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    Documentation

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    Documentation Principles

    Comprehensive and flexible

    Quality and continuity

    Track patient outcomes

    Reflect current standards

    Patient identification on every page of therecord

    Date, time and name/initials, title of the

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    Client Record

    Permanent legal document

    Provides an ongoing account of care

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    Purpose of Records

    Communicate information accurately, effectively

    and in a timely fashion.

    Financial billing. Education.

    Assessment.

    Research. Auditing.

    Legal record.

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    JCAHO Requirements

    Assessment of needs

    Physical

    Psychosocial

    ENVIROMENTAL

    Self care

    Client education

    Discharge plan

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    JCAHO Requirements

    Evaluation of outcomes

    Response to treatment

    Teaching

    Preventive care

    Client status

    Degree of progress

    Family involvement

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    Guidelines For Documentation

    Factual

    Accurate

    Complete

    Current

    Organized

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    Inaccurate Example

    Pt c/o stomach ache. Returned from x-ray 2

    hours ago. Dr. Smith called for change in

    medication order. Ate small amount ofbreakfast. No relief from pain medication.

    Up walking in hall, tolerated well.

    Discharge planner in to talk with familyprior to going to x-ray.

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    Accurate Example

    C/o abd. pain 4/10 RUQ for two hours

    becoming increasingly worse despite food

    and fluids. Position change and walkinghave not helped. Similar to previously dx

    gallbladder pain. Denies n/v/d or other

    symptoms. Declines pain meds at this time.VS WNL. I to call if became worse.

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    Record Keeping Forms

    Nursing history (HX)

    Graphic or flow sheet

    Medication administration record

    Nursing KARDEX

    Acuity recording systems Standardized care plans

    Discharge summary

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    Narrative Documentation

    Problem oriented medical records (PMOR)

    Database

    Problem list

    Nursing care plan

    Progress note

    Source records

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    Progress Notes

    Soap(IE)

    Subjective

    Objective

    Assessment

    Plan

    INTERVETNION

    Evaluation

    Pie

    Problem, intervention, evaluation

    Dar:

    Data, action, response

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    CHARTING BY EXCEPTION:

    All Standards Are Met Unless

    Otherwise Documented Reduces repetition and time

    Shorthand for normal findings and routinecare

    Based on clearly defined standards and

    criteria Predefined findings

    Predetermined interventions

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    Consequences Of Inadequate

    Documentation Fragmented care

    Repetition of tasks Delayed therapy

    Omitted therapy

    Delayed recovery

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    Other Forms of Communication

    Team meetings

    -Multidisciplinary team members share

    information-Members identify problems and solutions

    Consultation

    -One professional gives advice to another

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    Patient Report

    Nurse to nurse report when providers

    change.

    Nurse to nurse report at change of shift.

    Nurse to provider report for change of

    condition or for instruction.

    Diagnostic reports from diagnostic

    departments (x-ray, lab, etc.).

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    Long Term Care Documentation

    OBRA act

    Documentation

    Often done on flow sheets Less frequently

    Caregiver qualifications

    Assessments Individualized care plans

    Nursing care must be justified by the documentation

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    Computerized Documentation

    Legal risk of breaches of confidentiality

    Charting errors so nothing is deleted


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