Documentation Guidelines

Documentation Guidelines Greater Baltimore Medical Center

General Documentation Information • Most nursing documentation is completed on the computer using Meditech PCS • Agency nurses will be required to take an 8 hour Meditech course taught by GBMC before beginning to work at the hospital • This class will cover order entry, documentation, and barcoding medication delivery / using the electronic medication administration record

Patient Care System (PCS) • PCS is the system for documentation that reflects the nursing process, encourages clear and concise charting, is legally sound, and focuses on patient interventions to support patient outcomes • All information entered through PCS can be viewed in the EMR (Enterprise Medical Record)

With PCS, you are able to: • Fill out the Admission Database • Record vital signs and I&Os • Document the patient’s Past Medical History • Document your head-to-toe assessment (using System Flowsheets) • Enter nursing notes • Add Care Plans and record outcomes • View and print Kardexes and patient reports • Enter lab, radiology, respiratory, diet, and nursing orders through order entry • Document medication administration through the electronic MAR

Shift • A shift is defined as 12 hours • Documentation that is required q shift is to be documented once every 12 hours, unless physician orders or unit specific policies dictate otherwise • Change in patient status or change of care provider necessitates a repeat of the q shift documentation (i.e. Patient System Flowsheets)

Real Time Documentation • Documentation completed at the time the intervention is performed • In the event that “real-time” documentation is not possible, documentation that occurs within one hour of the intervention is acceptable, except for those interventions with a time interval less than one hour (i.e. q15min) • Any documentation entered into Meditech after the one hour time interval must be retrospectively documented by defining the exact time the intervention was actually completed • Continuous reassessment of the patient is a nursing expectation, with documentation expected as changes occur

Standard of Care • Upon admission, each patient will have the appropriate “Standard of Care” (SOC) added to their intervention list in Meditech • The SOC is a predefined set of interventions that are designed for that patient’s population • Once the SOC and all physician orders are entered through Meditech order entry, the intervention list the nurse will document from will be complete and ready to be documented on

Plan of Care • The plan of care for the patient includes all computer documentation, entered orders, as well as a defined Care Plan • Every admitted patient must have a care plan added within 24 hours of admission • Care plans all have problems and expected outcomes that are documented against once every 12 hours • Care plans can be updated as needed to reflect new problems or change in patient status

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

Documentation Details • A nurse can skip a question on an assessment if he/she is unable to assess the question due to patient condition or if the question is not applicable for the patient at that time • Any retrospective documentation can be entered up to 3 days following patient discharge

Documentation Details • Changes to documentation may only be made by the person who recorded the documentation • Partially documented entries, documentation editing, and undoing documentation can be completed by clicking in the History column for the appropriate intervention

Transfer of Patients • Transferring unit will change the status of any appropriate interventions from “Active” to “Complete” by clicking in the Status column • Completed Admissions Documentation • System Flowsheet • Receiving unit stops all nursing orders initiated in order entry, enters transfer orders according to policy and procedure, and the nurse will add on the correct system flowsheet for the patient on the intervention list using the “Add Intervention” Function

Order Entry • All paper physician order sheets must be faxed to pharmacy upon admission • Pharmacy will enter any medications and IVs into Meditech – the list of current medications can be viewed in the EMR by clicking on the Medications tab • All non-medication orders will be entered by the nurse or secretary into the Meditech order entry system

Order Entry • It is the RN’s responsibility to verify ALL orders (lab, radiology, nursing, etc.) are entered into Meditech from the Physician Order Sheet (Use Order History in the EMR) • Initial each individual order with red ink after verification that the order is in Meditech • After all orders have been entered and verified, a Kardex will be printed from the Meditech desktop using the Reports button

Verification of Physician Orders • For ancillary department orders requiring pager notification (Respiratory Therapy) the time of the page is written on the order sheet next to the order • Co-sign each set of physician orders with initials, title, date, and time

24-hour Chart Checks • Performed on 11pm – 7am shift • Review ALL orders written during the previous 24 hours and verify they are in Meditech by accessing the EMR (order history section, sorted by date) • Sign entire physician’s order sheet with name/initials, title, date and time in red ink

Legal Medical Record • Combination of the Patient’s PCS archived discharge summary and the archived notes, as well as any documentation from the paper chart • The Medical Records Department archives these items 60 days after discharge • The discharge summary and notes are available upon request from the Medical Records Department

Admission Documentation • Document all interventions that have a frequency of “On Admission” • Also required to document the following, as appropriate: • System Flowsheet • Fall Risk / Safety Assessment Tool • IV Assessment / Invasive Line Status • Pain Assessment / Reassessment • Skin Risk Assessment • CAM • General Education Record • Nursing Note with Admission Details • Add a Care Plan to patient using “Process Plan” • Print Out Home Medication Report from Meditech Desktop after entering in list of Patient’s Home Meds during admission

Discharge Documentation • The physician writes the discharge instructions • The nurse is responsible for reviewing all instructions with the patient and obtaining the patient signature • Carenotes can be printed out from the Infoweb (click on Micromedix link to access) for patient education • The nurse should make sure the patient understands the complete list of medications the patient is to take once being discharged (compared to any medications the patient was taking on admission), as part of the medication reconciliation process • Original form goes to medical records and a copy is given to the patient upon discharge

Blood Administration Documentation • Blood Transfusions are documented as an Intervention Set, which can be added using the “Add Intervention” link on the Intervention worklist (search for “set”) • The set is comprised of: • 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 Product Completion (completed at end of infusion) • Blood Vital Signs (baseline vitals taken at start, then q15min x 2 after initiation, then hourly)

Documentation of Wounds • Wounds are documented as an Intervention Set, which can be added using the “Add Intervention” link on the Intervention worklist (search for “set”) • The set is comprised of: • 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)

Critical Lab Values Documentation • The lab will call the nurse (as well as the physician) responsible for taking care of the patient with the critical lab value • The telephonic critical result, upon receipt, will be read back to the technologist/technician and documented as having been read back. If that does not happen, the technologist/technician will request that the nurse receiving the critical result read it back.

Critical Lab Values Documentation Procedure • Verify the result by verbally reading the result back to the technologist/technician • Notify the nurse assigned to the patient of the critical result if she/he was not the one to receive the telephonic notification. • Document receiving the phone call about the critical value, the critical result, and what you did about the result on the Critical Lab Values Intervention in Meditech PCS.

EMR • The Enterprise Medical Record (EMR) is where all the documentation for your patient is located • To open the EMR from PCS, click on “Open Chart” • Once in the EMR, you can click on the options on the right side of the screen to view documentation, reports, labs, orders, etc.

Computer Downtime • In the event of a computer downtime, the documentation system reverts back to paper (all paper forms will be stocked on units) • For downtime less than 4 hours (med/surg) and 2 hours (critical care), information that is recorded on paper will need to be entered into PCS • For downtime exceeding 4 hours (med/surg) and 2 hours (critical care), the paper system will replace PCS until the end of the shift and until the system is back up – the only data that must be re-entered into PCS in this case are the Vital Signs and the I&O, so the EMR record will be accurate

Unscheduled Downtime • A 24-hour report, by unit, will be available upon request from the MIS Helpdesk, x3725. The unit is responsible for picking up this report from the MIS department, building 9, 5th floor. The report includes the following documentation: • Vital Signs • Intake and Output • System Flowsheet • Pain Assessment • PCA: IV and Epidural

Scheduled Downtime • The unit is responsible for printing the following reports one hour prior to the downtime: • Nursing Downtime Flowsheet • Click on Reports button from desktop • Click on Patient Reports • Select Flowsheet Report • In Format box, Press F9 and select Nursing DT Flowsheet • Fill in Patient Last name and press F9 in Patient section • Select correct patient and click on green check mark to print • Patient Kardex • Click on Reports button from desktop • Click on Patient Reports • Select Profile Report • Fill in Patient Last name and press F9 in Patient section • In Use Profile Format box, press F9 and select Pt Kardex – Treatment record and click on green check mark to print

Meditech Help • Can be found on the nursing page of the Infoweb Scroll down on the nursing page and click on Meditech Help Link

What stays on paper? • Consent forms • Admission / Transfer Summaries • OR/Recovery Documentation • Physician Order Sheets • Documentation During Patient Codes • Pre-op Checklist • Discharge Instructions • Labor Event – Triage up until Delivery • Monitoring Strips

Paper Documentation Guidelines • When your signature is required on any form, legibly sign your full name and status (i.e RN) • Before using your initials on any paper form, be sure to sign the Signature/Initial record in front of the medical record • Use black or blue ink pen for all entries, except when signing off medications – which should be done using red ink • If part of the paper medical record is damaged in any way (spills, tears), do not destroy the form – simply cross-reference to a newly initiated form

Documenting a Telephone Order from a Physician • Indicate date/time order was received • Document order as stated by physician • Read the written order back to the physician to verify accuracy • Document under the order RBO (read back order) and the recorder’s initials • Sign order: v.o. Dr. Jones / Kay Smith RN • Place a “sign here” sticker next to order • Flag the record green for a regular order and red for a STAT order for the secretary

Time-Out VISA • To be completed on ALL surgical and invasive procedures for which consents are required. This includes bedside procedures such as central lines, chest tubes, thoracentesis, etc. • 3 Sections: Patient Verification, Site Marking, and Time Out for Procedure or Operating Room

Section 1: Patient Verification • Two identifiers: patient name and date of birth • Compare to ID band, consents, diagnostic images, and all other patient documentation related to the procedure • All areas on the VISA under section 1 are to be initialed

Section 2: Site Marking • Completed whenever laterality may become an issue • Performed by physician or person performing the invasive procedure • Exceptions • If not multiple digits/structures • Procedure occurs through an orifice (dental, colonoscopy, etc) • NICU babies • Green bracelet used on operative side when patient refuses site marking • All areas to be initialed if appropriate

Section 3: Time-Out • Completed just prior to the beginning of the procedure • Includes the patient • All members present for the Time-Out must be identified • All areas to be initialed and form signed • References: Verification of Correct Site, Correct Procedure, Correct Patient and “Time-Out” for Invasive or Surgical Procedure; and Guidelines for Completing Procedure Visa

Documentation Guidelines