Kelli Shugart RN,MS

Documentation- written or typed, legal record of all pertinent interactions with the patient

Contains data used to:Facilitate patient careServe as financial and legal recordHelp in clinical researchSupport decision analysis

Patient Record- is a compilation of a patient’s health information

Joint Commission on Accreditation of Healthcare Organizations (JCAHO)- specifies that nursing care data be implemented into the patient record.Patient assessmentNursing diagnosisPatient needsNursing interventionsPatient outcomes

Aim: complete, accurate, concise, current, factual, and organized data communicated in a timely and confidential manner to facilitate care coordination and serve as a legal document.ContentTimingFormatAccountabilityconfidentiality

Should be:Consistent with professional and agency

standardsCompleteAccurateConciseFactualOrganizedTimelyLegally prudentconfidential

Crucial Omissions Meaningless repetitious entries Inaccurate entries Length of time

ProblemsUndermine nurse’s credibility as a

professional disciplineCause legal problems for the nurse

responsible

All info about patients is considered private or confidential.Written on paperSaved on computerSpoken out aloud

Names Address Telephone number Fax number Social security Reason person is sick or in the hospital, office, or

clinic Treatment Information about PMH

Might be found in:Patient medical recordComputer systemsTelephone callsVoice mailsFax transmissionsE-mails that contain patient infoConversations about patients between

clinical staff

Giving info over phone Discussing a patient in areas where you

can be over heard (elevators/cafeteria) Discussing a patient you are not directly

involved with Leaving patient medical info in a public

area Failing to log off computer Sharing or exposing passwords Improperly accessing, reviewing, and/or

releasing confidential info ………

Workers must undergo HIPPA training and sign confidentiality agreements

Patients have a right to:See and copy their health recordUpdate their health recordGet a list of the disclosures a healthcare

institution has made independent of disclosures made for the purposes of treatment, payment, and healthcare options

Request a restriction on certain uses or disclosures

Choose how to receive health info

Everyone who has access to the record (direct caregivers) is expected to maintain its confidentiality

Most agency grant nursing students access for education purposes….must hold info in confidence…Never use patient’s name when preparing written or oral reports

Agency policy indicates which personnel are responsible for recording on each form in the record…

Policy also indicates order of chart

Policy may indicate frequency to record entries

What to record Manner to identify self

Kelli Shugart, RN, GBCNSally Cabbage Patch, SN, GBCN

Which abbreviations are acceptable– see table 17-2

Communication Diagnostic and therapeutic orders Verbal orders-order must be given

directly by the physician, or nurse practitioner to a registered nurse or registered pharmacist

The only circumstance in which an attending physician, nurse practitioner, or house officer may issue orders verbally is in a medical emergency, when they are present but unable to write the actual order.

The RN who receives the order will:1. Record the orders in the medical record2. Read the order back to verify accuracy3. Date and note the time 4. Record V.O. (verbal orders), name of the

MD who issued the orders, followed by the nurse’s name and title

Example: Give 0.25mg po lanoxin Daily, starting

in Am 9/18/09 V.O. Micheal Smith, MD/Kelli Shugart, RN

It is the responsibility of the physician or nurse practitioner who issued the verbal order to:

1.Review the order for correctness2.Sign the orders with his or her name,

title, and pager number3.Date and note the time he or she signs

the orders It is the responsibility of the unit

secretary and/or the registered professional nurse to see that the orders are transcribed according to procedure

Agency policy must be followed Every T.O. must be repeated back to

ensure that the nurse correctly understands what was ordered.

Must be on an order sheet Co-Signed by physicians within a

specific time Fax orders must be legible and issued

from a credentialed and privileged individual

Follow similar protocol as V.O. (1-3)4.Record T.O. (telephone order) and the full

name and title of the physician or nurse practitioner (NP) who issues the orders.

5.Sign the orders with name and title It is the responsibility of the physician or

NP dictating the orders to sign them as soon as practical. With exception of orders for narcotics, anticoagulants, and antibiotics, which must be signed within 24 hours.

Care Planning Quality review Research Decision analysis Education Legal documentation Reimbursement Historical documentation

Source oriented Records Advantage

Each discipline can easily find and chart data Disadvantage

Data fragmented

Problem-Oriented Medical Record- (POMR)

Example Box 17-3 Advantage

Entire health team works together to determine list of problems

Collaborative plan of care Progress notes clearly focus on patient problems

Major parts of POMR:Defined databaseProblem listCare planProgress notes

SOAP- originated from medical record SOAPE SOAPIE SOAPIER (Intervention, Evaluation,

Response)

PIE- Problem, Intervention, Evaluation- originated from nursing

Example figure 17-2 Does not develop separate plan of care At beginning of each shift patient problems are

identified, numbered and documented in progress notes, and worked up using PIE format

Resolved problems are dropped Advantage

Continuity and saves time (no separate Plan of Care)

Disadvantage Nurses have to read all nursing notes to

determine problems and planned interventions

Focus charting Focus may be on a patients

Strength Problem Need

Topics may includePatient concerns and behaviorsTherapies and responsesChanges in conditionSignificant events

FocusNarrative section uses the Data, Action,

Response (DAR) format- example figure 17-3

AdvantageHolistic emphasis on patientEase of charting

DisadvantageSome nurses argue that the DAR categories

are artificial and not helpful when documenting care

Charting by exception (CBE)- figure 17-4 Advantages

Decreased charting time Greater emphasis on significant data Easy retrieval of significant data Timely bedside charting Standardize assessment Greater interdisciplinary communication Better tracking of important patient responses Lower cost

Disadvantage – limited usefulness in response to negligence claims against nurses

Case Management Model Advantages

CollaborationCommunicationTeamwork among disciplinesEfficient use of time increases quality

DisadvantageWorks for “typical” patient

Case Management ModelCollaborative Pathways/critical

pathways/care mapping –figure 17-5Variance Charting

Personal Health Records (PHRs)

Computerized RecordsGuidelines/strategies for safe computer

charting Never share passwords Don’t leave computer unattended Follow protocol when correcting errors,

“mistaken entry” add correct info, date and initial entry. If wrong chart, write “mistaken entry – wrong chart”.

Never create, delete or change entries Back up files Don’t leave info about patient for others to see Never use email to send protect health info Follow policy for documenting sensitive material

Initial nursing assessment- Database Kardex and Patient Care Summary Plan of Care- student example chapter

14DiagnosisGoalsExpected outcomes Interventions

Critical/collaborative pathways-chapter 14, figure 17-5Abbreviated case management plan

Progress notesSee Table 17-5 for advantages and

disadvantages Flow Sheets

Graphic (clinical) Record24 Hour Fluid Balance RecordMedication Record24 Hour Patient Care Record and Acuity

Charting Forms

Discharge and Transfer Summary Home Healthcare Documentation Long-Term Care Documentation

Potential legal problems—see BOX 17-4, page 381

Reporting – Face to faceTelephone Messengers Written AudiotapedComputer messages

Table 17-6 see advantages and disadvantages

Change of Shift Reports Telephone/telemedicine Reports Transfer and Discharge Reports Report to Family and Significant Others Incident Reports

Basic identifying information about each patient

Current appraisal of each patient’s health status Changes in medical conditions and patient

response to therapy Where patient stands in relation to identified

diagnoses and goals Current orders (nurse and physician) Summary of each newly admitted patient Report on patient transferred or

discharged

Consultations and Referrals Nursing and Interdisciplinary team Care

Conferences Nursing Care Rounds