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Document it right: A Nurse’s Guide to charting

Document it right: A Nurse’s Guide to charting. Presented by,Shandy Adamson. Objectives. I dentify seven reasons as to why documentation is important Learn how to document properly Describe different document formats Learn how to document in different settings and in challenging situations

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Document it right: A Nurse’s Guide to charting

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  1. Document it right: A Nurse’s Guide to charting Presented by,Shandy Adamson

  2. Objectives • Identify seven reasons as to why documentation is important • Learn how to document properly • Describe different document formats • Learn how to document in different settings and in challenging situations • Explain the importance of documentation in the court room • Identify the advantages and disadvantages of computerized documentation systems • Identify how to save time when documenting

  3. Chapter 1:Documentation Fundamentals • Why Documentation is Important? • Coordination of care • Accreditation and licensing • Performance improvement activities • Peer review • Requirements for reimbursement • Legal protection • Research and continuing education

  4. Documentation guidelines • Document accurately and objectively • Get facts about situation before charting and don’t make assumptions • Document clearly and thoroughly • Note times carefully • Don’t use block charting that covers a wide range of time • Avoid assigning blame or calling attention to errors

  5. Documentation guidelines continued • Avoid using terms associated with errors • Fill out forms correctly, write in ink, sign each entry • Use standard abbreviations • For drug names use generic rather than trade names and spell drugs out correctly • Write legibly and spell correctly • Correct errors and omissions

  6. Documentation guidelines continued • Cosign correctly • Use caution when you countersign a subordinate’s chart entries • Don’t document care given by someone else • Follow correct procedures for late documentation

  7. Chapter2: Different formats, different settings • Documentation formats • Narrative or source oriented charting • Problem orientated charting • Focus charting • PIE charting • Charting by exception • Fact charting • Core charting

  8. Components of Problem-Oriented Charting • Patient database • Patient problem list • Initial plan for each identified problem • Progress notes • Discharge summary

  9. Documentation in different settings • Acute care documentation • Long term documentation • Documentation in homecare

  10. Criteria for Medicare Reimbursementfor Home Healthcare • Patient must be confined to the home. • Patient must need skilled services on an intermittent basis. • Care must be reasonable and medically necessary. • Patient must be under a physician’s care.

  11. Chapter 3:how to document in challenging situations • Refusal of treatment or failure to follow restrictions • Against medical advice • Incident reports • Advance directives • Difficult patients • How to document understaffing • How to document negligent or unsafe practice • Physician orders • Unlicensed assistive personnel

  12. Chapter 4:Will your documentation stand in court? • Laws and standards • Legal basics • Critical incidents

  13. Chapter 5:Technology and Time • Advantages of computerized documentation • Store and retrieve information quickly, simply and reliably • Update information consistently and efficiently • Link sources of patient information • Use standardized terminology • Promote communication among health care workers • Facilitate transmission of request slips and patient information between departments • Protect patient confidentiality • Provide legible and grammatically correct documentation • Contain valuable data on patient populations

  14. Technology and time continued • Disadvantages of computerized documentation • May scramble patient information if used improperly • Can interfere with patient’s right to confidentiality if security measures aren’t followed • May break down which causes important information to be temporarily unavailable • May be expensive • Can restrict the accuracy of information if the computer restricts vocabulary or phrasing • Can increase documentation time if too few terminals are available

  15. Technology and time continued • Save time when you document • Before documentation: right patient medical record and information • Use nursing process to document • Chart as soon as possible after you provide care • Use flow sheets and bedside charting if possible • Don’t repeat information • Sign off with initials

  16. reference • Habel, M. (2014). Document It Right: A Nurse's Guide to Charting. . Retrieved May 7, 2014, from http://ce.nurse.com/RetailCourseView.aspx?CourseNumber=60076&page=8&IsA=1

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