Documentation: What you need to know!

1. Documentation: What you need to know! Kindred Hospital Louisville Shannon Ash, RN, BSN

2. Sometimes documentation is funny...

3. Or just doesn’t quite come out right! • “Patient has chest pains if she lies on her left side for over a year.” • “By the time she was admitted to the hospital her rapid heart had stopped and she felt much better.” • “On the second day the knee was much better, and by the third it had completely disappeared.” • “While in the emergency department she was examined, x-rated and sent home. “ • “Healthy appearing, decrepit 69-year old female, mentally alert but forgetful.”

4. Funny? • While the humor can certainly be seen in some charting ‘mistakes’, every mistaken entry has the potential to cause problems for patients & for staff.

5. Purpose of the medical record • The medical record should be a complete and accurate record of the patient's condition and treatment. It should allow for clear communication between members of the healthcare team. • It is the basis for evaluating health care operations and how resources are utilized by providing research data and determining reimbursement by third party payers. • It also serves to pursue or defend from medical malpractice claims.

6. Importance of Medical Record • The reasons for maintaining a medical record clearly illustrate the extreme importance of maintaining an accurate, thorough medical record. • Inaccuracies and omissions can lead to poor communication, bad continuity of patient care, potential lack of reimbursement for care, and can open up the hospital & caregivers to liabilities.

7. Liability • The word liability means “the quality or state of being obligated according to law or equity”. • It means being responsible for something, in this case, being responsible for the care delivered to a patient of our hospital.

8. Liability • Who has liability? • the Hospital • Physicians • Hospital Administration • Direct providers of care • Indirect providers of care

9. Golden Rule of Charting #1 • Chart in “real time”. • Chart things as they happen. This makes your findings more likely to be charted accurately, decreases confusion about what happened when, and makes your documentation more credible.

10. Golden Rule of Charting #2 • Only chart what you know! • If you enter a room and find a patient on the floor, don’t chart “patient fell out of bed onto floor”. You don’t know that’s what happened!! • Instead, document “Patient found sitting in floor. Patient states “I tried to get out of bed and slipped.””

11. What happened here? Did the person who charted this witness the event, assume that what is described is what happened, or did the patient report that it happened this way? This type can make the information unclear. If this was witnessed, it is better to say “Witnessed patient sliding to end of chair and chair flipping over on top of patient. Tried to prevent patient from sliding out, but was unable to reach patient in time.”

12. Much clearer This charting tells us much more clearly what happened. It’s obvious the caregiver didn’t see the patient pull the tube out, but documented subjectively what happened. Don’t forget that any situation like the two described on these pages also warrants an event report to be filled out completely.

13. Golden Rule of Charting #3 • Chart only things YOU do. • Don’t chart things that are done by other staff members. For example, if a CNA obtains vital signs on a patient, the nurse shouldn’t chart them. Your charting something means YOU did it.

14. Not your work! The above note describes Hydromorphone being given IV x 2, not something within the scope of practice by an LPN. This charting could leave it open to interpretation that this person gave the meds. If it was given by someone else, THEY should chart it.

15. Golden Rule of Charting #4 • Use subjective terminology. • Instead of saying “I talked to the family member on the phone…” you should document “Spoke with daughter on the phone…” • There’s no need to chart “this therapist or this nurse” did something. If you are charting it, the presumption is that you did it!

16. Not as good Better

17. Golden Rule of Charting #5 • Proofread your charting! • You can provide the absolute best care in the world to your patients, but if your charting has typo’s, misspellings and mistakes, it can appear that you aren’t careful or that you’re prone to mistakes. • That’s not an image you want to project.

18. Documentation Tips • Document professionally. • If you must refer to other people, refer to them by their full names and titles. • Spell words correctly. • Don’t use slang or unapproved abbreviations. • Don’t gossip or speculate in the patient’s chart. • Use punctuation!

19. Things that should not be charted This sounds bad to everyone who reads it. Chart what you did (i.e., gave the medication, and rescheduled the lab draw). Make an event report if a medication error is made - and not giving a medication at the appropriate time IS a medication error.

20. Things that should not be charted This note would have been fine if it weren’t for the line with the extreme use of exclamation points. The tone of the note is blatantly critical. Report factually what happened. Not emotionally.

21. Too casual Talking about Michelle and Buffy is fine if you guys are hanging out. Documenting “Michelle” and “Buffy” is not appropriate in a patient’s chart.

22. Make Sure You Chart • Change of conditions • Resuscitation records (in computer too!) • IV Bag & tubing changes

23. Don’t Chart • Administrative problems like “short of staff” etc. • Equipment problems (“glucometer display hard to read”) • Judgemental words “has an abrasive voice” “obnoxious and manipulative” • Meaningless expressions like “pt had a good night” use specific examples.

24. Don’t chart the same thing on every patient every day! If the patient is resting in bed quietly, great, but that shouldn’t be the ONLY thing you chart. Never use slang or profanity. Don’t criticize or make judgements about care other care that is done. If your professional opinion is that the care ordered isn’t the most appropriate - inform a supervisor immediately. Important Documentation Tips

25. Important Documentation Tips • Don’t “double chart”. If you’re reporting changed / altered / new vital signs, don’t make a progress note on it - put it under the vital signs section! • Don’t ramble! Rambling charting makes you sound disorganized or not under control. • Re-read your progress note after you’ve written it. Have someone else read it if you’re not sure.

26. Happy Charting! • Charting should be like every other aspect of your care: • Thoughtful • Careful • Detailed • Informative • Accurate