1.32k likes | 1.66k Views
Documentation. N-205 Fundamentals Lecture. Objectives. Demonstrate the role of caregiver and communicator by documenting nursing care, following legal guidelines. Understand the purpose of patient records, ethical accountability and confidentiality.
E N D
Documentation N-205 Fundamentals Lecture
Objectives • Demonstrate the role of caregiver and communicator by documenting nursing care, following legal guidelines. • Understand the purpose of patient records, ethical accountability and confidentiality. • Review legal abbreviations used by all health care providers.
Objectives (cont’d.) • As caregiver, understand the different methods of documenting care (narrative, pie charting, focus charting, charting by exception and computerized records). • Describe the difference between a Kardex graphic and flow sheet and progress notes. • As the communicator, describe what a change of shift report should include and its purpose.
Objectives (cont’d.) • Discuss documentation mechanics that increase risk for legal problems. • Discuss difference between telephone reports and telephone orders • Identify ways to maintain confidentiality of records and reports
Important concepts: • Effective communication is essential to the coordination and continuity of care. • Avoid duplications and omission of care • Supports & complements one another’s care • 3 methods: • Documenting • Reporting • Conferring
Documenting Care • Documentation – a written, legal record of all pertinent interactions with patient: assessing, diagnosing, planning, implementing and evaluating. • Contains data to facilitate patient care, serve as financial & legal records, help in clinical research, & decision analysis • Patient record – a compilation of a patient’s health information. • legal document
What makes up the medical record? • Face sheet • Medical history & Physical exam • Initial nursing assessment form • Doctor’s order sheet • Problem or nursing diagnosis list • Nursing plan of care • Graphic sheet
What makes up the medical record? • Medication administration record • Nurse’s progress notes • Doctor’s progress notes • Diagnostic findings • Health care team records • Consultation sheets • Discharge plan and summary
Why is it important to document everything? • Patient record - a legal document that details all nurse’s interaction with the patient • It is the nurse’s best defense. • It should be: complete, accurate, concise, factual, organized and timely; legally prudent and confidential.
Guidelines for Effective Documentation • Content • Enter information in a complete, accurate, concise and factual manner • Record patient findings (not your interpretation but observation) • Reflects the nursing process & professional responsibilities • Avoid words like “good”, “average”, or “sufficient”; avoid generalizations “seems comfortable”
Guidelines for Effective Documentation • Content • Note problems in an orderly, sequential manner. • Document in a legally prudent manner. (adhere to agency policy & professional standards) • Document the nursing response to questionable medical orders or treatment (or failure to treat).
Guidelines … (cont’d.) • Timing • Chart in a timely manner. Follow agency policy and modify if patient’s status warrants it. • Indicate the date and the time. • Most agencies used military time to avoid confusion. • Document as closely as possible to the time of their execution. • NEVER document interventions before carrying them out.
Guidelines.. (cont’d.) • Format • Make sure you have the correct chart before writing. • Chart on the proper form as designated by agency policy. • Print or write legibly in dark ink. • Use correct grammar & spelling. • Use only standard terminology. • Follow computer documentation guidelines. • Date and time each entry • NEVER skip lines. Draw a single line through blank spaces. • Chart chronologically.
Guidelines (cont’d.) • Accountability • Sign your first initial, last name and title to each entry. • Do not use dittos, erasures or correcting fluids. • Draw a single line • Use words like “mistaken entry” or “error in charting” • Re-write the entry correctly • Identify each page of record • Ensure patient record is complete before sending to medical records.
Guidelines … (cont’d.) • Confidentiality • Patient have a moral and legal right to privacy. • Students should be familiar with agency policy • Most agencies allow students to access. • Students are bound professionally and ethically to keep in strict confidence all the info they read. • Actual patient names and other identifiers should not be used in reports.
What information is confidential? • All information about patients whether written on paper, saved on a computer or spoken aloud. • Names, addresses, telephone and fax numbers • Reason the patient is sick, treatments and info about past health condition.
Breaches of confidentiality: • Discussing patient info in any public area. • Leaving patient medical info in a public area. • Leaving a computer unattended in an accessible area with record info unsecured • Failing to log off • Sharing or exposing passwords • Improperly accessing, reviewing and/or releasing info to media or other individuals
HIPAA of 1996 • Health Insurance Portability and Accountability Act • Final regulations published in December 2000 • Modified and released in August 2002. • Every nurse undergo training about the HIPAA to maintain confidentiality. • Includes punishment for anyone violating privacy • Fines: $250,000.
Permitted Disclosure • Authorization Rule • Release of patient’s health information (PHI) for purposes other than treatment, payment and routine health care operations authorization form must be signed. • 3 exceptions: • Public health activities • Law enforcement and judicial proceedings • Deceased individuals – for coroners, MEs and funeral directors, organ donations
Incidental Disclosure • Secondary disclosure that can not reasonably be prevented. • Limited in nature and occurs as a by-product of an otherwise permitted use or disclosure • Examples: • Use of sign-in sheets • Possibility of confidential conversation being overheard • Placing patient charts outside exam rooms • Use of white boards; calling out names in the waiting room; leaving appointment reminder voicemail msgs
QUESTION Choose all that apply: Which of the following documentation guidelines are correct? • Enter information in a complete, accurate, concise, factual, and organized manner. • Use word such as “good”, “average”, “normal” or “sufficient” to communicate judgment about data. • Wait until the end of shift to document nursing interventions to ensure comprehensive charting • Date and time every entry.
ANSWER 1 & 4 • Enter information in a complete, accurate, concise, factual and organized manner. • Date and time every entry.
Important concepts: • Agency policies indicate which personnel are responsible for recording on each form in the record. • Additional policies regarding: • Frequency of entry • Recording of routine care • Identification manner of personnel after an entry • Manner in which recording errors are handled • Keeping of records – microfilmed or entered in to a computer • Types of abbreviations are acceptable
Other “do not use” abbreviations: • > or < - maybe misinterpreted as 7 or the letter L • Abbreviations for drug names • @ - mistaken for 2. • c.c. – mistaken for U; write “mL” • μg – mistaken for mg; write “mcg.”
Purposes of Patient Records • Communication • Diagnostic & therapeutic orders • Care Planning • Quality Review • Research • Decision Analysis • Education • Legal Documentation • Reimbursement • Historical Documentation
Communication • To help healthcare professionals from different disciplines communicate with one another. • Foster continuity of care • Keep in mind that other healthcare professionals make judgments about nurses and nursing’s contributions to the healthcare team on what is documented.
Diagnostic & therapeutic orders • The chart contains all the diagnostic studies ordered for the patient since admission. • Nurses should ensure that these orders are entered and implemented. • Orders should be written and signed except: • Emergencies (verbal orders) • Practitioner is unable to be present on the unit (telephone or faxed orders)
Diagnostic orders… (cont’d.) • Take order only from: (licensed and have credentials) • Physicians • Dentists • Psychologists • Podiatrists • Advanced practice nurses • Medical students: only when countersigned by the attending physician, nurse practitioner or a house officer
Verbal orders • Issued only during medical emergency when the physician/nurse practitioner is present but finds it impossible to write the order. • Order must be directly from the physician/nurse practitioner • Nurse receives, document and executes order • Mostly depends on agency policies.
Sample policy on verbal order documentation: • Record orders then read back the order to verify • Date and note the time orders were issued • Record V.O., name of physician, followed by nurse’s own name & title • After the conclusion of emergency, physician should review orders and sign orders. Date and note the time he/she signs the orders.
Telephone and Fax orders • Depends on agency policy. • Orders should be repeated back to the physician. • Must be transcribed on an order sheet. • Fax orders are acceptable as long as they are legible
Sample policy for telephone/fax orders • Physician or nurse practitioner should be referred to a house officer/ RN or registered pharmacist • Record the orders (T.O.) on patient’s record. Read the order back. • Date and note the time the orders were issued • Sign the orders with name & title • “Demerol 100mg IM now and q 4 hr p.r.n for pain. T.O. James E. Walker, MD/Mary Pint, RN”
Care Planning • Records help professionals how the patient is responding to the treatment plan from day to day. • Example: • If the patient is gradually becoming weaker and is not unable to tolerate ambulation, orders for physical therapy and other nurse-initiated ambulation will need to be modified.
Quality Review • Charts are usually evaluated for the quality of care patient’s received and the competence of the nurses • Nursing audits – random charts are selected and reviewed • Accreditations by agencies.
Research • Researchers use charts and study patient records. • Charts used in studies hoping to learn how best to recognize or treat identified health problems from the study of similar cases.
Decision Analysis • Charts/ records provide data needed by administrative strategies planners • Helps to identify needs and the means and strategies most likely to address needs • Record review might reveal: • Underused or overused services • Prolonged hospital stays • Financial information
Education • Healthcare students/professionals can learn a great deal about clinical manifestations of particular health problems. • Effective treatment modalities and factors that affect patient goal achievement can be highlighted.