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Kelli Shugart RN,MS
Documentation- written or typed, legal record of all pertinent interactions with the patient
Contains data used to:Facilitate patient careServe as financial and legal recordHelp in clinical researchSupport decision analysis
Patient Record- is a compilation of a patient’s health information
Joint Commission on Accreditation of Healthcare Organizations (JCAHO)- specifies that nursing care data be implemented into the patient record.Patient assessmentNursing diagnosisPatient needsNursing interventionsPatient outcomes
Aim: complete, accurate, concise, current, factual, and organized data communicated in a timely and confidential manner to facilitate care coordination and serve as a legal document.ContentTimingFormatAccountabilityconfidentiality
Should be:Consistent with professional and agency
standardsCompleteAccurateConciseFactualOrganizedTimelyLegally prudentconfidential
Crucial Omissions Meaningless repetitious entries Inaccurate entries Length of time
ProblemsUndermine nurse’s credibility as a
professional disciplineCause legal problems for the nurse
responsible
All info about patients is considered private or confidential.Written on paperSaved on computerSpoken out aloud
Names Address Telephone number Fax number Social security Reason person is sick or in the hospital, office, or
clinic Treatment Information about PMH
Might be found in:Patient medical recordComputer systemsTelephone callsVoice mailsFax transmissionsE-mails that contain patient infoConversations about patients between
clinical staff
Giving info over phone Discussing a patient in areas where you
can be over heard (elevators/cafeteria) Discussing a patient you are not directly
involved with Leaving patient medical info in a public
area Failing to log off computer Sharing or exposing passwords Improperly accessing, reviewing, and/or
releasing confidential info ………
Workers must undergo HIPPA training and sign confidentiality agreements
Patients have a right to:See and copy their health recordUpdate their health recordGet a list of the disclosures a healthcare
institution has made independent of disclosures made for the purposes of treatment, payment, and healthcare options
Request a restriction on certain uses or disclosures
Choose how to receive health info
Everyone who has access to the record (direct caregivers) is expected to maintain its confidentiality
Most agency grant nursing students access for education purposes….must hold info in confidence…Never use patient’s name when preparing written or oral reports
Agency policy indicates which personnel are responsible for recording on each form in the record…
Policy also indicates order of chart
Policy may indicate frequency to record entries
What to record Manner to identify self
Kelli Shugart, RN, GBCNSally Cabbage Patch, SN, GBCN
Which abbreviations are acceptable– see table 17-2
Communication Diagnostic and therapeutic orders Verbal orders-order must be given
directly by the physician, or nurse practitioner to a registered nurse or registered pharmacist
The only circumstance in which an attending physician, nurse practitioner, or house officer may issue orders verbally is in a medical emergency, when they are present but unable to write the actual order.
The RN who receives the order will:1. Record the orders in the medical record2. Read the order back to verify accuracy3. Date and note the time 4. Record V.O. (verbal orders), name of the
MD who issued the orders, followed by the nurse’s name and title
Example: Give 0.25mg po lanoxin Daily, starting
in Am 9/18/09 V.O. Micheal Smith, MD/Kelli Shugart, RN
It is the responsibility of the physician or nurse practitioner who issued the verbal order to:
1.Review the order for correctness2.Sign the orders with his or her name,
title, and pager number3.Date and note the time he or she signs
the orders It is the responsibility of the unit
secretary and/or the registered professional nurse to see that the orders are transcribed according to procedure
Agency policy must be followed Every T.O. must be repeated back to
ensure that the nurse correctly understands what was ordered.
Must be on an order sheet Co-Signed by physicians within a
specific time Fax orders must be legible and issued
from a credentialed and privileged individual
Follow similar protocol as V.O. (1-3)4.Record T.O. (telephone order) and the full
name and title of the physician or nurse practitioner (NP) who issues the orders.
5.Sign the orders with name and title It is the responsibility of the physician or
NP dictating the orders to sign them as soon as practical. With exception of orders for narcotics, anticoagulants, and antibiotics, which must be signed within 24 hours.
Care Planning Quality review Research Decision analysis Education Legal documentation Reimbursement Historical documentation
Source oriented Records Advantage
Each discipline can easily find and chart data Disadvantage
Data fragmented
Problem-Oriented Medical Record- (POMR)
Example Box 17-3 Advantage
Entire health team works together to determine list of problems
Collaborative plan of care Progress notes clearly focus on patient problems
Major parts of POMR:Defined databaseProblem listCare planProgress notes
SOAP- originated from medical record SOAPE SOAPIE SOAPIER (Intervention, Evaluation,
Response)
PIE- Problem, Intervention, Evaluation- originated from nursing
Example figure 17-2 Does not develop separate plan of care At beginning of each shift patient problems are
identified, numbered and documented in progress notes, and worked up using PIE format
Resolved problems are dropped Advantage
Continuity and saves time (no separate Plan of Care)
Disadvantage Nurses have to read all nursing notes to
determine problems and planned interventions
Focus charting Focus may be on a patients
Strength Problem Need
Topics may includePatient concerns and behaviorsTherapies and responsesChanges in conditionSignificant events
FocusNarrative section uses the Data, Action,
Response (DAR) format- example figure 17-3
AdvantageHolistic emphasis on patientEase of charting
DisadvantageSome nurses argue that the DAR categories
are artificial and not helpful when documenting care
Charting by exception (CBE)- figure 17-4 Advantages
Decreased charting time Greater emphasis on significant data Easy retrieval of significant data Timely bedside charting Standardize assessment Greater interdisciplinary communication Better tracking of important patient responses Lower cost
Disadvantage – limited usefulness in response to negligence claims against nurses
Case Management Model Advantages
CollaborationCommunicationTeamwork among disciplinesEfficient use of time increases quality
DisadvantageWorks for “typical” patient
Case Management ModelCollaborative Pathways/critical
pathways/care mapping –figure 17-5Variance Charting
Personal Health Records (PHRs)
Computerized RecordsGuidelines/strategies for safe computer
charting Never share passwords Don’t leave computer unattended Follow protocol when correcting errors,
“mistaken entry” add correct info, date and initial entry. If wrong chart, write “mistaken entry – wrong chart”.
Never create, delete or change entries Back up files Don’t leave info about patient for others to see Never use email to send protect health info Follow policy for documenting sensitive material
Initial nursing assessment- Database Kardex and Patient Care Summary Plan of Care- student example chapter
14DiagnosisGoalsExpected outcomes Interventions
Critical/collaborative pathways-chapter 14, figure 17-5Abbreviated case management plan
Progress notesSee Table 17-5 for advantages and
disadvantages Flow Sheets
Graphic (clinical) Record24 Hour Fluid Balance RecordMedication Record24 Hour Patient Care Record and Acuity
Charting Forms
Discharge and Transfer Summary Home Healthcare Documentation Long-Term Care Documentation
Potential legal problems—see BOX 17-4, page 381
Reporting – Face to faceTelephone Messengers Written AudiotapedComputer messages
Table 17-6 see advantages and disadvantages
Change of Shift Reports Telephone/telemedicine Reports Transfer and Discharge Reports Report to Family and Significant Others Incident Reports
Basic identifying information about each patient
Current appraisal of each patient’s health status Changes in medical conditions and patient
response to therapy Where patient stands in relation to identified
diagnoses and goals Current orders (nurse and physician) Summary of each newly admitted patient Report on patient transferred or
discharged
Consultations and Referrals Nursing and Interdisciplinary team Care
Conferences Nursing Care Rounds