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Documentation Documentation Presentation Transcript

  • DocumentationDocumentation is entered through the electronic medical record – CPSI’s Point of Care (POC) charting systemDocumentation occurs following any• Assessment/nursing intervention• Patient’s response to treatment/intervention• Medication administration• Completion of IV Piggybacks• Education• Routine nursing rounds• PRN medication reassessment • This is to include the effectiveness of the medication and relevant assessment information including vital signs, level of sedation, level of pain, and nausea/vomiting
  • Documentation - Physical Assessment A problem oriented assessment is performed in a timely manner by the RN with a comprehensive initial physical assessment performed and documented within 8 hours of admission • Subsequent physical assessments are performed at least every shift, more often according to unit specific protocol or if patient condition warrants When documenting the Physical Assessment, answer all the questions on the flowchart that are applicable to the patient Injury Risk assessments are documented on admission, daily on the AM shift, after a fall or change in patient condition, and after any in house transfer Braden Risk assessments are documented on admission and daily on the AM shift
  • Documentation – Admission Package The patient history is recorded within 8 hours of admission on the Initial Interview section of the Admission Package • This is where history of present illness, patient & family history, and referral screening is done The Tobacco Cessation Protocol section of the Admission Package is completed on all patients • If the patient does not use tobacco, the form will have only that one question • If the patient has used tobacco in the last 30 days, more questions will appear to further assess the patient’s tobacco use and interventions for quitting
  • Documentation – Admission PackageThe Influenza and Pneumococcal Vaccination Protocol section ofthe Admission Package is also completed on all patients atadmission Each part of this form must be completed down to the Evaluation, and if the evaluation result is that the vaccination is indicated (and not refused), the Education and Vaccination Decision parts must be completed as well Once all 5 pages of the Admission Package are completed, the reflexed orders are sent, the pages are printed and distributed according to the instructions on each page
  • Documentation – RN ValidationThe RN “validation” is documentation that the patient was observedduring the shift by an RNWhen an RN “validates” patients, he/she should: • Address or Evaluate each problem • Enter diagnosis specific assessment data • Enter a “note” through nursing activities for any other pertinent information
  • Documentation - Downtime ProceduresIn the event of system or power failure: • Down time procedures are initiated if CPSI is down longer than 2 hours • Paper documentation tools are available in the emergency box on each unit (on the CD) and on the intranet under “Downtime Procedures”Once nursing and multi-disciplinary staff have starteddocumenting on paper they will continue to document onpaper for the rest of their shift
  • Documentation - Intervention List (MedAct)The Intervention List (also known as the MedAct) is a listcontaining nursing orders either written by the physician orpart of a policy/protocol  Keeping the list current allows for an accurate, up-to-date look at the patient’s plan of care  Interventions are PERFORMED, DISCONTINUED, COMPLETED, or OTHER  Documenting PERFORMED marks the intervention has been done and keeps it on the list as a remaining active order  Documenting COMPLETED marks the intervention as done and removes it from the list  Documenting DISCONTINUED is for interventions that are no longer part of the patient’s plan of care  The OTHER option may be changed to suit the situation
  • Documentation - Intervention List (MedAct)Nursing orders may be entered through the MedAct or from theOrder Entry screen • The category that nursing orders are entered in through the Interventions list is very important because it affects the location of order in the listInterventions (nursing orders related to a problem) may beassociated to related problems at the time of order entry. • Nursing orders may be timed to start/stop at a specific time and will change color if overdue • This is especially useful for extended tests like 24 hour urine collectionVerify medications, nursing, and ancillary orders in CPSI beforenoting the order off • When verifying orders entered by a HUC, nurses may delete the order & reenter it, if it is inaccurate
  • Documentation – Physician Orders All orders must be dated and timed The date and time must also be noted when orders are faxed and signed off Limit using verbal orders unless necessary • If physician is on the unit he needs to write the orders For verbal or telephone orders or for receiving critical lab results be sure to use the “READBACK” standard and document when signing the order • Repeating the order or results is not sufficient • Write down the complete order or result then read it back and receive confirmation
  • Documentation – Problem ListThe Problem List is the plan of care for the patientIt is initiated by the RN within 8 hours of admissionProblems have suggested goals • They are measurable and should be obtainable during this hospitalization • These may be customized to the patient during implementation
  • Documentation - Problem ListExample: Patient admitted with a medical diagnosis ofgastroenteritis – complains of nausea, vomiting, diarrhea, andabdominal pain • Problem of ELIMINATION initiated for the patient • Goals:  The patient maintains 30 ml of urine per hour  Stool is normal color, amount, and consistency  Elimination occurs without pain and/or discomfort • The first goal may be updated to “Patient will tolerate PO intake without nausea, vomiting, diarrhea” to better suit this patient’s condition
  • Documentation – Problem List Problems should reflect the patient’s current admission Consideration is made of the patient’s medical diagnosis as well as the patient’s statement of present complaint Screenings and special situations may also call for a problem to be initiated • Patients screening a level II or III in fall prevention must always have a POTENTIAL FOR INJURY problem New problems may be added during the patient’s stay if the patient’s condition changes Problems are resolved as the patient’s condition improves • Problems may be re-opened if needed from the PL clipboard at the top, right of any flowchart
  • Documentation – Problem ListExample: Patient admitted with bronchitis with a statement of present complaint “my chest hurts when I cough” that is a Level II fall risk would have problems of Airway Clearance or Breathing Pattern as well as Alteration in Comfort and Potential for Injury
  • Documentation – Problem List Problems are documented on each shift. • Checking “ADDRESSED” with no further documentation is not sufficient When documenting through the problem list, chart: • Problem specific assessment data • Interventions specific to the problem • Any activities that relate to the problem To make documenting interventions easier, nurses may associate interventions with specific problems When documenting on the problem, select Intervention and Update to see a list of interventions that have been associated with specific Problems
  • Documentation – Problem List Once the appropriate interventions have been selected they will pop up and may be marked Performed, Discontinued, Completed, etc. • Comments may be made on the comment line Once documentation on the interventions is complete, the flowchart will enter the Problem Mode, indicated by a large red button on the left side of the screen • Any information entered from the physical assessment, pharmacy, or education screens while in PROBLEM MODE will be associated with the selected problem Problem specific documentation can be viewed by printing the Problem Activity Report under the printing tab
  • Documentation – Problem List When finished documenting on one problem, click the Problem Mode button to turn it off and begin documenting on another problem Using the double “up” arrow allows the nurse to easily return to the top of the assessment and access the problem list Problems are resolved as goals are reached All goals must be resolved before resolving the problem itself At discharge, all unresolved problems are to be addressed
  • Documentation – Problem List Example: Patient being discharged with pain medication. The problem ALTERATION IN COMFORT may be resolved as long as the goals are met Goals for this patient would include: • Reports pain is relieved or controlled • Follows prescribed pharmacological regimen • Verbalizes methods that provide relief A note stating that the patient is compliant with medication regimen and that pain is controlled with PO medication would be made when the problem was resolved on discharge