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Transcript of Chapter 16 Documentation and Reporting. 16-2 Copyright 2004 by Delmar Learning, a division of...
Chapter 16
Documentation and Reporting
16-2Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
Documentation as Communication
Communication is a dynamic, continuous, and multidimensional process for sharing information.
Reporting and recording are the major communication techniques used by health care providers.
16-3Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
Documentation as Communication
The medical record serves as a legal document for recording all client activities by health care practitioners.
16-4Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
Documentation as Communication
Documentation is defined as written evidence of:• The interactions between and among health
professionals, clients, their families, and health care organizations
• The administration of tests, procedures, treatments, and client education
• The results or client’s response to these diagnostic tests and interventions
16-5Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
Documentation as Communication
Nurses rely on charting, records, and systems that support the implementation of the nursing process.
Systematic documentation is critical to presenting the care administered by nurses in a logical fashion.
16-6Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
Documentation as Communication
Critical thinking skills, judgments, and evaluation must be clearly communicated through proper documentation.
16-7Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
Purposes of Health Care Documentation
Professional Responsibility and Accountability
Communication Education Research Legal and Practice Standards
16-8Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
Purposes of Health Care Documentation
Recording provides written evidence of what was done for the client, the client’s response, and any revisions made in the care plan.
16-9Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
Purposes of Health Care Documentation
Recording documents compliance with professional practice standards and accreditation criteria.
Written records are a resource for review, audit, reimbursement, and research.
Documentation provides a written legal record to protect the client, institution and practitioner.
16-10Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
Purposes of Health Care Documentation
Education• Health care students use the medical record
as a tool to learn about disease processes, diagnoses, complications, and interventions.
• Clinical rounds and case conferences rely heavily on information contained in the medical record.
16-11Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
Purposes of Health Care Documentation
Research• Researchers rely heavily on medical records
as a source of clinical data.• Documentation can validate the need for
research.
16-12Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
Purposes of Health Care Documentation
Legal and Practice Standards• In 80% to 85% of malpractice lawsuits
involving client care, the medical record is the determining factor in providing proof of significant events.
16-13Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
Legal and Practice Standards
Informed Consent Advance Directives American Nurses Association (ANA)
Standards of Care State Nurse Practice Acts Joint Commission on Accreditation of
Health Care Organizations (JCAHO)
16-14Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
Legal and Practice Standards
Informed consent means that the client understands the reasons and risks of the proposed intervention.
Witnessing confirms that the person who signs the consent is competent.
16-15Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
Legal and Practice Standards
An advance directive allows the client to participate in end-of-life decisions.
The Patient Self-Determination Act of 1990 requires health care facilities to document whether the client has such a directive.
16-16Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
Legal and Practice Standards
American Nurses Association Standards of Care make explicit the role of data collection and documentation in nursing practice.
16-17Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
Legal and Practice Standards
State Nurse Practice Acts have established guidelines to ensure safe practice.
Require evidence of compliance through documentation.
16-18Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
Legal and Practice Standards
The Joint Commission on Accreditation of Health Care Organizations (JCAHO) requires documentation of compliance with its standards of care requirements.
16-19Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
Purposes of Health Care Documentation
Reimbursement• Peer review organizations (PROs) are
required by the federal government to monitor and evaluate care.
• Medical record documentation is the mechanism for the PRO review.
16-20Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
Purposes of Health Care Documentation
Reimbursement • Diagnosis-Related Groups (DRG)
- The medical record must provide documentation that supports the DRG and appropriateness of care.
- If nurses fail to document the equipment or procedures used daily, reimbursement to the facility can be denied.
16-21Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
Purposes of Health Care Documentation
Reimbursement • Consolidated Omnibus Budget (COBRA)
Reconciliation Act- Any COBRA client receiving care in an
emergency room must be stabilized before being transferred to another facility.
- Facilities in violation of COBRA laws are fined and may lose their eligibility for Medicare and Medicaid funding.
16-22Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
Principles of Effective Documentation
Nursing notes must be logical, focused, and relevant to care, and must represent each phase of the nursing process.
Nursing documentation based on the nursing process facilitates effective care.
16-23Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
Elements of Effective Documentation
Use of Common Vocabulary Legibility Abbreviations and Symbols Organization Accuracy Documenting a Medication Error Confidentiality
16-24Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
Elements of Effective Documentation
Use of Common Vocabulary• Enhances the quality of documentation.• Supports the efforts of research.• Improves communication and lessens the
chance of misunderstanding between members of the health team.
16-25Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
Elements of Effective Documentation
Legibility• Print if necessary.• Do not erase or obliterate writing.• Draw one line through an erroneous entry.• State the reason for the error.• Sign and date the correction.
16-26Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
Elements of Effective Documentation
Correcting a documentation error
16-27Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
Elements of Effective Documentation
Abbreviations and Symbols• Always refer to the facility’s approved listing.• Avoid abbreviations that can be
misunderstood.
16-28Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
Elements of Effective Documentation
Organization• Start every entry with the date and time.• Chart in chronological order.• Chart in a timely fashion to avoid omissions.• Chart medications immediately after
administration.• Sign your name after each entry.
16-29Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
Elements of Effective Documentation
Charting a late entry
16-30Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
Elements of Effective Documentation
Charting a prn medication
16-31Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
Elements of Effective Documentation
Accuracy• Use factual, descriptive terms to chart
exactly what was observed or done.• Use correct spelling and grammar.• Write complete sentences.• Maintain continuity of care by recording with
respect to notes made on previous shifts.
16-32Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
Elements of Effective Documentation
Documenting a Medication Error• Chart the medication on the MAR.• Document in the nurses’ progress notes:
- Name and dosage of the medication- Name of the practitioner who was notified of the
error- Time of the notification- Nursing interventions or medical treatment- Client’s response to treatment
16-33Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
Elements of Effective Documentation
Confidentiality• The nurse is responsible for protecting the
privacy and confidentiality of client interactions, assessments, and care.
• The client’s significant others, insurance companies, or other parties not directly involved in care provided by the health team may not have access to clients’ records.
16-34Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
Methods of Documentation
Narrative Charting Source-Oriented Charting Problem-Oriented Charting PIE Charting Focus Charting Charting by Exception (CBE) Computerized Documentation Case Management with Critical Paths
16-35Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
Methods of Documentation
Narrative Charting• Describes the client’s status, interventions
and treatments; response to treatments is in story format.
• Narrative charting is now being replaced by other formats.
16-36Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
Methods of Documentation
Source-Oriented Charting• Narrative recording by each member
(source) of the health care team on separate records.
16-37Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
Methods of Documentation
Problem-Oriented Charting (POMR)• Uses a structured, logical format called
S.O.A.P.- S: subjective data- O: objective data- A: assessment (conclusion stated in form of
nursing diagnoses or client problems)- P: plan
16-38Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
Problem-Oriented Charting (POMR)
Uses flow sheets to record routine care. A discharge summary addresses each
problem. SOAP entries are usually made at least
every 24 hours on any unresolved problem.
SOAP was developed on a medical model.
16-39Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
Problem-Oriented Charting (POMR)
SOAPIE and SOAPIER refer to formats that add:• I: Intervention• E: Evaluation• R: Revision
16-40Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
Problem-Oriented Charting (POMR)
16-41Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
Methods of Documentation
PIE Charting• P: Problem• I: Intervention• E: Evaluation
Key components are assessment flow sheets and the nurses’ progress notes with an integrated plan of care.
PIE charting is a nursing model.
16-42Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
Methods of Documentation
16-43Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
Methods of Documentation
Focus Charting• A method of identifying and organizing the
narrative documentation of all client concerns.
• Includes data, action, response.• Uses a columnar format within the progress
notes to distinguish the entry from other recordings in the narrative notes.
16-44Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
Methods of Documentation
Charting by Exception (CBE)• The nurse documents only deviations from
preestablished norms.• Avoids lengthy, repetitive notes.• Enables the identification of trends in client
status.
16-45Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
Methods of Documentation
Computerized Documentation• Increases the quality of documentation and
save time.• Increases legibility and accuracy.• Enhances implementation of the nursing
process. Enhances the systematic approach to client care.
• Provides clear, decisive, and concise key words (standardized nursing terminology).
16-46Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
Methods of Documentation
Computerized Documentation• Provides access to other data, enhancing
critical thinking.• Information is quickly coordinated and
integrated by other departments.• Facilitates statistical analysis of data.
16-47Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
Methods of Documentation
Point-of-Care System• A handheld portable computer is used for
inputting and retrieving client data at the bedside.
• Provides each health care practitioner with all pertinent client data to ensure continuity of care without duplication.
• Provides crucial client information in a timely fashion.
16-48Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
Methods of Documentation
Case Management Process• A methodology for organizing client care
through an illness, using a critical pathway.• A critical pathway is a monitoring and
documentation tool used to ensure that interventions are performed on time and that client outcomes are achieved on time.
16-49Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
Forms for Recording Data
Kardex Flow Sheets Nurses’ Progress Notes Discharge Summary
16-50Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
Forms for Recording Data
The Kardex is used as a reference throughout the shift and during change-of-shift reports.• Client data• Medical diagnoses and nursing diagnoses• Medical orders• Activities
16-51Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
Forms for Recording Data
Flow sheets reduce the redundancy of charting in the nurses’ progress notes.
The information on flow sheets can be formatted to meet the specific needs of the client.
16-52Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
Forms for Recording Data
Nurses’ progress notes are used to document the client’s condition, problems and complaints, interventions, responses, achievement of outcomes.
Progress notes can be completely narrative or incorporated into a standardized flow sheet.
16-53Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
Forms for Recording Data
Discharge Summary• Client’s status at admission and discharge• Brief summary of client’s care• Interventions and education outcomes• Resolved problems and continuing need• Referrals• Client instructions
16-54Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
Trends in Documentation
Standardized data bases are required to ensure accuracy and precision in nursing information systems.
16-55Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
Trends in Documentation
Nursing Minimum Data Set (NMDS) Nursing Diagnoses (Taxonomy II) Nursing Intervention Classification (NIC) Nursing Outcomes Classification (NOC)
16-56Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
Reporting
Verbal communication of data regarding the client’s health status, needs, treatments, outcomes, and responses
Summary of current critical information to facilitate clinical decision making and continuity of client care
16-57Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
Reporting
Reporting is based on the nursing process, standards of care, and legal and ethical principles.
Reports require participation from everyone present.
16-58Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
Reporting
Summary Reports Walking Rounds Telephone Reports and Orders Incident Reports
16-59Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
Summary Reports
Commonly occur at change of shift (or when client is transferred).• Assessment data• Primary medical and nursing diagnoses• Recent changes in condition, adjustments in
plan of care, and progress toward expected outcomes
• Client or family complaints
16-60Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
Walking Rounds
Nursing, physician, interdisciplinary Occur in the client’s room and include the
client
16-61Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
Telephone Reports and Orders
Report transfers, communicate referrals, obtain client data, solve problems, inform a physician and/or client’s family members regarding a change in the client’s condition.
Telephone orders are documented in the nurses’ progress notes and the physician order sheet.
16-62Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
Documenting a Telephone Order
16-63Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
Incident Reports
Used to document any unusual occurrence or accident in the delivery of client care.
The incident report is not part of the medical record, but it may be used later in litigation.