Documentation Fundamentals Unit 13 Documentation Termsof course n

Documentation Terms…of course! n Introduction n Remember, hospitalization is anxiety producing l We must

Documentation Admissions n Introduction n Admitting department n Arrival on unit-what will you do?

Documentation Clothing n Assisting to bed n Prevention of dehumanization n n Anxiety and

Documentation Admissions n Assessment/reporting n Things you will document n Vital Signs n Patient

Documentation n Orientation to facility n Check the orders n Put away personal belongings

Documentation Transfers n Steps to follow n n n Explain to the patient Notify

Documentation Divisional n Other facility n Discharge n l l l l Collect all

Documentation n AMA Type of discharge that occurs against medical advice, there is no

Documentation Charting n Introduction n Reasons that you chart n Communication n. A legal

Documentation n Rules for your charting n Confidentiality!!! n Legibility n Spelling must be

Documentation n Rules for your charting n Always verify n All entries must be

Documentation What information should be charted? n Various styles of charting n Traditional or

Documentation n Examples of chart pages/tabs n Admission or face sheet n Drs. order

Documentation n Examples of chart pages/tabs n Admit, transfer, and discharge forms n Flowsheets

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Documentation Fundamentals Unit 13

Documentation Terms…of course! n Introduction n Remember, hospitalization is anxiety producing l We must understand basic human needs and stages of development l Safety and clear communication is a must! l Discharge planning begins on admission l

Documentation Admissions n Introduction n Admitting department n Arrival on unit-what will you do? n Prepare the bed and unit n Introductions n Note how pt. is admitted n ID band n Treat the pt. with respect

Documentation Clothing n Assisting to bed n Prevention of dehumanization n n Anxiety and apprehension n Fear of the unknown n Fear of changing body image n Care of personal belongings n Clothing n Valuables

Documentation Admissions n Assessment/reporting n Things you will document n Vital Signs n Patient medications n Allergies n Listen to the chief complaint n Teach about specimen collection n Prepare for tests and procedures

Documentation n Orientation to facility n Check the orders n Put away personal belongings n Show them the room n Explain mealtimes n Provide an admission kit n Show them where supplies are n Explain daily routine and services n Share visiting hours and rules Reporting n Charting n

Documentation Transfers n Steps to follow n n n Explain to the patient Notify your supervisor and family Collect patient belongings Prepare paperwork Notify receiving department or facility Make notation in the chart Arrange for transport Notify all other departments Introduce and orient the patient Give report What happens to the chart?

Documentation Divisional n Other facility n Discharge n l l l l Collect all belongings Make sure all instruction is done and charted Help patient pack and dress Financial arrangements Transportation and escort Close the chart. It will be sent to medical records in a complete state Clean the room

Documentation n AMA Type of discharge that occurs against medical advice, there is no discharge order l Try to explain the need for continued medical treatment l Insurance coverage l Form must be signed, with two witnesses signatures l Student nurses do not witness documents ! l

Documentation Charting n Introduction n Reasons that you chart n Communication n. A legal document n Education n Research n Quality assurance n Reimbursement

Documentation n Rules for your charting n Confidentiality!!! n Legibility n Spelling must be accurate n Abbreviations must be correct n Black ink n Corrections n Never chart for someone else n Only chart after the fact n No ditto marks

Documentation n Rules for your charting n Always verify n All entries must be signed n No blank spaces or lines n Be concise n Patient is the subject of entries n Using quotation marks n Words to avoid n Ownership of charts n Use military time

Documentation What information should be charted? n Various styles of charting n Traditional or narrative l Problem oriented or focused l n SOAP n DAR Flowsheets l Assessment sheets l

Documentation n Examples of chart pages/tabs n Admission or face sheet n Drs. order sheet n History and physical n Progress sheet n Graphics n Medication administration sheet n Nurse’s notes n Diagnostic data n Consent forms

Documentation n Examples of chart pages/tabs n Admit, transfer, and discharge forms n Flowsheets n Surgical reports, recovery reports n Nursing care plans n Kardex type forms n Change of shift report You are finished with Fundamentals!