for those inter$entionswith a time inter$al less than one hour 'i9e9 7


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Standard of Care

• =pon admission% each patient will ha$e the

appropriate :Standard of Care; 'S0C( added to

their inter$ention list in Meditech

• #he S0C is a predefined set of inter$entions that

are designed for that patient1s population

• 0nce the S0C and all physician orders are

entered through Meditech order entry% theinter$ention list the nurse will document from

will be complete and ready to be documented on


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Plan of Care

• #he plan of care for the patient includes allcomputer documentation% entered orders% as wellas a defined Care Plan

• *$ery admitted patient must ha$e a care plan addedwithin 8> hours of admission

• Care plans all ha$e problems and e6pectedoutcomes that are documented against once e$ery

78 hours• Care plans can be updated as needed to reflect new

problems or change in patient status


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?otes

• ?ursing notes are entered on

a patient in the following situations-

) Admission

) #ransfer

) Discharge

) ,hen an unusual e$ent occurs or with change of

patient status

) ,hen an appropriate inter$ention cannot be found to

document on


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Documentation Details

• A nurse can s!ip a uestion on an

assessment if he&she is unable to assess the

uestion due to patient condition or if theuestion is not applicable for the patient at

that time

• Any retrospecti$e documentation can be

entered up to @ days following patient

discharge


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Documentation Details

• Changes to documentation may only be

made by the person who recorded the

documentation• Partially documented entries%

documentation editing% and undoing

documentation can be completed by

clic!ing in the 2istory column for the

appropriate inter$ention


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#ransfer of Patients

• #ransferring unit will change the status of anyappropriate inter$entions from :Acti$e; to:Complete; by clic!ing in the Status column

) Completed Admissions Documentation ) System .lowsheet

• +ecei$ing unit stops all nursing orders initiated inorder entry% enters transfer orders according to policyand procedure% and the nurse will add on the correctsystem flowsheet for the patient on the inter$entionlist using the :Add Inter$ention; .unction


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0rder *ntry

• All paper physician order sheets

must be fa6ed to pharmacy upon

admission

• Pharmacy will enter any medications and I4s intoMeditech ) the list of current medications can be$iewed in the *M+ by clic!ing on the Medicationstab

• All non3medication orders will be entered by thenurse or secretary into the Meditech order entrysystem


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0rder *ntry

• It is the +?1s responsibility to $erify A orders

'lab% radiology% nursing% etc9( are entered into

Meditech from the Physician 0rder Sheet '=se

0rder 2istory in the *M+(

• Initial each individual order with red in! after

$erification that the order is in Meditech

• After all orders ha$e been entered and $erified% a5arde6 will be printed from the Meditech des!top

using the +eports button


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4erification of Physician 0rders

• .or ancillary department orders reuiring

pager notification '+espiratory #herapy(

the time of the page is written on the ordersheet ne6t to the order

• Co3sign each set of

physician orders withinitials% title% date% and time


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8>3hour Chart Chec!s

• Performed on 77pm ) am shift

• +e$iew A orders written during the

pre$ious 8> hours and $erify they are inMeditech by accessing the *M+ 'orderhistory section% sorted by date(

• Sign entire physician1s order sheet with

name&initials% title% date and time in red in!


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egal Medical +ecord

) Combination of the Patient1s PCS archi$eddischarge summary and the archi$ed notes% as

well as any documentation from the paper chart ) #he Medical +ecords Department archi$es

these items days after discharge

) #he discharge summary and notes are a$ailable

upon reuest from the Medical +ecordsDepartment


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Admission Documentation

• Document all inter$entions that ha$e a freuency of :0n Admission;

• Also reuired to document the following% as appropriate-

) System .lowsheet

) .all +is! & Safety Assessment #ool

) I4 Assessment & In$asi$e ine Status

) Pain Assessment & +eassessment

) S!in +is! Assessment

) CAM

) General *ducation +ecord

• ?ursing ?ote with Admission Details

• Add a Care Plan to patient using :Process Plan;

• Print 0ut 2ome Medication +eport from Meditech Des!top after entering in listof Patient1s 2ome Meds during admission


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Discharge Documentation

• #he physician writes the discharge instructions

• #he nurse is responsible for re$iewing all instructionswith the patient and obtaining the patient signature

• Carenotes can be printed out from the Infoweb 'clic! onMicromedi6 lin! to access( for patient education

• #he nurse should ma!e sure the patient understands thecomplete list of medications the patient is to ta!e once

being discharged 'compared to any medications the

patient was ta!ing on admission(% as part of themedication reconciliation process

• 0riginal form goes to medical records and a copy is gi$ento the patient upon discharge


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Blood Administration

Documentation• Blood #ransfusions are documented as an Inter$ention

Set% which can be added using the :Add Inter$ention;

lin! on the Inter$ention wor!list 'search for :set;(

• #he set is comprised of- ) Blood Administration 4erification 'completed Eust prior to

starting infusion(

) Blood Product Infusion 'start time and initial rate(

) Infusion Changes 'any rate changes during infusion(

) Blood Product Completion 'completed at end of infusion(

) Blood 4ital Signs 'baseline $itals ta!en at start% then 7


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Documentation of ,ounds

• ,ounds are documented as an Inter$ention Set%which can be added using the :Add Inter$ention;

lin! on the Inter$ention wor!list 'search for :set;(• #he set is comprised of-

) ,ound & Pressure =lcer Status Assessment- for initial%wee!ly% and change of status wound documentation

'more detailed( ) ,ound Care & Dressing Change Assessment- for daily

documentation of dressing changes 'focusedassessment specifically for dressing changes(


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Critical ab 4alues

Documentation• #he lab will call the nurse 'as well as the physician( responsible for ta!ing care of the

patient with the critical lab $alue

• #he telephonic critical result% upon receipt% will

be read bac! to the technologist&technician and

documented as ha$ing been read bac!9 If that

does not happen% the technologist&technician willreuest that the nurse recei$ing the critical result

read it bac!9


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Critical ab 4alues

DocumentationProcedure

79 4erify the result by $erbally reading the result bac! to the technologist&technician

89 ?otify the nurse assigned to the patient of thecritical result if she&he was not the one to recei$ethe telephonic notification9

@9 Document recei$ing the phone call about the

critical $alue% the critical result% and what you didabout the result on the Critical ab 4aluesInter$ention in Meditech PCS9


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*M+

• #he *nterprise Medical +ecord '*M+( is where

all the documentation for your patient is located

• #o open the *M+ from PCS% clic! on :0pen

Chart;

• 0nce in the *M+% you can clic!

on the options on the right side

of the screen to $iew documentation%

reports% labs% orders% etc9


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Computer Downtime

• In the e$ent of a computer downtime% the documentationsystem re$erts bac! to paper 'all paper forms will bestoc!ed on units(

• .or downtime less than > hours 'med&surg( and 8 hours

'critical care(% information that is recorded on paper willneed to be entered into PCS

• .or downtime e6ceeding > hours 'med&surg( and 8 hours'critical care(% the paper system will replace PCS until theend of the shift and until the system is bac! up ) the onlydata that must be re3entered into PCS in this case are the4ital Signs and the I/0% so the *M+ record will beaccurate


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=nscheduled Downtime

• A 24-hour report, by unit, will be availableupon request from the MIS Helpdes,!"#2$% &he unit is responsible for pi'in(up this report from the MIS department,buildin( ), $th *oor% &he report in'ludes thefollowin( do'umentation+ ) 4ital Signs

) Inta!e and 0utput

) System .lowsheet ) Pain Assessment

) PCA- I4 and *pidural


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Scheduled Downtime

• &he unit is responsible for printin( the followin( reports onehour prior to the downtime+

ursin( .owntime /lowsheet • 0li' on 1eports button from destop

• 0li' on atient 1eports

• Sele't /lowsheet 1eport• In /ormat bo!, ress /) and sele't ursin( .& /lowsheet

• /ill in atient 3ast name and press /) in atient se'tion

• Sele't 'orre't patient and 'li' on (reen 'he' mar to print

atient arde!• 0li' on 1eports button from destop

•0li' on atient 1eports• Sele't ro5le 1eport

• /ill in atient 3ast name and press /) in atient se'tion

• In 6se ro5le /ormat bo!, press /) and sele't t arde! &reatmentre'ord and 'li' on (reen 'he' mar to print


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Meditech 2elp

• Can be found on the nursing page of the

Infoweb

Scroll down on the

nursing page and clic!

on Meditech 2elp

in!


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,hat stays on paperF

• Consent forms

• Admission & #ransfer Summaries

• 0+&+eco$ery Documentation

• Physician 0rder Sheets• Documentation During Patient Codes

• Pre3op Chec!list

• Discharge Instructions

• abor *$ent ) #riage up until Deli$ery• Monitoring Strips


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Paper Documentation Guidelines

• ,hen your signature is reuired on any form% legiblysign your full name and status 'i9e +?(

• Before using your initials on any paper form% be sure to

sign the Signature&Initial record in front of the medicalrecord

• =se blac! or blue in! pen for all entries% e6cept whensigning off medications ) which should be done usingred in!

• If part of the paper medical record is damaged in anyway 'spills% tears(% do not destroy the form ) simplycross3reference to a newly initiated form


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Documenting a #elephone 0rder

from a Physician• Indicate date&time order was recei$ed

• Document order as stated by physician

• +ead the written order bac! to the physician to $erify

accuracy• Document under the order +B0 'read bac! order( and

the recorder1s initials

• Sign order- $9o9 Dr9 ones & 5ay Smith +?

• Place a :sign here; stic!er ne6t to order • .lag the record green for a regular order and red for a

S#A# order for the secretary


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#ime30ut 4ISA

• #o be completed on A surgical and

in$asi$e procedures for which consents are

reuired9 #his includes bedside procedures

such as central lines% chest tubes%

thoracentesis% etc9

• @ Sections- Patient 4erification% Site

Mar!ing% and #ime 0ut for Procedure or

0perating +oom


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Section 7- Patient 4erification

• #wo identifiers- patient name and date of

birth

• Compare to ID band% consents% diagnosticimages% and all other patient

documentation related to the procedure

• All areas on the 4ISA under section 7 areto be initialed


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Section 8- Site Mar!ing

• Completed whene$er laterality may become an issue

• Performed by physician or person performing the in$asi$e procedure

• *6ceptions

) If not multiple digits&structures

) Procedure occurs through an orifice 'dental% colonoscopy% etc(

) ?IC= babies

• Green bracelet used on operati$e side

when patient refuses site mar!ing

• All areas to be initialed

if appropriate


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Section @- #ime30ut

• Completed Eust prior to the beginning of the procedure

• Includes the patient

• All members present for the #ime30ut must beidentified

• All areas to be initialed and form signed

• +eferences- 4erification of Correct Site% Correct

Procedure% Correct Patient and :#ime30ut; forIn$asi$e or Surgical ProcedureH and Guidelines forCompleting Procedure 4isa

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