1. Documentation and RecordingCommunication with the Healthcare Team Subtitle

2. Document and Reporting Ensures quality of care Regulatory agencies require it Medicare reimbursement depends upon it Shows nursing action Serves as a legal document

3. Reporting Summary of activities, observations, and actions performed Objective and non-judgmental

4. Reports Oral or written Shift report Verbal reports to physicians Miscellaneous Written lab reports Dietary reports Social workers notes PT, OT, Speech therapies

5. Types of Reports Change of shift Oral, audiotape, rounds Telephone Transfer Incident Any event not consistent with routine care of client Concise, objective Not a part of the chart Oral, audiotape, rounds

6. Confidentiality Law protects any information gained by exam, observation, conversation, or treatment Information not discussed or shared with anyone not directly involved in patient’s care Nurses are legally and ethically obligated to keep patient information confidential

7. Medical Records Permanent written communications Continuing account of care status Discussion, discharge planning, conferences, consultations All caregivers can benefit from information and plan accordingly

8. Purpose of Records Communication Financial billing Education Assessment Research Auditing and monitoring Legal documentation

9. Documentation Anything written or printed that is relied upon as a record of proof for authorized persons

10. Standards for Documentation Federal regulations-Medicare and Medicaid State and Federal regulations – JCAHO Professional standards – ANA Facility policies- charting techniques and responsibilities

11. Legibility All charting should be easy to read Reduces errors May be used in court years after care given

12. Factual Descriptive, objective information Decreases misinterpretation Do not use “seems”, “appears”, “apparently”, “good” “well” Subjective information is documented with client’s own words in quotations No opinions

13. Complete and Concise Thorough, exact, brief, and NO blah, blah, blah blah Clear and succinct Eliminate irrelevance Short and to the point (long notes difficult to read) Too abbreviated gives impression of being hurried and incomplete

14. Timeliness Delay in reporting can result in serious omissions and delays in care Late entries may be interpreted as negligence Certain things must be reported at time of occurrence Routine activities need not be charted immediately Military time used No leaving until important information recorded Avoids errors and duplication of care

15. Accurate Reliable and precise Exact measurements when possible Use only accepted abbreviations Spell correctly

16. More accuracy No charting for someone else Student’s notes are countersigned by person who assured care was given Descriptive entries signed with full name and status (first initial, last name, and title)

17. Guidelines for Documentation and Reporting Certain abbreviations not acceptable Abbreviations used

18. Organization Logical format and order Chronological flow of events

19. Chart Components Data base Assessment data Problems list Care plan Progress notes Narrative Flow sheets Discharge planning summaries

20. Documentation Methods Problem oriented medical record S.O.A.P. or S.O.A.P.I.R P.I.E. Source records Charting by exception Flow sheets Focused charting D.A.R.

21. Problem Oriented Medical Record Focus on patient’s problems Follows the nursing process Organized by problems or diagnoses Coordinated care

22. Advantages of POMR Easy to retrieve information and follow progress Easy to monitor for QA purposes SOAP notes establish structure that reflects what nurses do

23. PIE Charting PIE Daily assessment data appears on flow sheets Continuing problems documented daily Focuses exclusively on single client problem

24. Source Records Each discipline has a separate section of the chart for recording Can easily locate proper section Examples: admission sheet, physician's order sheet, history and physical, flow sheets, nurses notes, medication record

25. Charting by exception Reduces repetition Clearly defined standards of practice and predetermined criteria Nurses documents only significant findings or exceptions Preventive and wellness-focused functions not documented

26. Focus Charting - DAR Easily understood and adaptable to most settings Reflects analysis and conclusions Does not indicate problem assessment

27. Standardized Care Plans Pre-printed and established guidelines for clients with similar problems Improved continuity Less time to document Inhibits unique or individualized therapies

28. Writing the Nursing Care Plan Prioritize problems ABC’s Maslow Problems perceived by patient

29. Formats 5 columns Assessment data or defining characteristics Diagnosis Goals/outcomes Interventions Evaluation Concept Map Same five components linked by rationales Better indicates process of critical thinking

30. Critical Pathways Documentation tool to integrate standards of care for multiple disciplines List problems, key interventions, expected outcomes, expected timelines Attempt to control and decrease length of stay

31. Discharge Summaries Multidisciplinary involvement is required by HCFA Client leaves hospital in timely manner with the necessary resources Client signs original for chart and takes copy home

32. Kardex Information Medication IV’s Treatments Diagnostic procedures Allergies Data Problem list

33. Computer Documentation Saves time in storage and retrieval Information is permanent Various departments can coordinate information Can be used at the bedside

34. Protocol Charting Newest method Primary use in outpatient care Written for use as a references or guide for care Individualized, current, according to intended purpose