Effective Documentation: Consistency, Accuracy, and Confidentiality

1. Chapter 17Documenting, Reporting, and Conferring

2. Characteristics of Effective Documentation • Consistent with professional and agency standards • Complete • Accurate • Concise • Factual • Organized and timely • Legally prudent • Confidential

3. Using the 24-hr Cycle Military Clock for Documenting Times

4. What Is Confidential? • All information about patients written on paper, spoken aloud, saved on computer • Name, address, phone, fax, social security • Reason the person is sick • Treatments patient receives • Information about past health conditions

5. Potential Breaches in Patient Confidentiality • Displaying information on a public screen • Sending confidential e-mail messages • Sharing printers among units with differing functions • Discarding copies of patient information in trash cans • Holding conversations that can be overheard • Faxing confidential information to unauthorized persons • Sending confidential messages overheard on pagers

6. Patient Rights • See and copy their health record • Update their health record • Get a list of disclosures • Request a restriction on certain uses or disclosures • Choose how to receive health information

7. Policy for Receiving Verbal Orders in an Emergency • Record the orders in patient’s medical record • Read back the order to verify accuracy • Date and note the time orders were issued in emergency • Record VO, the name of the physician followed by nurse’s name and initials

8. Policy for Physician Review of Verbal Orders • Review orders for accuracy • Sign orders with name, title, and pager number • Date and note time orders signed

9. Duties of RN Receiving a Telephone Order • Record the orders in patient’s medical record • Read orders back to practitioner to verify accuracy • Date and note the time orders were issued • Record TO, full name and title of physician or nurse practitioner who issued orders • Sign the orders with name and title

10. Purposes of Patient Records • Communication with other healthcare professionals • Record of diagnostic and therapeutic orders • Care planning • Quality of care reviewing • Research • Decision analysis • Education • Legal and historical documentation • Reimbursement

11. Purposes of Recording Data • Facilitate patient care • Serve as a financial and legal record • Help in clinical research • Support decision analysis

12. Methods of Documentation • Source-oriented records • Problem-oriented medical records • PIE charting • Focus charting • Charting by exception • Case management model • Computerized records

13. Sample PIE Patient Care Note

14. Sample Focus Patient Care Notes

15. Case Management Models • Collaborative pathways • Variance charting

16. Major Components of POMR • Defined database • Problem list • Care plans • Progress notes

17. Formats for Nursing Documentation • Initial nursing assessment • Kardex and patient care summary • Plan of nursing care • Critical collaborative pathways • Progress notes • Flow sheets • Discharge and transfer summary • Home healthcare documentation • Long-term care documentation

18. Types of Flow Sheets • Graphic record • 24-hour fluid balance record • Medication record • 24-hour patient care records and acuity charting forms

19. Medicare Requirements for Home Healthcare • Patient is homebound and still needs skilled nursing care • Rehabilitation potential is good (or patient is dying) • The patient’s status is not stabilized • The patient is making progress in expected outcomes of care

20. Four Basic Components of RAI (Resident Assessment Tool) • Minimum data set • Triggers • Resident assessment protocols • Utilization guidelines

21. Benefits of RAI • Residents respond to individualized care • Staff communication becomes more effective • Resident and family involvement increases • Documentation becomes clearer

22. Change of Shift Report • 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

23. Two Nurses Confer at Change of Shift Report

24. Methods of Reporting • Face-to-face meetings • Telephone conversations • Messengers • Written messages • Audio-taped messages • Computer messages

25. Conferring About Care • Consultations and referrals • Nursing and interdisciplinary team care conferences • Nursing care rounds

26. Question Tell whether the following statement is true or false. A nurse who fails to log off a computer after documenting patient care has breached patient confidentiality. A. True B. False

27. Answer Answer: A. True A nurse who fails to log off a computer after documenting patient care has breached patient confidentiality.

28. Question Tell whether the following statement is true or false. A patient has the right to obtain, review, and revise the patient information in his or her health record. A. True B. False

29. Answer Answer: B. False A patient has the right to obtain and review, but not revise the patient information in his or her health record.

30. Question Tell whether the following statement is true or false. One of the purposes of creating a patient record is to evaluate the quality of care patients have received and the competence of the nurses providing that care. A. True B. False

31. Answer Answer: A. True One of the purposes of creating a patient record is to evaluate the quality of care patients have received and the competence of the nurses providing that care.

32. Question Which of the following methods of documentation is unique in that it does not develop a separate plan of care but instead incorporates the plan of care into the progress notes? A. Source-oriented records B. Problem-oriented records C. PIE (problem, intervention, evaluation) D. Focus charting

33. Answer Answer: C. PIE (problem, intervention, evaluation) Rationale: Pie charting incorporates the plan of care into progress notes in which problems are identified by number. In source-oriented records, each healthcare group keeps data on its own separate form. Problem-oriented records are organized around patient problems rather than around sources of information. Focus charting brings the focus of care back to the patient and the patient’s concerns.

34. Question PIE notes, SOAP notes, focus charting, and charting by exception are examples of which of the following formats for nursing documentation? A. Critical/collaborative pathways B. Progress notes C. Flow sheets D. Discharge summary

35. Answer Answer: B. Progress notes Rationale: Progress notes inform caregivers of the progress a patient is making using the specified formats. Critical/collaborative pathways are standardized plans of care developed for a patients with designated diagnoses. Flow sheets are documentation tools included in the progress notes that record routine aspects of care. Discharge summaries are clinical reports written to summarize the patient record.