Download - Documentation Principles[1]
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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