Nursing Documentation and Patient Record System

11/13/12
NomiWG ACI-PIMS
11
C ONTINUING URSING DUCATION N E

D E P A R T M E N TO F N U R S I N G
OBJECTIVES
At the end of this presentation

11/13/12 NomiWG ACI-PIMS 22
C ONTINUING URSING DUCATION N E

D E P A R T M E N TO F N U R S I N G
OBJECTIVES
Describe how to create and

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Documentation
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44
Apply Your Knowledge

What is the purpose of documentation in a patients medical record?
ANSWER: Documentation in the medical record provides evidence of appropriate care. If a procedure is not documented, it is considered not done.
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Good Job! 55
If it wasnt charted, it wasnt done
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Documentation Problems Seen in Malpractice Cases _____________________________________

1.
Not charting the correct time events occur. Failing to record verbal orders or to get them signed by the doctor. Charting actions in advance to save time. Documenting incorrect data.
2.
3.
4.
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12
Nurses needs any training for documentation.
10
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Nurses notes are actual reflection of the nursing work done by the shift.
12 10
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12
Doctors or any one else reads nurses notes.
10
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DOCUMENTATION
Any printed or written record of activities. Recording and reporting are the major ways health care providers communicate. The clients medical record is a legal document of all activities regarding client care.
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Documenting Nursing Notes
Nursing notes are entered on a patient in the following situations:
Admission Transfer Discharge When an unusual event occurs or with change of patient status When an appropriate intervention cannot be found to document on
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Ethical and legal considerations

The nurse has a duty to maintain confidentiality of all patient information (ANA code of ethics 2001).The records are used in client conferences, clinics, rounds, client studies, and written papers. It is the responsibility of the student or health professional to protect the clients privacy by not using a name or any statements in the document that would identify the client.
Purposes of documentation
1. 2. 3.
Communication Legal documentation Diagnostic and Therapeutic Orders Care Planning Financial Billing Education Research
4. 5. 6. 7.
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COMMUNICATION: Documentation confirms the care provided to the client and clearly outlines all important information regarding the client.
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PRACTICE AND LEGAL STANDARDS
The legal aspects of documentation require:
Writing legible and neat Spelling and grammar properly used Authorized abbreviations used Time-sequenced factual and descriptive entries
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3.
Diagnostic and Therapeutic Orders

a)
Verbal orders/Telephone orders:

a) b) c)
repeat back to MD to verify; write on chart; must be signed by ordering MD within 24 hours
b)
written or computerized orders:

must contain MDs name, NomiWG ACI-PIMS
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a) 11/13/12
4.
Care Planning: Outlining Nursing or interdisciplinary goals for the patients care
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5. Financial Billing: Reimbursement from insurance or private companies
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6. Education
Health care students use medical record as tool to learn about disease processes, nursing diagnoses, complications and interventions. Students can enhance criticalthinking skills by examining the records and following health care teams plan of care.
7. Research (Requires consent from the patient) The clients medical record is used by researchers to determine whether a client meets the research criteria for a study. Documentation can also indicate a need for research.
8. Auditing/Monitoring (Quality Improvement) Method of evaluating the quality of
care Includes: Safety measures Treatment interventions and responses Expected outcomes Client teaching Discharge planning Adequate staffing
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9. Historical Documentation: because entries are by date and time, can give a history of patients condition
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Purpose of Documentation
Decision Analysis: Organizational strategic planning about treatment methods, patient services
Example : Panadol usage is minimum, solucortef not used in CPR
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24 Hour Time
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Real Time Documentation
Documentation that occurs within one hour of the intervention is acceptable.
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GENERAL GUIDELINES FOR RECORDING

1- Date and Time, document the date and time of each recording. This is essential not only for legal reasons but also for client safety. Accurate according to the 24-hours clock (military clock) or in the conventional manner (am, pm).
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2- Timing,. No recording should be done before providing nursing care. 3- Legibility, all entries must be understandable and easy to read. 4- Permanence, all entries made in dark ink so that the record is permanent and changes can be identified.
5- Correct Spelling, is essential for accuracy in recording. Incorrect spelling gives a negative impression to the reader and, thereby, decreases the nurses credibility. 6- Signature, each recording on the nursing notes is signed by the nurse making it. The signature includes the name and title. For example, Nomi WG, RN. Nomi WG, RN
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7- Accuracy: Before making any entry, check that it is the correct chart. Do not identify charts by room number only, check the clients name. Do not give OPINION give FACT..! for example, to write that the client refused medication (fact) than 11/13/12 NomiWG ACI-PIMS 3232 to write that the client was uncooperative (opinion).
Charting a PRN medication
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3316-33

What is the appropriate way to correct an error in a patients medical record?
ANSWER: To correct an error in a patients medical record: Draw a line through the original information It must remain legible Insert correct information above or below original line or in margin Document why correction was made Date, time, and initial correction
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When describing something, avoid general words, such as large ,good, or normal, for example, chart specific data such as 2cm* 3cm bruise rather than large bruise. When a recording mistake is made, draw a line through it and write the words mistaken entry above or next to the original entry, with your initials or name. Do not erase, or use correction fluid. Write on every line but never between lines.
Correcting a documentation error

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8- Sequence, document events in the order in which they occur 9- Appropriateness, records only information that relates to the clients health problems and care. Recording irrelevant information may be considered an attack of the clients privacy.
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12-Conciseness, recording need to be brief as well as complete to save time in communication. 13. Accepted Terminology, Use only commonly accepted abbreviations, symbols, and terms are specified by the agency. Many abbreviations are standard and used universally. 13- Legal Prudence, accurate, complete documentation should give legal protection to the nurse, the clients other caregivers, the health care facility, and the client. Complete charting for example by using the steps of the nursing process as a framework, is the best defense 11/13/12 NomiWG ACI-PIMS 3838 against malpractice. (ADPIE)

What is important to remember when you are documenting in the medical records?
ANSWER: It is important that medical records be neat and legible, timely, accurate, and maintain a professional tone.
Very Good!

What section of the patient record contains information about smoking, alcohol use, and occupation?
ANSWER: Information about smoking, alcohol use, and occupation is part of the patients past medical history.
Correct!
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Documentation Guidelines
Factual 2. Accurate 3. Complete 4. Current 5. Organized
1. 11/13/12 NomiWG ACI-PIMS 4343
Factual
- be objective not subjective; quote the patient, if necessary
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Accurate
- use exact measurements: Midline abd. incision measure 5 in length and 1 in depth with no obvious drainage or odor; not Incision healing well.
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Complete
- If it wasnt charted, it wasnt done
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Current
-
vital signs Medications Treatments changes in condition test preps

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Organized
-
should be in a logical, time sequential order, written in 3rd person, not 1st person, passive tense
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Documentation
Ex: Patient medicated for pain with Morphine 2 mg. IV for a complaint of pain of 8/10 @ 8:45. Not: I gave the patient 2 mg. of Morphine because he said he was in sever pain Ex: 11/13/12 NomiWG ACI-PIMS 4949
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ADPIE

Assessment Diagnosis Planning Intervention Evaluation

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Label the following items as either (S) subjective or (O) objective. ____ headache S ____ vomited x 3 O ____ skin color O ____ chest pain ____ pulse 72 O ____ nausea S ____ respirations 16, labored O ____ poor appetite
ANSWER:
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Good ACI-PIMS NomiWG
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Methods of Documentation
1. 2. 3. 4. 5. 6. 7.
Source-oriented records Problem-oriented medical records PIE charting Focus charting Charting by exception Case management model Computerized documentation
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01. Source-Oriented Records:
Each healthcare discipline has its own section of the chart;
sections for MDs, nursing, laboratory, social services, physical therapy, procedure reports;
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all healthcare disciplines use the same forms referencing patient problems;
2.Problem-Oriented Medical Records (POMR)
uses SOAP or SOAPIE or SOAPIER

Subjective Objective Assessment Plan
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SOAP Documentation
The treatment plan to correct the illness or problem The impression of the patients problem that leads to diagnosis What the physician observes during the examination Information the patient tells you
P
lan ssessment
bjective data
S
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ubjective data NomiWG ACI-PIMS
5656

What type of documentation provides an orderly series of steps for dealing with any medical case, and what are the components of this type of documentation?
ANSWER: SOAP documentation provides an orderly series of steps for dealing with any medical case. The components are S Subjective data A - Assessment O Objective date P - Plan
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GOOD
5757
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5858
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3. PIE

Problem, Intervention, Evaluation; problems are identified by number and addressed in the documentation used flow sheets; no formal care plan
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6060
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4- Focus Charting
Is intended to make the client and client concerns and strengths the focus of care. The progress notes are organized into (DA-R) (D) Data which reflects the assessment phase of the nursing process. (A) Action which reflects planning and implementation and includes immediate 11/13/12future nursing action. NomiWG ACI-PIMS 6262 and
Date/Hour 2/11/08 0900
Focus Pain
09:15
//
Progress Notes D: Guarding abdominal incision. Facial grimacing. Rates pain at 8 on scale of 0- 10 A:Administered morphine sulfate 4mg IV. R:Rates pain at1states willing to ambulate
0930
//
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5. Charting by exception (CBE)

1.
2.
3.
The nurse documents only deviations from pre established norms. Avoids lengthy, repetitive notes. Enables the identification of trends in client status.
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Benefits of CBE
Standards allow for consistent quality of care and documentation within organization Abnormal findings are highlighted Repetitive documentation of routine care is eliminated through use of standards documentation time
6. Case Management Models
A collaborative process of assessment, planning, facilitation, care coordination, evaluation, and advocacy for options and services to meet an individual and familys comprehensive health needs through communication and available resources to promote quality costeffective outcomes
NomiWG ACI-PIMS chronic care management 6969
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7. Electronic Medical Record
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7272
08. COMPUTERIZED DOCUMENTATION
Reduces time taken, increases accuracy. Increases understandablility. Stores, retrieves information quickly. Improves communication among health care departments.
Confidentiality and costs can be problems. NomiWG ACI-PIMS 11/13/12 7373
8. Computerized Bedside Charting
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7474
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09. NARRATIVE CHARTING
Traditional method of nursing documentation. Chronologic account in paragraphs describing client status, interventions and treatments, and clients response. The most flexible system. Usable in any clinical setting.
Blood Administration Documentation
Blood Administration Verification (completed just prior to starting infusion) Blood Product Infusion (start time and initial rate) Infusion Changes (any rate changes during infusion) Blood Vital Signs (baseline vitals taken at start, then q15min x 2 after initiation, then hourly)
Documentation of Wounds
Wound / Pressure Ulcer Status Assessment: for initial, weekly, and change of status wound documentation (more detailed) Wound Care / Dressing Change Assessment: for daily documentation of dressing changes (focused assessment specifically for dressing changes)
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Critical Lab Values Documentation

Procedure
1.
Verify the result by verbally reading the result back to the technologist/technician Document receiving the phone call about the critical value, the critical result, and what you did about the result on the Critical Lab Values.
2.
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8080
Documenting a Telephone Order
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8116-81
Reporting
Reporting
To communicate something that has been seen, heard, done or considered. It can be written, oral, audio taped, computerized Ex: 1. Lab reports 2. Procedure reports (x-ray, biopsies)
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8383
Forms for Recording Data

Kardex Flow Sheets Nurses Progress Notes Discharge Summary
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Kardex
The Kardex is used as a reference throughout the shift and during change-of-shift reports.
Client data (name, age, marital status, religious preference, physician, family contact). Medical diagnoses: listed by priority. Allergies. Medical orders (diet, IV therapy, etc.). permitted. NomiWG ACI-PIMS
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Activities 11/13/12
Flow Sheets
Vertical or horizontal columns for recording dates and times and related assessment and intervention information. Also included are notes on:
Client teaching. Use of special equipment. IV Therapy.

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Nurses Progress Notes
Used to document:
Clients condition, problems, and complaints. Interventions. Clients response to interventions. Achievement of outcomes.
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Discharge Summary
Highlights clients illness and course of care. Includes:
Clients status at admission and discharge. Brief summary of clients care. Intervention and education outcomes. Resolved problems and continuing care needs. instructions regarding NomiWG ACI-PIMS
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Release of Records
Records are property of physician
Contain confidential patient health information Must have patients written consent to release Exceptions: cases of contagious disease or court order
NomiWG ACI-PIMS
Release of Information to HMO Insurance Company
I authorize Dr. J. Jones to release my healthcare information to the above-named insurance company. Christopher Hansen mm/dd/yyyy Patient Signature Date
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Release of Records
(cont.)
Procedures for releasing records
Obtain a signed and newly dated release form authorizing the transfer of information, and place it in the patients record Make photocopies of original materials
Copy and send only documents covered in the release authorization
Call to confirm receipt of materials

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Release of Records
(cont.)
Special cases
Confidentiality
Death

18-year-olds
Next of kin Legally authorized representative
Considered adults in most states
If unsure, ask supervisor
Must have Legal and ethical written consent principle: to release their Protect patients right records
to privacy at all times.

9191
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NomiWG ACI-PIMS

The medical assistant receives a fax transmittal authorizing transfer of medical record information for a client to another physicians office. What would you do in this situation?
ANSWER: It is difficult to know the actual originator of a fax transmittal and to verify the signature. The safest solution would be not to release any information based on a fax request and release of information form.
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References
Will be provided on request
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THANK YOU
Nomi Waqas Gul Asst. Clinical Instructor Continuing Nursing education (CNE) Pakistan Institute of Medical Sciences, Islamabad, Pakistan For More Information Email: nomiwg@yahoo.com Facebook: add as friend (by email address) To download free Notes Visit: www.scribd.com/nomiwg NomiWG-ACI NomiWG ACI-PIMS 9494
11/13/12

Nursing Documentation and Patient Record System

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Nursing Documentation and Patient Record System

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11/13/12

C ONTINUING URSING DUCATION N E

At the end of this presentation

C ONTINUING URSING DUCATION N E

Describe how to create and

Apply Your Knowledge

If it wasnt charted, it wasnt done

Documentation Problems Seen in Malpractice Cases _____________________________________

Nurses needs any training for documentation.

Doctors or any one else reads nurses notes.

Documenting Nursing Notes

Nursing notes are entered on a patient in the following situations:

Ethical and legal considerations

The legal aspects of documentation require:

Diagnostic and Therapeutic Orders

Verbal orders/Telephone orders:

written or computerized orders:

Example : Panadol usage is minimum, solucortef not used in CPR

Real Time Documentation

Documentation that occurs within one hour of the intervention is acceptable.

GENERAL GUIDELINES FOR RECORDING

Charting a PRN medication

Apply Your Knowledge

Super Job!NomiWG ACI-PIMS

Correcting a documentation error

Apply Your Knowledge

Apply Your Knowledge

vital signs Medications Treatments changes in condition test preps

Assessment Diagnosis Planning Intervention Evaluation

Apply Your Knowledge

Good ACI-PIMS NomiWG

01. Source-Oriented Records:

Each healthcare discipline has its own section of the chart;

2.Problem-Oriented Medical Records (POMR)

uses SOAP or SOAPIE or SOAPIER

ubjective data NomiWG ACI-PIMS

Apply Your Knowledge

Date/Hour 2/11/08 0900

5. Charting by exception (CBE)

6. Case Management Models

7. Electronic Medical Record

08. COMPUTERIZED DOCUMENTATION

Confidentiality and costs can be problems. NomiWG ACI-PIMS 11/13/12 7373

8. Computerized Bedside Charting

09. NARRATIVE CHARTING

Blood Administration Documentation

Critical Lab Values Documentation

Documenting a Telephone Order

Forms for Recording Data

Kardex Flow Sheets Nurses Progress Notes Discharge Summary

Client teaching. Use of special equipment. IV Therapy.

Nurses Progress Notes

Records are property of physician

Release of Information to HMO Insurance Company

Procedures for releasing records

Copy and send only documents covered in the release authorization

Call to confirm receipt of materials

Next of kin Legally authorized representative

Considered adults in most states

If unsure, ask supervisor

to privacy at all times.

Apply Your Knowledge

Will be provided on request

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