Documenting the Nursing Process NUR 104 1 Otten403

Documenting the Nursing Process NUR 104 1 Otten/403

If it’s not charted…. . It was never done…. 2 Otten/403

Documenting the Nursing Process JCAHO Standard: Patient-Specific Data/Information IM. 7. 1 A medical record is initiated and maintained for every individual assessed or treated. The medical record incorporates information from subsequent contacts between the patient and the organization. 3 Otten/403

Documenting the Nursing Process JCAHO Standard: Patient-Specific Data/Information IM. 7. 2 The medical record contains sufficient information to identify the patient, support the diagnosis, justify the treatment, document the course and results accurately, and facilitate continuity of care among healthcare providers. 4 Otten/403

Role of Documentation A requirement for accreditation A legal requirement A record of the use of the nursing process for the delivery of individualized client care 5 Otten/403

Role of Documentation Assessment is recorded in the client history or database. Identification of client needs and the planning of client care recorded in the plan of care. Implementation of the plan is recorded in the progress notes and /or flow sheet. Evaluation of care may be documented in the progress notes and/or plan of care. 6 Otten/403

Chart/Client Record Include all significant events Be clear and objective Reflect progress toward outcomes 7 Otten/403

Purposes of client record 7 Functions Staff documentation Evaluation Relationship monitoring Reimbursement Legal documentation Accreditation Training and supervision 8 Otten/403

Importance Staff Communication Colleague-to-colleague Among nurses Between the nursing staff and other healthcare providers 9 Otten/403

Evaluation For the purposes of review, the medical record should: Be written to facilitate an assessment of the care provided Serve as a method of tracking the client’s response to treatment Be a means for evaluating the quality of care 10 Otten/403

Relationship Monitoring Nurse/client relationship is a therapeutic relationship built on a series of interactions. Notes detailing observations and monitoring of the client’s interactions are an important component of nursing care. 11 Otten/403

Reimbursement The medical record provides proof of services. Absence of such documentation may result in termination of funding or treatment. 12 Otten/403

Legal Documentation All aspects of the medical record may be important for legal documentation Notations need to be— ◦ written in permanent ink/computer-entered ◦ specific about date and time (military time) ◦ signed by the person making the entry 13 Otten/403

Legal Documentation An error must be— crossed out with one line still legible identified as an “error” initialed by the author White-outs are not acceptable 14 Otten/403

Accreditation JCAHO standards: “Nursing care data related to patient assessments, nursing diagnoses, and/or patient needs, nursing interventions, and patient outcomes are permanently integrated into the medical record. ” Progress notes must be completed on schedule and in a way that facilitates data retrieval 15 Otten/403

Notes must give the reader a clear picture of what occurred with the client To ensure clarity, use descriptive (or observational) statements Avoid use of judgmental language 16 Otten/403

Judgmental Language Statements of opinion Open to varying interpretation Lack supporting data 17 Otten/403

Judgmental Language Types of judgmental statements include phrases that: Make reference to undefined time periods Refer to undefined quantities Refer to qualities Fail to specify any objective basis for the judgment made 18 Otten/403

Undefined Periods of Time Statements that refer to undefined periods of time without clarification may leave the statement unclear and judgmental. 19 Otten/403 Watch for words such as: some a lot enough many a great deal very little too much

Qualities Slang words are unclear and should not be contained in a professionally written note. 20 Otten/403 Watch for words such as: hyped-up loose spaced-out pushy cool bummed tanked-up crazy

Watch for words such as: friendly attentive aloof unhappy excited 21 Otten/403 apathetic enthusiastic bored proud

Descriptive Language Contains observations only Avoids statements that are evaluative or judgmental Contains measurable periods of time Contains measurable quantities Provides a basis or rationale for qualities named in the note 22 Otten/403

Content of Note/Entry As specific and accurate as possible Correct grammar and spelling Legible writing Abbreviations used cautiously or not at all 23 Otten/403

Content of Note/Entry Concise, short, succinct sentences or phrases Redundancy avoided Consistent in style and format 24 Otten/403

Findings to document at time of occurrence Critical changes in VS Meds and treatments Prep for a test or surgery Critical change in status Admission—nursing hx must be completed on admission to the nursing unit Discharge Transfer Death 25 Otten/403

Format of note entry may vary— Block notes, with a single entry covering an entire shift Narrative--storylike POMR--Problem-oriented medical record system Focus charting—viewing the client from a positive rather than a problem-oriented perspective 26 Otten/403

SOAP—subjective, objective, assessment, plan DAR—data, action, response PIE—Problem, intervention, evaluation Standardized forms Flow sheets 27 Otten/403

Most common documentation omissions Administration of drug Effect of treatment Recording of bowel movements 28 Otten/403

Change of shift report Nurses report information about their assigned clients to the nurses working on the next shift Provide continuity of care among nurses who are caring for a client Oral in person, tape, walking/rounds 29 Otten/403

Telephone report Change in condition Lab reports Dx test info 30 Otten/403

Unclear communication leads to errors Mixed messages: “Start the coumadin today at 5” “Give a GI cocktail to the patient in room 4” Distractions interrupting follow through Order documentation 31 Otten/403

SBAR Clear communication accepting responsibility for what is sent and received Organized communication Anticipate the team member’s needs & workload Shared model Leads to action by empowering others with specific information 32 Otten/403

What if…you are the captain on the ship and you are called in the middle of the night Captain, I’m sorry I had to call you, well I wasn’t going to but the Sergeant said I should, well this isn’t my fault, but I thought I saw something and then I heard a noise. What do you want me to do? 33 Otten/403

SBAR S: Captain, this is the watch man, we are cruising at 30 knots and I believe the starboard hull hit an iceberg B: We are in northern waters and there are many icebergs present A: I believe we are taking on water R: I recommend we should carefully load the life boats and abandon ship 34 Otten/403

SBAR Situation: I am calling about Mrs. Smith because she has a fever and is not tolerating po’s Background: Mrs. Smith is POD 2 for a TAHBSO and has a temp of 101. 6, BP 105/60, P 103, R 24 and is c/o abd pain increasing since yesterday and has received 2 mg of MS every 2 hrs today. Abd exam shows mild rebound, tenderness and guarding 35 Otten/403

SBAR Assessment: I am concerned about a perforation Recommendation: I would like you to come by and examine her as I am concerned she may need to return to the OR 36 Otten/403

SBAR: Situation My name is ________ I am calling about <Pt. and location> Admitted for <diagnosis> The problem is _______ Vital signs are ________ Baseline VS are -------- 37 Otten/403

S BAR: Background Remember the person you are speaking to may know nothing about the patient Restricted work hours Cross-coverage The patient was admitted (when) for (diagnosis) This problem has already been evaluated with these tests: _________ Meds, allergies, IV fluids, latest labs 38 Otten/403

SB AR: Assessment I think the problem is: (cardiac, respiratory, neuro, infectious) or I don’t know what is wrong, bus she/he is getting worse or The patient appears unstable 39 Otten/403

SBA R: Recommendation I suggest you: Transfer to ICU Work up for an infection Come to see the patient immediately Get a _____ order (med, ABG, lab) Tell me what to watch for and when to call you back. 40 Otten/403