By: Cindy Quisenberry. Care Plan – a written, interdisciplinary document developed for each...

DocumentationBy: Cindy Quisenberry

Documentation• Care Plan – a written, interdisciplinary

document developed for each patient, listing the patient’s needs and goals as well as the actions and approaches that staff will take to help the patient meet their goals

Documentation• Documentation – written reports that the

facility maintains• Objective – information that can be observed;

factual; not subjective• Subjective – guess or hunch about what you

observe, or something a patient feels inside and tells you about (not objective)

Documentation• Assessment – an evaluation of a patient or

condition• Minimum Data Set (MDS) resident information

on the RAI, including levels of physical functioning and bowel and bladder continence

• Resident Assessment Instrument (RAI) – an assessment tool used in long term care facilities to document key information about residents including their care plans and outcomes

Documentation• Resident Assessment Protocols (RAPs) –

section of the RAI that includes a more detailed assessment of problem areas

• Quality Indicators – outcomes or a summary of the entire facility’s MDS information, which indicates the quality of care provided by a facility– Summary report can tell an agency (for example)

how many residents have pressure ulcers, etc.

Documentation• Think back to a special event you experienced

months ago, like a birthday or holiday. Try to remember the event in detail.

• What were people wearing? • What did they talk about?• What did they eat and how much?• What was their mood?• What time did each person come and go?

Documentation• You have probably forgotten many facts. It’s

only human to forget details like these.• Because of memory limits, we often have to

write things down. • If we do not write down details, the only known

“facts” might be what we happen to remember.• We do not know at the time how important

some details could be later on.• Therefore, the documentation you do on the job

is essential so that we do not loose information.

Documentation• Some written notes may be used months or

years later. • You and others in a facility can later state facts

with certainty because you wrote them down.

Documentation• Sources of Information– The patient is usually the main source of

information• Their needs• Their preferences• Verify with the charge nurse, etc.; some patient’s might

be confused.

– The Family– Other Staff

Documentation• Sources of Information– The Chart (Medical Record)• Main communication tool used by the interdisciplinary

team• Legal Record• Basic Tool for Planning, Recording, and Evaluating Plan

of Care• Confidential and Belongs to the Facility• Must be Complete and Accurate

– If it isn’t charted, it wasn’t done

• Contains the Patient’s Medical Hx, Current Records, Care Plans, Medication Records, etc.

Documentation• The Chart Contains– Patient’s identifying Information (Face Sheet or

Demographic Sheet)• Name • Medical Record Number• DOB, etc.

– Admission Papers (reason for admission)– Permission Forms • Consent to Treat• Instructions• DNR

Documentation• The Chart Contains– Sections of Documentation (from individual

disciplines)• Physician’s Orders• Nurse’s Notes• Graphics or Flow Sheets (VS’s, I & O, ADL’s, BM’s, etc.)• Progress Notes

– Physician– Physical Therapy– Respiratory Therapy– Dietary

• Lab, X-rays, etc.

Documentation• Other Communication Devices and Systems– Patient Wristbands– Colored Wristbands– Words or Symbols on the Patient’s Door, Bed or

Chart

Documentation• Facility Policies and Procedures– Rules for how to do things in the facility– Tell you how and why things are done• Completing the Personal Possession Record• Residents Leaving the Facility• HIPAA

If you are unsure of anything when talking with members of the team, the resident or family members, just ask. Don’t assume anything you are not sure of.

Documentation• Resident Assessment – CNA’s area key part of

gathering data, because they spend so much time with the residents– RAI-is first completed on a resident on admission,

and a new assessment is done at least yearly or whenever the resident’s condition changes (improvement or decline)• Five Parts

– The Minimum Data Set (MDS) – Done on Computer– Resident Assessment Protocols (RAPs)– Care Plan Development– Care Plan Implementation– Evaluation and Outcome

Documentation• RAI - different sections are completed by

different staff members– Nursing Section – Nurses complete this section,

however the nurse will ask the CNA for information• Examples

– Objective Data – “Mr. Brown puts on his own shirt, but he doesn’t button the buttons himself.”

– Subjective Data – “I think he could button his shirt if he had bigger buttons.”

Documentation• RAPs – done after the MDS is completed; a

detailed assessment of possible problem areas– Example• Mobility Problem

– Gives the staff additional information or “protocols” to determine if there is a problem

Documentation• Care Plan – an interdisciplinary document that

lists a resident’s needs and goals as well as the actions and approaches the team will use to help the resident to meet their goals.

• Use of the care plan ensures consistent care• List each patient’s medical, nursing and

psychological needs.• Good communication skills are needed in

care-plan meetings because many people are sharing a lot of information

Documentation• Care Plan– Problem - Poor appetite and weight loss since

beginning chemotherapy– Nursing Diagnosis – Imbalanced nutrition; less

than body requirements related to decreased appetite secondary to chemotherapy

– Goal – Patient will gain 2 pounds within three weeks

– Plan• Dietary and physician consult• Weigh every Friday morning

Documentation• Care Plan– Plan• High Calorie Diet• Monitor Intake and Output• High protein drink at 1000 and qhs• Offer ice cream if refuse to drink high protein drink

(resident likes ice cream)• Offer snack at bingo• Son will eat with resident at noon• Serve try in A wing lounge

Documentation• How to Report Information– Use a private place to give an oral report– Be careful when talking with family members and

visitors– Routine Reporting – reported at the end of a shift• What did you see, hear, smell, or touch when caring for

each patient?• Was anything new or changed?• Did I meet each resident’s needs?

Documentation• How to Report Information– Immediate Reporting• Frayed electrical cord• Any unusual incident, such as a resident’s fall• Any suspicion of resident abuse• Any resident’s complaint of ill health, such as a

complaint of pain or dizziness• Any unusual observations, such as a resident’s

temperature of 103 F or confusion and agitation in a normally alert resident

Documentation• How to Report Information– “By a Certain Time” Reporting• Example – the nurse may need a resident’s

temperature before the physician calls

Documentation• Incident Reports– Document an accident or an injury• Provide information about what happened• Protect residents, you, the facility, and others• Documents the incident and all related facts• May give information about what you:

– Heard– Saw– Smelled– Touched

• Do not document in the patient’s chart that you filled out an incident report

Documentation• Documentation:– Helps you to notice changes in the patient’s

condition (ie: comparing blood pressures) and the need for reporting

– Helps you watch trends as well as changes– Be sure you understand your facility’s policies and

procedures for your documentation– Some facilities use checklists or a combination of

different charting methods.

Documentation• Documentation may include:– General statements of care given– The resident’s appointments and activities– Any complaints from the resident– General statements about the resident’s

psychological well-being– Visitors, including physician’s visits

Documentation• Guidelines for Documentation (to prevent

misunderstandings)

– The patient’s name should be on every page.– Write all entries in permanent black ink, not pencil or

felt tip markers that may smear when wet.– Write each entry so that it is easy to read.– Charting is continuous. Do not leave spaces or skip

lines between entries.– Document only your own actions and observations.– Do not tamper with or change entries made into the

chart unless you make an error. If you make an error, correct it immediately and properly.

Documentation• Guidelines for Documentation (to prevent

misunderstandings)

– Use standard medical terminology and standard abbreviations.

– Write down the date and the time of each entry as required.

– Sign each entry and include your title after your name. In some cases you may initial the entry when your signature is somewhere else on the form.

Documentation• Correcting a Mistake– Draw a single line through the word.– ? Print the word “error” above or beside the word

(depends on the facilities policy).– Add your initials and date above it.– Then write the correct word before continuing– Do not try to cover an error with “x’s” or scribble all

over it, use white out, etc.– If you are correcting a large amount of writing, be

sure to write the reason you are making the correction. (discovered that you wrote information on the wrong patient’s chart)

Documentation• Correcting a Mistake– Do not try to erase a mistake. (NEVER erase a

mistake)– Ask someone for help if you cannot figure out how

to clearly correct a documentation mistake.

Documentation• The interdisciplinary care team uses the

minimum data set (MDS) to:a. Make roommate assignmentsb. Develop a resident’s care planc. Keep a record or monthly expensesd. Teach nurse assistants correct medical

terminology

Documentation• Who is the primary source of information

about a resident?a. The residentb. The charge nurse c. The social workerd. The resident’s physician

Documentation• A medical record is used to maintain:

a. The facility’s financial informationb. The facility’s equipment maintenance recordc. Lab results and reports by all care staffd. Correspondence between the resident and their

family

Documentation• Mr. Houston’s weight is checked each day.

Before the end of your shift, you would record this information on:a. A wall calendarb. A flow sheetc. The Quarterly Review formd. The Resident Assessment Protocols

Documentation• You have just taken Mrs. Cotton’s

temperature. It is 98.4˚. This is a type of:a. A wall calendarb. A flow sheetc. The Quarterly Review formd. The Resident Assessment Protocols

Documentation• The minimum data set (MDS) is one part of

the:a. Quality indicatorsb. Resident’s care planc. Resident Assessment Instrument (RAI)d. Resident Assessment Protocols (RAPs)

Documentation• A resident’s care plan is used as a tool to:

a. Determine whether the resident qualifies for Medicaid payments

b. Invite family members to facilities partiesc. Plan for new building improvementd. Coordinate all treatments and services for the

resident

Documentation• Your role in the care plan meeting includes:

a. Sharing information about the residentb. Serving coffee and doughnuts to the

interdisciplinary teamc. Deciding which doctors and nurses should attendd. Diagnosing the resident’s medical condition

Documentation• Routine information about residents is usually

shared with the charge nurse:a. On your lunch breakb. At the end of your shiftc. During weekly personnel meetingsd. Immediately

Documentation• When you write in a resident’s chart, you

should:a. Erase any mistakes and then write in the correct

informationb. Get the doctor’s permission before you write

anythingc. Write neatly and legiblyd. Correctly any mistakes you see that were made

by others

By: Cindy Quisenberry. Care Plan – a written, interdisciplinary document developed for each...

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