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Documentation 101 - BMH/Tele


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Documentation 101 - BMH/Tele

  1. 1. Documentation 101 Natalie Bermudez, RN, BSN, MS Clinical Educator for Telemetry For Novice and Experienced Nurses New to Bethesda Memorial Hospital
  2. 2. Nursing Documentation <ul><li>“ Documenting your patient’s care has always been important. But with health care growing increasingly complex, expert documentation skills have become indispensable.” </li></ul><ul><li>(Seeber-Combs, 2006, p. 1) </li></ul>
  3. 3. Nursing Documentation <ul><li>Cost constraints, sicker patients, and nurses’ growing roles further emphasize the need for a properly documented medical record. </li></ul><ul><li>(Seeber-Combs, 2006, p. 1) </li></ul>
  4. 4. Nursing Documentation <ul><li>“ When you document effectively, your patient’s medical record reflects your professionalism.” </li></ul><ul><li>(Seeber-Combs, 2006, p. 1) </li></ul>
  5. 5. Reasons for Documentation <ul><li>Continuity-of-Care Tool </li></ul><ul><li>Patient Protection Device </li></ul><ul><li>Quality Management Aid </li></ul><ul><li>Legal Safety Net </li></ul><ul><li>(Seeber-Combs, 2006, p. 1) </li></ul>
  6. 6. Documentation Systems <ul><li>Source-Oriented </li></ul><ul><li>Problem-Oriented </li></ul><ul><li>Narrative Notes </li></ul><ul><li>Focus Charting (DAR) </li></ul><ul><li>PIE Documentation </li></ul><ul><li>Charting By Exception </li></ul><ul><li>(Seeber-Combs, 2006) </li></ul>
  7. 7. Charting By Exception <ul><li>When you use CBE, you document only abnormal or significant findings or deviations from established norms. </li></ul><ul><li>(Seeber-Combs, 2006, p. 7) </li></ul>
  8. 8. Charting By Exception <ul><li>This system eliminates lengthy, repetitive notes and makes trends or changes in the patient’s condition more obvious. </li></ul><ul><li>(Seeber-Combs, 2006, p. 7) </li></ul>
  9. 9. Documentation Made Easy <ul><li>Document what the patient tells you </li></ul><ul><li>Document what you assess </li></ul><ul><li>Document what you do </li></ul><ul><li>Document outcomes of what you do </li></ul><ul><li>Document what you teach </li></ul>
  10. 10. BMH Tools for Documentation <ul><li>PCAR (Patient Care Activity Record) </li></ul><ul><li>Patient Logistics </li></ul><ul><li>Medical Diagnosis/Diagnoses </li></ul><ul><li>Medication List </li></ul><ul><li>Recent Vital Signs & Lab Results </li></ul><ul><li>Pending Procedures/Labs/Tests </li></ul><ul><li>Diet/Activity/Code Status </li></ul><ul><li>Nursing Interventions </li></ul><ul><li>IVFs & Cardiac Rhtyhm </li></ul>
  11. 11. Tools for Documentation <ul><li>Problem List </li></ul><ul><li>Nursing Diagnoses </li></ul><ul><li>Specific Goals and Interventions </li></ul><ul><li>Nurses Notes </li></ul><ul><li>CBE documentation </li></ul><ul><li>Narrative-style documentation </li></ul>
  12. 12. Tools for Documentation <ul><li>Shift Assessment </li></ul><ul><li>Documentation of initial multi-system assessment </li></ul><ul><li>Charting By Exception </li></ul><ul><li>Cardiac Monitoring Strips </li></ul><ul><li>Provides important assessment data </li></ul><ul><li>Remains part of permanent health record </li></ul>
  13. 13. Tools for Documentation <ul><li>Flow Sheets and Checklists </li></ul><ul><li>IV Site </li></ul><ul><li>Neuro-checks </li></ul><ul><li>PCA Pumps </li></ul><ul><li>Post-Cardiac Catheterization </li></ul>
  14. 14. Incident Reports <ul><li>Medication errors or harm to clients, staff, or visitors </li></ul><ul><li>Risk management tool </li></ul><ul><li>Use to track trends and patterns </li></ul><ul><li>For Quality Assurance </li></ul><ul><li>Not for punitive measures </li></ul><ul><li>Kept separately of health record </li></ul>
  15. 15. Legal Aspects <ul><li>A patient chart is a legal document </li></ul><ul><li>Any documentation on the patient’s chart is permanent </li></ul><ul><li>Assure that only pertinent information is entered </li></ul>
  16. 16. Telephone Orders <ul><li>Only registered nurses may obtain a telephone order </li></ul><ul><li>A telephone order may only be taken via the telephone </li></ul><ul><li>All telephone orders must have the date and time the order is received </li></ul><ul><li>Must also include name of RN and physician </li></ul>
  17. 17. EXAMPLES <ul><li>Nurses’ Notes: </li></ul><ul><li>Pertinent Information </li></ul><ul><li>Precise and concise </li></ul><ul><li>Descriptive words </li></ul><ul><li>Quotation marks when necessary </li></ul><ul><li>Avoid words like “appears to be” or “seems to be” </li></ul>
  18. 18. EXAMPLES <ul><li>Nurses’ Notes: </li></ul><ul><li>826/10 – 08:00 </li></ul><ul><li>Patient received in bed awake. Alert and oriented x 3. Patient c/o nausea. Medicated with Phenergan 25 mg IM – left deltoid. Will continue to monitor for medication effectiveness and/or adverse reactions. No other complaints or concerns verbalized at this time. </li></ul>
  19. 19. EXAMPLES <ul><li>Nurses’ Notes: </li></ul><ul><li>8/26/10 – 17:30 </li></ul><ul><li>Patient stated “I have pain in my chest. It feels like an elephant is sitting on me”. Patient is pale, diaphoretic, and has SOB. Vital signs: B/P 130/70, HR 120, O2 Sat 92% on RA. Nitro-stat SL x 2 tabs administered with complete relief of chest pain. Stat call placed to physician. Stat EKG done and faxed to physician’s office as requested. Patient started on a Nitro drip @ 20 mcg/min per physician orders and will be transferred to ICU when bed available. </li></ul>
  20. 20. EXAMPLES <ul><li>Shift Assessment: </li></ul><ul><li>8/26/10 – 08:00 </li></ul><ul><li>Neuro: WNL </li></ul><ul><li>Resp: WNL </li></ul><ul><li>If WITHIN NORMAL LIMITS is documented there is no need to write in “Comments” that “Patient is AAO x 3” or “Lungs are clear”. </li></ul>
  21. 21. EXAMPLES <ul><li>Shift Assessment: </li></ul><ul><li>8/26/10 – 08:00 </li></ul><ul><li>If you documented the shift assessment @ 0800, then it is not necessary to document a narrative assessment in the Nurse’s Notes for the same time. </li></ul>
  22. 22. EXAMPLES <ul><li>Shift Assessment is done: </li></ul><ul><li>8/26/10 – 08:00 </li></ul><ul><li>AAO x 3. No neuro deficits. Lungs are clear/diminished at bases bilaterally. O2 sat with 2L NC is 100%. Oral mucosa and nailbeds are pink with adequate CR. Heart sounds are regular; no murmurs. Rhythm is sinus 70’s. Abdomen soft, non-tender. Bowel sounds are positive x 4; last BM 9/29/07. Foley catheter in place draining clear, yellow urine. MAE. Ambulates to bathroom independently; steady gait. 0/9% NaCL @ 50 ml/hr infusing to LFA IV site; no redness or swelling at insertion site. </li></ul>
  23. 23. EXAMPLES <ul><li>Admission Assessment </li></ul><ul><li>& </li></ul><ul><li>Nursing Admission History </li></ul>
  24. 24. EXAMPLES <ul><li>Nursing Admission History/Assessment </li></ul><ul><li>Needs to be completed ASAP </li></ul><ul><li>Includes Home Meds </li></ul><ul><li>Immunization & TB History </li></ul><ul><li>Past Medical/Surgical History </li></ul><ul><li>Social History </li></ul><ul><li>Assessment Needs to be Thorough </li></ul>
  25. 25. EXAMPLES <ul><li>Problem List: </li></ul><ul><li>Documentation needs to be completed for each problem on the list once per shift </li></ul><ul><li>If problem goals have been met, problem may be removed from the list (Resolved) </li></ul><ul><li>Problem list may be updated to include new problems </li></ul>
  26. 26. EXAMPLES <ul><li>PCAR: </li></ul><ul><li>Needs to be initiated on admission and updated by nursing on an as needed basis </li></ul><ul><li>Communication tool for nurses!!!!!!!!!!!! </li></ul>
  27. 27. EXAMPLES <ul><li>PCAR: </li></ul><ul><li>Routine Activities… </li></ul><ul><li>Conditioning Parameters… </li></ul><ul><li>Call Physician If… </li></ul>
  28. 28. EXAMPLES <ul><li>Telephone Orders: </li></ul><ul><li>All telephone orders should be verified by repeating the orders to the physician </li></ul><ul><li>Label verbal orders with RBTO </li></ul><ul><li>RBTO = Read Back Telephone Order </li></ul><ul><li>All telephone orders need to be signed by physician with date and time within 48 hours!!! </li></ul>
  29. 29. EXAMPLES <ul><li>Verbal Orders: </li></ul><ul><li>8/26/10 19:00 </li></ul><ul><li>1) Start IV Nitro drip @ 20 mcg/min and titrate for chest pain relief. </li></ul><ul><li>2) Stat EKG </li></ul><ul><li>3) Cardiac enzymes every 6 hours x 3, first set stat </li></ul><ul><li>4) O2 2L NC, titrate to keep O2 sat > 92% </li></ul><ul><li>RBTO: Dr. Von Sohsten/N. Bermudez, RN </li></ul>
  30. 30. Incident Reports <ul><li>What is an incident report? </li></ul><ul><li>What info do I include in an incident report? </li></ul><ul><li>Do I document the event/occurrence in the nurses’ notes? </li></ul><ul><li>How should I document the occurrence … what should I say? </li></ul>
  31. 31. Documentation in a Nutshell <ul><li>Documentation should tell a story without making it sound like a novel!!! </li></ul><ul><li>Parts of documentation are like pieces of a puzzle </li></ul><ul><li>Document facts </li></ul><ul><li>Avoid judgments or suggestive comments </li></ul>
  32. 32. Documentation in a Nutshell <ul><li>Be sure to TIME and DATE all entries </li></ul><ul><li>Change TIME and DATE to the actual time of occurrences </li></ul><ul><li>Incident Reports should not be documented as such </li></ul><ul><li>Document details of incident only </li></ul>
  33. 33. Documentation in a Nutshell <ul><li>Remember that the patient chart is a LEGAL document </li></ul>
  34. 34. Reference <ul><li>Seeber-Combs, C. (2006). Mosby’s surefire documentation: How, what, and when nurses need to document, (2 nd ed. ). St. Louis, MO: Mosby Elsevier. </li></ul>