Documentation and Informatics in Nursing
description
Transcript of Documentation and Informatics in Nursing
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Documentation and Informatics in Nursing
Entry Into Professional Nursing Summer 2009
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Why Document?
Accreditation (TJC)
Reimbursement (DRG’s, Medicare)
Communication (Continuity, education)
Legal (Not documented, not done)
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Multi-Disciplinary Communication
Reports-Oral: End of shift Written Record-Chart: Permanent, legal,
healthcare management on-going account
Healthteam: All disciplines, nursing, social workers, discharge planning PT, OT, RT
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Documentation
Anything written or printed that is relied on as a record of proof for authorized persons
Reflects quality of care
Provides evidence of healthcare team members care rendered
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Purposes of Records
Communication Legal Documentation Financial Billing Education Research Audits-Monitoring
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Guidelines for Quality Documentation & Reporting Factual
Accurate
Complete
Current
Organized
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Follow TJC Standards
Physical Psychosocial Environmental Self-care Client education Discharge Planning Evaluation of outcomes Nursing Process oriented
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Types of Documentation
Narrative POMR Source records Charting by Exception Critical Pathways Record Keeping Forms Acuity Recording Systems Standardized Care Plans Discharge Summary Forms
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Types of Documentation
Discharge Summary Forms Home Health Long Term care Computerized
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Narrative
Traditional type of nursing charting Story-like, repetitive Time consuming
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Problem-Oriented Medical Records
Data organized by problem or diagnosis Ideally all healthcare team members can
contribute to list Coordinated plan of care POMR Components: Database, problem
list, NCP, progress notes
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POMR Database
History and physical Nursing admission assessment On-going assessment Labs Radiology reports Record of each hospital visit
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POMR Problem List
Holistic needs based on data
Chronological list on front of chart
Dates when problem resolved or new problem occurs
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POMR Progress Notes
SOAP/SOAPIE Notes: Subjective data, objective data, assessment, plan, intervention, evaluation
PIE Charting: Problem-Intervention-Evaluation
Focus Charting/DAR-Data (subjective and objective) Action (intervention) Response of Client (evaluation)
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Source Records
Chart is so organized that each discipline has own section to record data
Sections can be easily located Disadvantage: Not organized by client
problems Narrative style notes
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Charting by Exception
Streamlines documentation Reduces repetition, saves time Short version to document normals, routine
care items Based on established standards Progress note when standard not met Assumes all standards are met unless
otherwise charted Exceptions must be noted
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Critical Pathways
Multi-disciplinary care plans used in case management
Key interventions, expected outcomes, time frame
Variances charted and analyzed
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Record Keeping Forms
Admission Assessment/Nursing history
Graphic Sheets (Vitals, weights, I&O)
Nursing Kardex
Medication Administration Records
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Acuity Reporting Systems
Staffing patterns based on acuity of patients
Numeric rating for interventions Varies per unit and standard Update every 24 hours and justify
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Standardized Care Plans
Pre-printed established guidelines Based on health problems Need to modify based on individual
assessment, update and use judgement Standards of care are known, promotes
continuity, staff knowledge
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Discharge Summary Forms
DRG’s encourage early discharge, but must ensure good patient outcomes
Necessary resources, Client and family involved in process
Begins at admission Client education integral to process
(food-drug interactions, rehab referrals, medications, disease process)
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Home Health
Medicare/Medicaid Guidelines 50% of nursing time is documentation Care witnessed by client and family Good assessment skills Health care team focused Direct care in home Use of laptops for documentation
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Long Term Care
Residents not clients Governmental agencies: Many
standards and policies regarding assessments, individualized plan of care
Dept. of Health in each state determines frequency of charting
Skilled Nursing Units
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Nursing Informatics
Computer based patient care record Assessments, care plans, MAR’s
physician orders Maintain confidentiality with pass codes,
looking at other records Nursing Information Systems Clinical Information Systems Electronic Medical Record
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Reporting
Oral or written Change of shift Nurse to nurse Promotes continuity Report on client health status, care
required for next shift, significant facts, head to toe assessment, pertinent labs, priority needs, treatments, family issues
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SBAR Technique for Communication
S- Situation B- Background A- Assessment R- Recommendation
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End of Shift Report
Keep professional Avoid judgemental language Include assistive personnel
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Telephone Reports
Inform physician of changes Client transfers to different units Result reports from lab or radiology Client transfers to different institutions Info needed: When call made, to whom,
info given Keep clear, accurate, repeat info if
necessary
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Telephone Orders
Physician to RN Physician must co-sign within 24 hours Nightime, emergency orders Guidelines and procedure per institution Be careful, precise and accurate with
order Write order as said by physician, repeat
it back
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Transfer Reports
Unit to unit report Phone or in person All pertinent data about patient Send all belongings with client Review clothing/belonging list prior to
transfer Transfer Sheet Documentation
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Incident Reports
Any event not considered routine (falls, needlesticks, med errors, accidental omissions, visitor injury)
Risk Management will analyze trends Changes in policy/procedure, educational
programs may be related to findings Notify supervisor, physician of incident Nurse who witnesses makes out report Do not assign blame, be objective, facts only
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Tips for Documentation
Accurate, timely, thorough, factual, neat Use only approved abbreviations & terms Blue or black ink Always get and give report Focus on a team approach Date, time each entry, do not block chart Document in a timely fashion Follow the nursing process Use appropriate forms
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Documentation Tips
Correct errors promptly, using proper technique
Write on every line, leave no spaces Sign each entry with full signature and
correct title Follow institution policy and procedure
for charting Military vs standard time
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