Documentation

VN230 Vocational Nursing Spring 2007

What is Documentation 
 

Anything written or printed Relied on as a record of proof for authorized persons Vital part of professional practice

What is Documentation 

Nightingale described the need for nurses to record "the proper use of fresh air, light, warmth, cleanliness, & the proper selection & administration of diet".

What is Documentation 

In Nightingale's time, documentation was a way to communicate implementation of MD orders & not a means to observe or assess the patient's status, as it is today

Purposes of Documentation 

Quality of care
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provides evidence that care was necessary describes responses to care describes any changes made in plan of care plan interventions decision making about ongoing interventions evaluation of patient's progress used by all team members 

Coordination of care
± ± ± ±

Purposes of Documentation 

Accrediting & licensing
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±

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JCAHO provides eligibility for government funding JCAHO accreditation demonstrates that facility provides quality care clinical records are reviewed to ensure the facility meets the required standards assessed for ongoing compliance

Purposes of Documentation 

Accrediting & licensing cont¶d
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common standards for documentation 
   

assessment plan of care medical orders progress notes discharge summary

Purposes of Documentation 

Quality assurance monitoring
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committees use established indicators to monitor & evaluate the contents of the clinical record when the care described in the clinical record doesn't meet an established indicator of care, the committee decides what action to take to correct the problem

Purposes of Documentation 
  

Peer review Requirements for reimbursement Legal protection Research & continuing education

Guidelines for Documentation 


Purpose
±

Prevention of errors Consistent with standards Complete, Accurate, Relevant, Factual, Timely Orderly & Sequential Legally prudent Confidential

Guidelines
± ± ± ± ±

Purposes of Patient Records 
       

Communication Care Planning Quality Review Research Decision Analysis Education Legal Documentation Reimbursement Historical Documentation

Communication 


Primary purpose Used by all team members

Care Planning 
 

Plan interventions Decision making about ongoing interventions Evaluation of patient's progress

Quality Review 
     

Provides evidence that care was necessary Describes responses to care Describes any changes made in plan of care JCAHO provides eligibility for government funding JCAHO accreditation demonstrates that facility provides quality care Clinical records are reviewed to ensure the facility meets the required standards Assessed for ongoing compliance

Research  

Can supply data for a study [to determine validity of nursing diagnoses] Research studies can then lead to improved documentation

Decision Analysis 
 

Used in strategic planning Identification of under/overused services Cost control

Education 
 

Clinical manifestations Effective treatment modalities Factors affecting patient goal achievement

Legal Documentation 
 



To you, other caregivers, facility, & patient Admissible in court as a legal document & serve as evidence Proof of quality of care given What you document - or don't document can mean the difference between winning & losing court cases

Reimbursement  

Determine amount of reimbursement Look for inconsistencies in documentation [discrepancy between treatment ordered & treatment provided]

Historical Documentation 

Past history information

Nursing Documentation 

Narrative Notes /is a traditional part of the ³Source Oriented record´
± ± ±

Diary or story format: oldest form of documentation ³oldschool method´ Paragraph describing patient's status, interventions & treatments, and patient's response to interventions Chronological Problem oriented medical record (POMR) documentation method 

SOAP, SOAPE, SOAPIE, SOAPIER
±

Nursing Documentation 

PIE
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Problem oriented medical record (POMR) Originated from nursing process Documents: problems, interventions, & evaluation of nursing care Incorporates plan of care into daily documentation

Nursing Documentation 

PIE cont¶d
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Simplifies documentation process, unifies plan of care & progress notes, and provides concise record of nursing care planned & provided Patient care & assessment flow-sheet and progress notes (*) represents deviations from normal Document specific problems on progress notes Generate problem list

Nursing Documentation 

Focus Charting
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³DAR´ nsg. note or *³AIO´ note=Los Al 
 

Organizes narrative documentation to include data, action, & response for each identified concern Focus is key word used to describe concerns & eliminates negative connotations of the word problem Focus may be nursing diagnoses or behavior/concern, signs & symptoms, acute change in status, significant patient care event

Nursing Documentation 

DAR cont¶d 
    

Organized in columns Data: subjective or objective Action: nursing interventions Response: patient's response to interventions Tasks & assessments documented on flow sheets AIO=assessment; intervention; outcome used at Los Alamitos Hospital basically the same as DAR

Nursing Documentation 

Charting by Exception (CBE)
± ± ± ± ± ± ±

Flow sheets and / Place Check-marks if normal Documentation by reference to standards of practice Eliminates repetitive charting: Nursing data base Nursing diagnosis-based care plans Only significant findings or exceptions to norms are recorded =* describe abnormals in narrative style Fast-charting! Often documentation forms (graphs, checklists/flowsheets are at the bedside

Nursing Documentation 

CBE cont¶d
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Use of specific abbreviations ˜ = assessment complete; WNL * = significant abnormal findings; note written p = status remains unchanged from previous asterisk

Nursing Documentation 

Variance Charting (VAR)
± ± ± ± ±

Unexpected event Cause of event Actions taken Discharge planning Response

Nursing Documentation 

Computer-based Records
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Standardization Legible Follow policies and procedures to ensure confidentiality 

HIPPA (Health Insurance Portability & Accountability Act of 1996)

Formats of Nursing Documentation 
    

Initial Nursing Assessment Kardex and Patient Care Summary Plan of Nursing Care Critical/Collaborative Pathways Progress Notes Flow Sheets

Formats of Nursing Documentation 

Flow Sheets
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Graphic record 24-hour fluid balance Medication record (MAR) 24-hour patient care records

Progress Notes Medication Graphic Flow Sheet 

  

Acuity charting forms Discharge/transfer summary Home healthcare documentation Long-term care documentation

Legal Aspects of Charting 
 

  

Do not erase, use white-out, or scribble out errors Do not write retaliatory or critical comments; do not place blame Correct all errors promptly Spell correctly Record all facts in objective terms Document completely [in court - if it's not documented, it wasn't done]

Legal Aspects of Charting   



Be accurate about time & chart as soon as possible after an event Document omissions (med not given or treatment not completed) & reason & actions taken Do not leave blank spaces Record legibly & in black ballpoint pen

Legal Aspects of Charting 
   

Use only approved abbreviations Record clarification requests &/or corrections Chart only for yourself Avoid vague statement Begin with time and end with appropriate signature

Reporting 

Change-of-shift report
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Accurate information Factual information Organized What & how you say it can make a big difference in quality of care Avoid negativism & subjectivity Use written or printed guide to prompt thoroughness & organization

Reporting 

Change-of-shift report cont¶d
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Give background information first Be specific & avoid vague terms Describe presence of all invasive treatments Stress abnormal findings and variations from routine or the norm

Reporting 

Telephone report
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Nurse to MD Nurse to nurse Nurse to lab, dietary, etc Document time, persons involved, information given/received Be clear, accurate, & concise

Reporting 

Transfer report
± ± ± ± ± ± ± ± ±

Unit to unit Acute care to LTC Summarize medical progress Background information Current status Current nursing diagnoses Critical assessments or interventions to be completed shortly after transfer Special considerations Need for special equipment

Reporting 

Incident report
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±

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To document any occurrence not consistent with routine operation or care Used for quality improvement to document trends and areas needing changes Complete even if no injury occurs Routed to risk-management

Reporting 

Incident report cont¶d
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Be concise & accurate; report exactly what was observed & what action was taken Do not try to explain the cause or make excuses Do not place blame in the report Do not specify in the medical record that an incident report was prepared Do not make a photocopy of the report

Conferring 
 

Consultations and Referrals Nursing care conference Nursing care rounds

Skills Used in Documentation 
  

Cognitive Technical Interpersonal Ethical/Legal

Summary 

Documentation
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Conferring
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Written Legal record Uses nursing process Oral Written Computer-based 

Reporting
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Consultations Referrals Nursing care conference Nursing care rounds

QUESTIONS

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