Practical nursing clinical (online help)

Jack Fowler

PNC121StudentPPTDocumentation2221.ppt

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Documentation

What is Documentation?

It is a nursing action that produces a written account of pertinent patient data, nursing clinical decisions and interventions and patient responses in a health record (Potter & Perry, 2019).

It reflects the nursing care that is provided (CNO 2008).

Purpose of Nursing Documentation

Reflects a client’s perspective.
Communicates to all health care providers
Integral component of interprofessional documentation
Demonstrates the nurse’s commitment to safe, effective and ethical care
Meets the professional standard regulations

(CNO, 2008)

What Activities do Nurses Document?

What is a Medical Record? (Client Record or Chart)

A formal, legal document that provides evidence of a client’s care and can be written or computer based.

Although health care organizations use different systems and forms for documentation, all client records contain similar information.

Potter & Perry, 2019

Purpose of Medical Records (Client’s Records or Charts)

Facilitate interdisciplinary communication and care planning
Provide a legal record of care provided
Facilitate funding and resource management
Allow for auditing monitoring and evaluation of care provided
Serve as sources of research data and as learning resources for nursing and health care education

Potter & Perry, 2019

Access to Client’s Charts and Documentation

Where are client’s charts kept in community settings, hospitals, doctor’s offices, and long term care facilities?

Who has access to them?

Potter & Perry, 2019

Ethical and Legal Considerations of Documentation

Accurate documentation is one of the best defenses against a legal claim

. Documentation must be clear, concise, accurate, relevant, and completed in a timely manner.

Subjective opinions must be avoided and objective language should be used when documenting or reporting client care.

Potter & Perry, 2019

Legal Guidelines for Documentation

What legal guidelines should the nurse follow for documentation?

Potter & Perry, 2019

8 Common Charting Mistakes that can Result in Malpractice

Failing to record pertinent health or drug information

Failing to record nursing actions

Failing to record that medications have been given

Recording on the wrong chart

Potter & Perry, 2019

8 Common Charting Mistakes that can Result in Malpractice (cont’d)

Failing to document a discontinued medication

Failing to record drug reactions or changes in the patient’s condition

Transcribing orders improperly or transcribing improper orders

Writing illegible or incomplete records

Potter & Perry, 2019

CNO Documentation Standard

How does the nurse meet the CNO standards below?

Communication

Accountability

Security

CNO, 2088

Electronic Documentation

What do you think are advantages of electronic documentation?

What about disadvantages?

Potter & Perry, 2019

Security for Computerized Records

What can we do as students and nurses to prevent breaches of security for computerized records?

Potter & Perry, 2019

PHIPA ACT (2004)

PHIPA specifies that health information custodians should ensure that clients’ personal health information is kept confidential and secure.

PHIPA also ensures that clients have a right to access their health information records and sets out a process for access and corrections, should they be needed.

Potter & Perry, 2019

Confidentiality

Nurses must follow principles to maintain patient confidentiality

Only members of a health care team that are directly involved in a patient’s care have legitimate access to the patients record.

Potter & Perry, 2019

Content of Patient Record or Chart

Patient identification and demographic data
Informed consent
Advance Directives
Admission nursing history
Nursing problem/diagnosis and care plan
Record of nursing care treatment and evaluation
Medical history
Medical diagnosis
Therapeutic orders
Progress notes for various health care providers
Reports of physical exams and consults
Reports of diagnostic studies
Record of patient and family education
Summary of Operations and procedures
Discharge plans and summary

Potter & Perry, 2019

Guidelines for Quality Documentation

Factual

Accurate

Complete

Current

Organized

Compliant with Standards

Potter & Perry, 2019

Methods of Documentation

Narrative

Problem Orientated Medical Record (POMR)

Source Records

Charting by exception

Case management and Use of Critical Pathways

Potter & Perry, 2019

Narrative Charting

Narrative: The use of a story-like format to document information. This method can be time consuming and repetitious.

Potter & Perry, 2019

Problem-Oriented Medical Records

Consists of database, problem list, care plan and progress notes

Progress notes follow POMR format of SOAP, SOAPIE, PIE or DAR

Potter & Perry, 2019

SOAP & SOAPIE

S – Subjective
O – Objective
A – Assessment
P – Plan

I - Intervention
E - Evaluation

Potter & Perry, 2019

PIE

P- Problem

I – Intervention

E - Evaluation

Potter & Perry, 2019

DAR Note

D – Data

A – Action

R - Response

Potter & Perry, 2019

Source Records

Organized so each discipline makes notations in a separate section

Disadvantage is that information about a particular problem is distributed throughout the record

Potter & Perry, 2019

Charting by Exception

The philosophy behind charting by exception (CBE) is that a patient meets all standards unless otherwise documented

The predefined statements used to document nursing assessment of body systems are called within defined limits (WDL) or within normal limits (WNL) definitions. They consist of written criteria for a “normal” assessment for each body system.

Potter & Perry, 2019

Case Management Model

Emphasizes quality, cost effective care delivered within an established length of stay.

Uses a multidisciplinary approach to planning and documenting client care by using critical pathways.

Potter & Perry, 2019

Critical Pathways

Critical pathways (also known as clinical pathways, practice guidelines, or CareMap tools) are interprofessional care plans that identify patient problems, key interventions, and expected outcomes within an established time frame.

Potter & Perry, 2019

Common Record Keeping Forms

Admission Nursing History Form

Flow Sheets and Graphic Records

Patient Care Summary or Kardex

Standardized Care Plans

Discharge Summary Forms

Potter & Perry, 2019

Guidelines for Home Health Care Documentation

Potter & Perry, 2019

Patients/family members complete documentation, nurse often teaching and helping client and family members achieve greater independence.

Documentation needs to provide the entire health care team with information to work effectively together.

Potter & Perry, 2019

Documentation in the Long-Term Health care Setting

Daily documentation often occurs on flow sheets with progress notes only for changes in condition, specific incidents or weekly assessments

May have paper charts and electronic documentation

Potter & Perry, 2019

Documentation using the Nursing Process

Assessment data: Initial assessment forms, flow sheets, progress notes (nurses’ notes)

Nursing diagnoses: Care plans, critical pathways, progress notes, problem lists

Planning: Nursing care plans, critical pathways, Kardex

Implementation: Progress notes, flow sheets

Evaluation: Progress notes

Potter & Perry, 2019

Telephone, Verbal and Written Orders

TO: Health care provider gives orders over the phone

VO: Health care provider gives orders to a registered nurse while they are standing near each other.

Written orders: may be transcribed by nurses or pharmacist. Need to clarify all orders if unsure.

Potter & Perry, 2019

Incident or Occurrence Reports

An incident or occurrence is any event that is not consistent with the routine, expected care of a patient or the standard procedures in place on a health unit

An incident report is completed whenever an incident or occurrence occurs

Potter & Perry, 2019