Documentation student outline


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Documentation student outline

  1. 1. Documentation and RecordingCommunication with the Healthcare Team <br />Subtitle<br />
  2. 2. Document and Reporting<br />Ensures quality of care<br />Regulatory agencies require it<br />Medicare reimbursement depends upon it<br />Shows nursing action<br />Serves as a legal document<br />
  3. 3. Reporting<br />Summary of activities, observations, and actions performed<br />Objective and non-judgmental<br />
  4. 4. Reports<br />Oral or written<br />Shift report<br />Verbal reports to physicians<br />Miscellaneous<br />Written lab reports<br />Dietary reports<br />Social workers notes<br />PT, OT, Speech therapies<br />
  5. 5. Types of Reports<br />Change of shift<br />Oral, audiotape, rounds<br />Telephone<br />Transfer<br />Incident<br />Any event not consistent with routine care of client<br />Concise, objective<br />Not a part of the chart<br />Oral, audiotape, rounds<br />
  6. 6. Confidentiality<br />Law protects any information gained by exam, observation, conversation, or treatment<br />Information not discussed or shared with anyone not directly involved in patient’s care<br />Nurses are legally and ethically obligated to keep patient information confidential<br />
  7. 7. Medical Records<br />Permanent written communications<br />Continuing account of care status<br />Discussion, discharge planning, conferences, consultations<br />All caregivers can benefit from information and plan accordingly<br />
  8. 8. Purpose of Records<br />Communication<br />Financial billing<br />Education<br />Assessment<br />Research<br />Auditing and monitoring<br />Legal documentation<br />
  9. 9. Documentation<br />Anything written or printed that is relied upon as a record of proof for authorized persons<br />
  10. 10. Standards for Documentation<br />Federal regulations-Medicare and Medicaid<br />State and Federal regulations – JCAHO<br />Professional standards – ANA<br />Facility policies- charting techniques and responsibilities<br />
  11. 11. Legibility<br />All charting should be easy to read<br />Reduces errors<br />May be used in court years after care given<br />
  12. 12. Factual<br />Descriptive, objective information<br />Decreases misinterpretation<br />Do not use “seems”, “appears”, “apparently”, “good” “well”<br />Subjective information is documented with client’s own words in quotations<br />No opinions<br />
  13. 13. Complete and Concise<br />Thorough, exact, brief, and NO blah, blah, blah blah<br />Clear and succinct<br />Eliminate irrelevance<br />Short and to the point (long notes difficult to read)<br />Too abbreviated gives impression of being hurried and incomplete<br />
  14. 14. Timeliness<br />Delay in reporting can result in serious omissions and delays in care<br />Late entries may be interpreted as negligence<br />Certain things must be reported at time of occurrence<br />Routine activities need not be charted immediately <br />Military time used<br />No leaving until important information recorded<br />Avoids errors and duplication of care<br />
  15. 15. Accurate<br />Reliable and precise<br />Exact measurements when possible<br />Use only accepted abbreviations<br />Spell correctly<br />
  16. 16. More accuracy<br />No charting for someone else<br />Student’s notes are countersigned by person who assured care was given<br />Descriptive entries signed with full name and status (first initial, last name, and title)<br />
  17. 17. Guidelines for Documentation and Reporting<br />Certain abbreviations not acceptable<br />Abbreviations used<br />
  18. 18. Organization<br />Logical format and order<br />Chronological flow of events<br />
  19. 19. Chart Components<br />Data base<br />Assessment data<br />Problems list<br />Care plan<br />Progress notes<br />Narrative<br />Flow sheets<br />Discharge planning summaries<br />
  20. 20. Documentation Methods<br />Problem oriented medical record<br />S.O.A.P. or S.O.A.P.I.R<br />P.I.E.<br />Source records<br />Charting by exception<br />Flow sheets<br />Focused charting<br />D.A.R.<br />
  21. 21. Problem Oriented Medical Record<br />Focus on patient’s problems<br />Follows the nursing process<br />Organized by problems or diagnoses<br />Coordinated care<br />
  22. 22. Advantages of POMR<br />Easy to retrieve information and follow progress<br />Easy to monitor for QA purposes<br />SOAP notes establish structure that reflects what nurses do <br />
  23. 23. PIE Charting<br />PIE<br />Daily assessment data appears on flow sheets<br />Continuing problems documented daily<br />Focuses exclusively on single client problem<br />
  24. 24. Source Records<br />Each discipline has a separate section of the chart for recording<br />Can easily locate proper section<br />Examples: admission sheet, physician's order sheet, history and physical, flow sheets, nurses notes, medication record<br />
  25. 25. Charting by exception<br />Reduces repetition<br />Clearly defined standards of practice and predetermined criteria<br />Nurses documents only significant findings or exceptions<br />Preventive and wellness-focused functions not documented<br />
  26. 26. Focus Charting - DAR<br />Easily understood and adaptable to most settings<br />Reflects analysis and conclusions<br />Does not indicate problem assessment<br />
  27. 27. Standardized Care Plans<br />Pre-printed and established guidelines for clients with similar problems<br />Improved continuity<br />Less time to document<br />Inhibits unique or individualized therapies<br />
  28. 28. Writing the Nursing Care Plan<br />Prioritize problems<br />ABC’s<br />Maslow<br />Problems perceived by patient<br />
  29. 29. Formats<br />5 columns<br />Assessment data or defining characteristics<br />Diagnosis<br />Goals/outcomes<br />Interventions<br />Evaluation<br />Concept Map<br />Same five components linked by rationales<br />Better indicates process of critical thinking<br />
  30. 30. Critical Pathways<br />Documentation tool to integrate standards of care for multiple disciplines<br />List problems, key interventions, expected outcomes, expected timelines<br />Attempt to control and decrease length of stay<br />
  31. 31. Discharge Summaries<br />Multidisciplinary involvement is required by HCFA<br />Client leaves hospital in timely manner with the necessary resources<br />Client signs original for chart and takes copy home<br />
  32. 32. Kardex<br />Information<br />Medication<br />IV’s<br />Treatments<br />Diagnostic procedures<br />Allergies<br />Data <br />Problem list<br />
  33. 33. Computer Documentation<br />Saves time in storage and retrieval<br />Information is permanent<br />Various departments can coordinate information<br />Can be used at the bedside<br />
  34. 34. Protocol Charting<br />Newest method<br />Primary use in outpatient care<br />Written for use as a references or guide for care<br />Individualized, current, according to intended purpose<br />