Documentation and Informatics in Nursing

Entry Into Professional Nursing Summer 2009

Why Document?

Accreditation (TJC)

Reimbursement (DRG’s, Medicare)

Communication (Continuity, education)

Legal (Not documented, not done)

Multi-Disciplinary Communication

Reports-Oral: End of shift Written Record-Chart: Permanent, legal,

healthcare management on-going account

Healthteam: All disciplines, nursing, social workers, discharge planning PT, OT, RT

Documentation

Anything written or printed that is relied on as a record of proof for authorized persons

Reflects quality of care

Provides evidence of healthcare team members care rendered

Purposes of Records

Communication Legal Documentation Financial Billing Education Research Audits-Monitoring

Guidelines for Quality Documentation & Reporting Factual

Accurate

Complete

Current

Organized

Follow TJC Standards

Physical Psychosocial Environmental Self-care Client education Discharge Planning Evaluation of outcomes Nursing Process oriented

Types of Documentation

Narrative POMR Source records Charting by Exception Critical Pathways Record Keeping Forms Acuity Recording Systems Standardized Care Plans Discharge Summary Forms

Types of Documentation

Discharge Summary Forms Home Health Long Term care Computerized

Narrative

Traditional type of nursing charting Story-like, repetitive Time consuming

Problem-Oriented Medical Records

Data organized by problem or diagnosis Ideally all healthcare team members can

contribute to list Coordinated plan of care POMR Components: Database, problem

list, NCP, progress notes

POMR Database

History and physical Nursing admission assessment On-going assessment Labs Radiology reports Record of each hospital visit

POMR Problem List

Holistic needs based on data

Chronological list on front of chart

Dates when problem resolved or new problem occurs

POMR Progress Notes

SOAP/SOAPIE Notes: Subjective data, objective data, assessment, plan, intervention, evaluation

PIE Charting: Problem-Intervention-Evaluation

Focus Charting/DAR-Data (subjective and objective) Action (intervention) Response of Client (evaluation)

Source Records

Chart is so organized that each discipline has own section to record data

Sections can be easily located Disadvantage: Not organized by client

problems Narrative style notes

Charting by Exception

Streamlines documentation Reduces repetition, saves time Short version to document normals, routine

care items Based on established standards Progress note when standard not met Assumes all standards are met unless

otherwise charted Exceptions must be noted

Critical Pathways

Multi-disciplinary care plans used in case management

Key interventions, expected outcomes, time frame

Variances charted and analyzed

Record Keeping Forms

Admission Assessment/Nursing history

Graphic Sheets (Vitals, weights, I&O)

Nursing Kardex

Medication Administration Records

Acuity Reporting Systems

Staffing patterns based on acuity of patients

Numeric rating for interventions Varies per unit and standard Update every 24 hours and justify

Standardized Care Plans

Pre-printed established guidelines Based on health problems Need to modify based on individual

assessment, update and use judgement Standards of care are known, promotes

continuity, staff knowledge

Discharge Summary Forms

DRG’s encourage early discharge, but must ensure good patient outcomes

Necessary resources, Client and family involved in process

Begins at admission Client education integral to process

(food-drug interactions, rehab referrals, medications, disease process)

Home Health

Medicare/Medicaid Guidelines 50% of nursing time is documentation Care witnessed by client and family Good assessment skills Health care team focused Direct care in home Use of laptops for documentation

Long Term Care

Residents not clients Governmental agencies: Many

standards and policies regarding assessments, individualized plan of care

Dept. of Health in each state determines frequency of charting

Skilled Nursing Units

Nursing Informatics

Computer based patient care record Assessments, care plans, MAR’s

physician orders Maintain confidentiality with pass codes,

looking at other records Nursing Information Systems Clinical Information Systems Electronic Medical Record

Reporting

Oral or written Change of shift Nurse to nurse Promotes continuity Report on client health status, care

required for next shift, significant facts, head to toe assessment, pertinent labs, priority needs, treatments, family issues

SBAR Technique for Communication

S- Situation B- Background A- Assessment R- Recommendation

End of Shift Report

Keep professional Avoid judgemental language Include assistive personnel

Telephone Reports

Inform physician of changes Client transfers to different units Result reports from lab or radiology Client transfers to different institutions Info needed: When call made, to whom,

info given Keep clear, accurate, repeat info if

necessary

Telephone Orders

Physician to RN Physician must co-sign within 24 hours Nightime, emergency orders Guidelines and procedure per institution Be careful, precise and accurate with

order Write order as said by physician, repeat

it back

Transfer Reports

Unit to unit report Phone or in person All pertinent data about patient Send all belongings with client Review clothing/belonging list prior to

transfer Transfer Sheet Documentation

Incident Reports

Any event not considered routine (falls, needlesticks, med errors, accidental omissions, visitor injury)

Risk Management will analyze trends Changes in policy/procedure, educational

programs may be related to findings Notify supervisor, physician of incident Nurse who witnesses makes out report Do not assign blame, be objective, facts only

Tips for Documentation

Accurate, timely, thorough, factual, neat Use only approved abbreviations & terms Blue or black ink Always get and give report Focus on a team approach Date, time each entry, do not block chart Document in a timely fashion Follow the nursing process Use appropriate forms

Documentation Tips

Correct errors promptly, using proper technique

Write on every line, leave no spaces Sign each entry with full signature and

correct title Follow institution policy and procedure

for charting Military vs standard time