Paper Charting Essentials

Sahiris Aybar, BS, RNOld Dominion University

sayba001@odu.edu

“But why can’t we just go electronic?!” Research shows that only 2% of behavioral health

settings are utilizing the Electronic Health Record method.

Electronic health software today allows for safety alerts, as well as exposes safety hazards and contradictions as they occur.

However, the transition from paper to electronic is costly and making the minimal return on investment cost a barrier to small practices(APA, 2014)

Therefore it is vital we utilize appropriate paper charting methods until this organization has fully transitioned over to electronic medical records (EMR) in order to decrease errors.

The purpose of this training is to provide the Staff Psychiatric-Mental Health Registered Nurse with the information necessary to competently transcribe, implement, and identify errors in handwritten orders.

The Purpose

The goal of this teaching session is to improve patient outcomes by preventing knowledge deficit related medical errors associated with paper charting.

The Goal

Following this teaching session you will be able to:

Define the standards of care of the Psychiatric-Mental Health Registered Nurse (PMH-RN) from the “Scope and Standards of practice” identified by the ANA

Recall the 8 basic components of a drug order outlined by the Institution of Safe Drug Practices (ISDP)

List other pertinent information that should be included on the order and MAR page outlined by ISDP

Course Objectives

Following this teaching session you will be able to:

Demonstrate the ability to transcribe an order from the chart to the paper MAR according to protocol, including all accessory pertinent patient information

Demonstrate proper ability to understand and transcribe telephone and verbal orders in the chart followed by transcription of the order on the MAR page according to protocol

Course Objectives Continued

Following this teaching session you will be able to:

Identify the importance of being able to use critical thinking to assess orders for potential adverse reactions as per the ISDP and the Joint Commission “Look alike sound alike” drug publication

Accept and appraise the implications of using safe medication practices and express any concerns or questions regarding this focus area.

Demonstrate proper ability to understand and transcribe telephone and verbal orders in the chart followed by transcription of the order on the MAR page according to protocol

Course Objectives Continued

So Let’s Get Started!

Our specialty’s standards are divided into two parts. The first set of standards are known as standards of practice. These standards are based off the fundamental nursing process and include: assessment, diagnosis, outcome identification, planning, implementation of care, and evaluation

The next set is known as standards of professional

performance. Professional performance standards are focused around the psychiatric-mental health registered nurses’ area of concern and includes: quality of practice, education, evaluation, collegiality, collaboration, ethics, research, resource utilization, and leadership (ANA, 2007, p. 6)

Standards and Scope of Practice : Standards of the PMH-RN

PMH-RNs are commonly recognized as registered nurses who are educationally prepared and licensed to practice in their states. These RNs exhibit the competence, knowledge, skills and abilities required to treat those with psychiatric and mental health issues. Those who have advanced practice subspecialties are expected to have a current second license and/or certification as applicable.

The scope of practice for a PMH-RN varies by state however traditional authorities that are commonly granted to the nurse include the ability to: provide interventions such as health promotion and maintenance, admission, evaluation and discharge screenings, case management, implementation of milieu therapy, promoting self-care activities, implementing psychobiological therapies, crisis intervention, and psychiatric rehabilitation.

Standards and Scope of Practice : Scope of Practice of the PMH-RN

Complete listing of Standards of Care as outlined by ANA

Figure 1. The detailed descriptions of the standards of care identified for the Psychiatric-Mental Health nurse. Adapted from “Scope and Standards of Practice” by M. A. Boyd, 2008, Psychiatric Nursing Contemporary Practice, p. 5. Copyright 2008 by Wolters Kluwer Health.

The Massachusetts Coalition for the Prevention of Medical Errors publication Safety First Alert

(2001) confirmed during its issue summarizing the USP medication Error Reporting Program the

significance of proper transcription.

◦ It was revealed that 25% of the medication errors found during this study occurred during the administration

phase of the medication use process.

Although the administration process may vary between settings, the basic components the

competent RN should be able to demonstrate is universal; transcribing, retrieving and administering

the dose, and monitoring.

◦ We as care takers, healers and health facilitators, need to ensure that we are properly trained on the

fundamental order components.

This will ultimately decrease medication errors and improve patient outcomes!

Setting the Standard

1. DATE AND TIME THE ORDER IS WRITTEN

2. DRUG NAME (GENERIC OR TRADE)

3. DRUG DOSAGE

4. ROUTE OF ADMINISTRATION

8 Basic Components of a Drug Order

5. FREQUENCY AND DURATION OF ADMINISTRATION.

6. ANY SPECIAL INSTRUCTIONS FOR WITHHOLDING OR ADJUSTING DOSAGE BASED ON EFFECTIVENESS OR LABORATORY RESULTS

7. PHYSICIAN OR PROVIDER’S SIGNATURE OR NAME IF TELEPHONE ORDER (T.O.)/VERBAL ORDER (V.O.), WRITTEN ORDER / READ BACK VERIFIED

8. SIGNATURE(S) OF LICENSED PRACTITIONER TAKING WRITTEN ORDER, TELEPHONE ORDER, OR VERBAL ORDER.

WHEN A COMPONENT IS MISSING FROM THE DRUG ORDER, THE DRUG ORDER IS INCOMPLETE AND YOU SHOULD NOT ADMINISTER

THE MEDICATION UNTIL CLARIFICATION IS OBTAINED!!

8 Basic Components of a Drug Order

The 6 Rights are: The right medication, the right dose, to

the right patient by the right route at the right time for the

right reason.

The RN must double-check that the order he/she is taking

and transcribing from the M.D. displays no potential for

error when cross-checking the order with the 6 rights.

Massachusetts Coalition for the Prevention of Medical Errors January 2001

The 6 Right of Drug Administration

Ensure that patient information is current and available

consistently to all health care providers.

Include patient information such as age, weight, height

(as needed to calculate body surface area), date of birth

and known allergies.

Know the treatment plan and the prognosis.

Massachusetts Coalition for the Prevention of Medical Errors January 2001

The Right Patient at the Right Time

Ensure that the drug information is current and readily available.

Know the indications and appropriate dosing for the medication prescribed. If you are not sure,

look it up or call the pharmacy.

Know the precautions and contraindications.

Know the expected outcomes after the use of the medication.

Know about potential adverse reactions.

Know the drug/drug and drug/food interactions.

Know how to minimize the effects of an adverse reaction.

Know how the drug should be administered and stored.

Have pharmacy identify patient's own medications and provide drug fact sheets prior to

medication administration.

The Right Drug, Dose, Route, and Reason.

Lack of information and appropriate checks when dealing with high alert drugs have

also been significantly correlated to medication errors and adverse drug events (ADE). It

is important to follow the protocol which guides us through the critical steps in the drug

administration process and recommends monitoring parameters.

What can you do to minimize the opportunity for error? •

Ensure that all nursing staff (full time and PRN) is aware of the protocols.

Ensure that protocols are current and readily available.

Review protocols periodically and update as needed.

Always have your medication orders second checked!

High Alert Drugs

As the recipient we play a vital role in either creating or reducing errors.

By adhering to our standards we may reduce creating errors by the

following: Minimize the use of verbal or telephone orders to emergency situations. Repeat to the prescriber/caller the order (WRV). Record the order directly onto the patient record at the time it is

received. Have verbal/telephone orders followed up with a written order. Ensure that orders are signed and dated according to hospital policy. Verbal/telephone orders for high alert drugs should be minimized.

HAVE YOUR ORDERS 2nd CHECK BY ANOTHER NURSE!!

Verbal / Telephone Orders

Make sure your order sheet has: Resident’s Name, Allergy Information, Age, Weight, Diagnosis. Sticker All orders are written with a date, time, and signature and noted

and 2nd check by nursing. Medication orders on the “right”, all other orders (transports,

bedrest, close watch etc) are placed on the “left” side.

MARS must have: Resident’s name, unit assigned, DOB, and DOA. Allergy information Physician's name. “Charting through” date. EX: 04/1/15-4/30/15 Page number. All transcribed prescription details we’ve mentioned thus far!

Order Sheets/ Medication Administration Records (MARS)

Clarify the order before the prescriber leaves the unit.

Contact the prescriber if the order is not legible.

Do not process incomplete orders.

Orders must contain the following information: drug name, dose, route, dosage form and frequency of

administration.

Minimize the use of abbreviations and certainly avoid the use of unapproved abbreviations on the

MAR.

Never use the letter 'U' as an abbreviation for units.

Use a leading zero before a decimal. •

Do not use a trailing zero after the decimal.

Include indications whenever possible.

Check your own handwriting: is it legible? If not, think about printing using block letters.

Complete the transcription process in a quiet area well lit area, away from distractions. If you are

transcribing orders in a busy environment, there is the likelihood that you may make an error.

Implement a system to check the medication administration record document against active orders .

Again -- Implement a second check system for the transcription.

Transcription

By being competent in all the vital components necessary to carry out a safe drug administration (whether the order be verbal, written, telephone or standing) we may now swiftly and effectively exhibit the ability to:

Double Check The 8 Components of an Order are PresentCross-Check for the 6 “Rights”, Can This Order Be Carried

Out Safely and Effectively?Repeat The Order Back AccuratelyTranscribe The Order as Prescribed by The Physician,

Including All Extraneous Pertinent Information as Required On the MAR

Summary

Accurately transcribe the following written for Resident John Doe, admitted for Mood Disorder DOB 4/5/1997, DOA 4/1/2015, Allergic to Penicillin, patient of Dr. Get Well on your example MAR.

1. Tylenol 650mg by mouth every 4-6 hours as needed for pain or headache.

Lets Practice !

Verbal order time!!

Lets Practice !

Geodon 20mg IM now (one dose only) for severe aggression and agitation.

How well did you do?

Telephone order time!!

Lets Practice !

Benadryl 25mg capsule. Take two capsules by mouth (2 capsules = 50mg) every six hours as needed for allergic reactions, nasal allergies, hives and itching.

How well did you do?

Transcription, the transfer of information from an order sheet

to nursing documentation forms, is a source of many

medication errors. Contributing factors include incomplete or illegible prescriber

orders; incomplete or illegible nurse handwriting; use of

abbreviations; and lack of familiarity with drug names. In addition to errors associated with transcribing the drug

name, there is also opportunity for errors when transcribing

the dose, route or frequency. Preparing a medication

administration record (MAR) in an environment that is noisy

or poorly lit can also contribute to errors.

Final Notes on Order Taking and Transcription

 A nurse from Wisconsin was charged with criminal “neglect of a patient causing great bodily harm” in the medication error-related death of a woman during labor.  The nurse accidentally administered a bag of epidural analgesia by the intravenous route instead of the intended penicillin.◦ She faces up to six years in jail and a $25,000 fine, It has been alleged that the

nurse failed to follow the “six rights” reviewed earlier in this session and did not use an available bedside bar-coding system

The Extent of Medication Errors. How adverse events have effected human lives in the past

◦ A similar case involved three nurses in Denver who were indicted for criminally negligent homicide and faced a possible five year jail term for their role in the death of a newborn who received IV penicillin G benzathine.

◦  ISMP found more than 50 deficiencies in the medication use system that contributed to the error. Had even one of them been addressed before the incident, the error would not have happened or would not have reached the infant. 

The Extent of Medication Errors. How adverse events have effected human lives in the past

We are here to serve as the facilitators of health while our residents receive ongoing treatment for their various conditions and disorders.

All tasks preformed within our scope of practice should be beneficial and therapeutic to the patient.

Much can be achieved by continuing to work as a team and implementing the knowledge gain today concerning writing/checking

our own and peer’s transcriptions.

By abiding by the current facility standards and protocol we can look forward to a future filled with bright patient

outcomes and safe treatment periods.

--Thank you!

Lets work together to promote cures not casualties.

For more information or a copy of this power point, email Sahiris Aybar BS, RN at sayba001@odu.edu

Questions, Comments?

Now let’s go make Florence proud!

Agency for Healthcare Research and Quality (2015). Health information technology best practices transforming quality, safety, and efficiency: Electronic medical record systems. Rockville, MD: U.S. Department of Health and Human Services.

American Psychiatric Association. (2014). Medicare and medicaid electronic health record (EHR) incentive payment programs. Arlington, Virginia: Author

Bell, B, Thornton, K. (2011). From promise to reality achieving the value of an EHR. Healthcare Financial Management, 65(2), 51-56.

Denning, S. (2002). “Using Stories to Spark Organizational Change.” Journal of Storytelling and Business Excellence, http://www.storytellingcenter.com/articles.htm

HealthIT.gov (2014). Benefits of EHRs: Improved diagnostics & patient outcomes. Retrieved from http://www.healthit.gov/providers-professionals/improved-diagnostics-patient-outcomes

Massachusetts Coalition for the Prevention of Medical Errors (2001). Errors in transcribing and administering medications. Safety First Alert. Retrieved from http://www.macoalition.org/documents/SafetyFirst3.pdf

Sole, D., & Wilson, D. G. (2002). Storytelling in organizations: The power and traps of using stories to share knowledge in organizations. LILA, Harvard, Graduate School of Education.

Williams, A., B. (2013). Issue brief: Behavioral health and health IT. Washington, DC: U.S. Department of Health and Human Services

References