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DOCUMENTATIONDEFINITION

Nursing documentationis a vital component of safe, ethical and effectivenursingpractice, regardless of the context of practice or whether thedocumentationis paper-based or electronic.

PURPOSES OF DOCUMENTATIONEvidence of the care provided.Evidence of quality care.Evidence of necessary and ordered care.Impact on regulatory requirements, reimbursement and litigation;

3Professional responsibilityAccountabilityCommunicationEducationResearchSatisfaction of Legal and Practice standardsReimbursement

Why is clinical documentation important?

Documentation is critical for patient careServes as a legal document Quality ReviewsValidates the patient care providedGood documented medical records reduce the re-work of claims processingCompliance with CMS, Tricare and other payers regulations and guidelinesImpacts coding, billing and reimbursement

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Principles of Documentation

Complete and legibleAll entries should be dated and authenticated by physician/providerDocumentation of each patient encounterDate & Reason for the encounterAppropriate H&P and prior diagnostic test resultsReview of lab, x-ray data and other ancillary servicesAssessment and Plan of Care (discharge plan)Codes reported should reflect the documentation

Principles of Documentation

Past & present diagnoses should be accessible to physician (treating or consulting)Reason for and results of x-ray, labs should be documentedRelevant health risk factors should be identifiedDocumentation should supportDiagnosis and describe the patients treatment

Principles of Documentation

Patients progress notes should includeChange in diagnosisResponse to treatmentChange in treatmentPatient non-compliance

Discharge Plan/Plan of Care should includeTreatments and medicationsFrequency of medication & dosageAny ReferralsDischarge instructions for follow-up

ELEM ENTS OF EFFECTIVE CHARTINGDate and timeOrder as given by the physicianSignature beginning with t.o. (telephone order)Physicians nameNurses signaturePhysician must countersignAccurate nursing documentation canprevent a lawsuit!

Documentation must be: TIMELY, ACCURATE& COMPLETEPROTECT Y OUR PRACTICE

Sign Your Note and Include Your CredentialsRecord your full name, credentials and jobtitle in the appropriate section on forms.Your signature must be in cursive.Take the time to sign your name legiblyWhy is clinical Documentation Important?

Improved quality of care Correct, complete, accurate documentation impacts patients, physicians and MTFsAll clinicians are responsible for documenting the treatment and outcomes of the patientDocumentation is used for clinical research and education Supports diagnoses and procedures that were billedImpacts reimbursementCompliance with CMS regulations

Documenting a Telephone Order from a PhysicianIndicate date/time order was receivedDocument order as stated by physicianRead the written order back to the physician to verify accuracyDocument under the order RBO (read back order) and the recorders initialsSign order: v.o. Dr. Jones / Kay Smith RNPlace a sign here sticker next to orderFlag the record green for a regular order and red for a STAT order for the secretary

Nurses NotesUsed to document:

Clients condition, problems, and complaints.

Interventions.

Clients response to interventions.

Achievement of outcomes.

Example:

Pain: 11:00 a.m., Resident complains of leftknee pain 7/10, dull and throbbing, facialgrimacing and moaning with movement.Treatment: 11:10 a.m. Tylenol #3, i tab p.o.per order given and pillow placed betweenresidents knees.Response: 12:00 resident reports left kneepain is improved, dull ache 2/1Chronology: Date and TimeDate and time.Yeara.m. or p.m.Do not chart in blocks of time such as 0700 to1500.Late entry:"late entry for _______" to designate the timeof the events or observations documented.Chart important information from visits byphysicians or other health care team memberssuch as dietician, social worker, hospice, etc.Chart as soon as possible after giving care.Chart the resident's subjective data includingwhat the resident perceives and the way theyexpress it. Use direct quotes when possible using quotation marksIf you don't give a medication as ordered,circle the time and document the reason forthe omission.Include important information rememberedlater as a "late entry", noting the date andtime of the late entry.If information on a pre-printed form does notapply to your client, write NA for "notapplicable" rather than leaving it blank.Incident ReportsThe documentation of any unusual occurrence or accident in the delivery of client care, such as falls or medication errors.Discharge SummaryHighlights clients illness and course of care. Includes:Clients status at admission and discharge.Brief summary of clients care.Intervention and education outcomes.Resolved problems and continuing care needs.Client instructions regarding medications, diet, food-drug interactions, activity, treatments, follow-up and other special needs.

Thank you