Documentation Purpose of Documentation Provide a written record

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Documentation

Documentation

Purpose of Documentation Provide a written record of the history, treatment, care and response

Purpose of Documentation Provide a written record of the history, treatment, care and response of nursing and medical care Acuity / Staffing Justifies claims for reimbursement May be evidence of care in the court of law If it’s not charted – it didn’t happen!! (CYA!)

Characteristics of Documentation factual accurate complete current or timely organized compliant with current standards

Characteristics of Documentation factual accurate complete current or timely organized compliant with current standards and facility standards

Essentials of Documentation A clear, concise statement of the patient status (including physical, psychological,

Essentials of Documentation A clear, concise statement of the patient status (including physical, psychological, & spiritual) Relevant assessment data (including client/family comments as appropriate) All ongoing monitoring and communications The care/service provided (all interventions, including advocacy, counseling, consultation and teaching) and evaluation of outcomes, including the client’s response and plans for follow up Discharge planning

____________________ HIPAA – Health Information Portability Accountability Act Guarantees patient right to view, obtain

____________________ HIPAA – Health Information Portability Accountability Act Guarantees patient right to view, obtain a copy of the chart, and request chart be amended the record Only those directly caring for the patient will have access to the chart and information regarding the patient

Source oriented vs. Problem oriented Methods for organizing data found in a medical record

Source oriented vs. Problem oriented Methods for organizing data found in a medical record Source oriented records are organized according to the type of data, using a specific section for each. See table 5 -4 in your book for examples of the sections Problem oriented records are organized into one of four categories

Types of Charting 1. Narrative - You must chart the normal and the abnormal

Types of Charting 1. Narrative - You must chart the normal and the abnormal - Should be accurate, brief and complete (succinct) - Do not chart in the future or what you plan to do - Be precise, be specific – give exact size or amount – not little, large etc - Does not have to be a full sentence. Start with a capital letter and end with a period. - Leave out small words such as “a, the” - Never use “I” or “me” in your documentation - If you are charting in the patient’s chart you do not have to use the word “patient” - Use abbreviations – but don’t make them up. Look at Policy and Procedure Manual for a list of acceptable abbreviations. You aren’t texting!!

Narrative Continued - Don’t double chart - Put in quotations what is said. Patient

Narrative Continued - Don’t double chart - Put in quotations what is said. Patient stated, “I am not eating the jello” - WRITE or TYPE LEGIBLY!! - If you document a problem – document what you did about it! - Avoid using the word “normal” - Complete is more important than brief - Use only black ink - Use military time - Chart in chronological order – if documenting a late entry, the time is usually circled and marked “late entry” - Use correct spelling - Leave no blank space – draw a line

Narrative Continued When finished with entry, draw a line to end of line, first

Narrative Continued When finished with entry, draw a line to end of line, first initial, last name and title. Example ---------------------- N. Student, SPN When an error has been made in documentation, draw a line through the error, write mistaken entry or incorrect entry and initials. void then initials -- not error then initials Useful tip--- read over other nurse’s notes while at work or at clinicals

Document it correctly The patient got up to go to the bathroom and was

Document it correctly The patient got up to go to the bathroom and was able to go on her own without any help from anyone. She voided into the specimen pan. I measured 500 ml of very light colored urine that does not have any sediment or particles. She then walked from the bathroom back to her bed by her self. I placed her call light on her bed.

Types of Charting, continued 2. SOAP & SOAPIER Subjective, objective, assessment, plan, intervention, evaluation,

Types of Charting, continued 2. SOAP & SOAPIER Subjective, objective, assessment, plan, intervention, evaluation, revision 3. PIE Charting Problem, Interventions, Evaluation 3. Focus Charting – centers on the patient in a positive perspective Data, Action, Response (DAR) 4. Charting by exception – highlights abnormal data

Types of Charting 5. Computer Assisted Charting - Good. Better communication between departments Information

Types of Charting 5. Computer Assisted Charting - Good. Better communication between departments Information can be retrieved easier Entries can be made at point of care Speeds reimbursement for services - Bad – Reliance on checkbox descriptions More difficult to train Increased potential for HIPAA exposure More problems when down

____________________ Computerized Assisted Charting - Refresh computer often - Chart timely - Do not

____________________ Computerized Assisted Charting - Refresh computer often - Chart timely - Do not share passwords - Never walk away without logging off Remember, a computer password does not give you permission to freely access all medical records!

____________________ Types of Charting - Continued 6. Case Management 7. Flow Charts – tracks

____________________ Types of Charting - Continued 6. Case Management 7. Flow Charts – tracks things that are done frequently – VS, Weights, I&O 8. Combination of several different types of charting --Know your facility’s requirements--

Documentation FYI’s Charting must be objective Avoid subjective comments When charting subjective data –

Documentation FYI’s Charting must be objective Avoid subjective comments When charting subjective data – use patient states “… Time generally documented in military time or 24 hour clock.

What not do do… When documenting, avoid generalizations or vague phrases/expressions which cannot be

What not do do… When documenting, avoid generalizations or vague phrases/expressions which cannot be supported such as: status unchanged, had a good day, slept well, is up and about, or looks good The following words demonstrate uncertainty and suggest that a nurse is unsure of the facts: appears, seems, apparently, could, might, assume An exception may be when the supposed fact cannot be verified. For example, “appears to be sleeping” may be appropriate as the only means to verify would be to wake the patient and ask if he/she was actually asleep.

Other Do’s & Don’ts Don’t chart a symptom without an action Don’t chart what

Other Do’s & Don’ts Don’t chart a symptom without an action Don’t chart what someone else did/heard/said/… Don’t chart what you are going to do Don’t blame or make excuses in your charting Don’t make accusations Don’t make assumptions or judgements Don’t ever alter a record Don’t use imprecise terms (appears, good, well) • Do Write legibly • Do chart factually & accurately • Do chart normal findings when charting • Do chart preventive measures (side rails) • Do chart what you report to others

Misc FYI Nursing Process, Plan of Care, Care Plan – Assessment, Plan, Interventions, and

Misc FYI Nursing Process, Plan of Care, Care Plan – Assessment, Plan, Interventions, and Evaluation The chart is the legal property of the hospital or facility. The patient has the legal right to the document. Kardex – 1 pg summary – Includes medical diagnosis, allergies, orders, treatments, and care – may change frequently Face Sheet – Includes name, address, insurance, next of kin

DOCUMENTATION FUNNIES Both breasts are equal and reactive to light and accommodation. She is

DOCUMENTATION FUNNIES Both breasts are equal and reactive to light and accommodation. She is numb from her toes down. Exam of genitalia was completely negative except for the right foot. The patient was to have a bowel resection. However, he took a job as stockbroker instead. When she fainted, her eyes rolled around the room. Examination reveals a well-developed male lying in bed with his family in no distress. She has no rigors or chills but her husband says she was very hot in bed last night. She can’t get pregnant with her husband, so I will work her up. She was examined, X-rated and sent home. The patient states there is a burning pain in his penis which goes to his feet. On the second day the knee was better and on the third day it had completely disappeared. The patient has been depressed ever since she began seeing me in 1983. I will be happy to go into her GI system, she seems ready and anxious.

More Documentation Funnies She slipped on the ice and apparently her legs went in

More Documentation Funnies She slipped on the ice and apparently her legs went in separate directions in early December. The patient experienced sudden onset of severe shortness of breath with a picture of acute pulmonary edema at home while having sex which gradually deteriorated in the emergency room. Patient has chest pains if she lies on her left side for over a year. He had a left-toe amputation one month ago. He also had a left-knee amputation last year. By the time he was admitted, his rapid heart had stopped, and he was feeling much better. The patient is a 79 -year-old widow who no longer lives with her husband. The patient refused an autopsy. Many years ago the patient had frostbite of the right shoe. The patient left the hospital feeling much better except for her original complaints “unresponsive and in no distress” “nonverbal, non-communicative and offers no complaints” “He is allergic to wives. ”