Transcript Documenting the Nursing Process

Documenting the Nursing Process
NUR 104
1
Otten/403
If it’s not charted…..
It was never done….
2
Otten/403
Documenting the Nursing Process
JCAHO Standard: Patient-Specific Data/Information
IM.7.1 A medical record is initiated and maintained for every
individual assessed or treated.The medical record incorporates
information from subsequent contacts between the patient and the
organization.
3
Otten/403
Documenting the Nursing Process
JCAHO Standard: Patient-Specific Data/Information
IM.7.2 The medical record contains sufficient information to
identify the patient, support the diagnosis, justify the treatment,
document the course and results accurately, and facilitate continuity
of care among healthcare providers.
4
Otten/403
Role of Documentation
 A requirement for accreditation
 A legal requirement
 A record of the use of the nursing process
for the delivery of individualized client care
5
Otten/403
Role of Documentation
 Assessment is recorded in the client history or
database.
 Identification of client needs and the planning of
client care are recorded in the plan of care.
 Implementation of the plan is recorded in the
progress notes and /or flow sheet.
 Evaluation of care may be documented in the progress
notes and/or plan of care.
6
Otten/403
Chart/Client Record
 Include all significant events
 Be clear and objective
 Reflect progress toward outcomes
7
Otten/403
Purposes of client record
7 Functions
 Staff documentation
 Evaluation
 Relationship monitoring
 Reimbursement
 Legal documentation
 Accreditation
 Training and supervision
8
Otten/403
Importance
Staff Communication
 Colleague-to-colleague
 Among nurses
 Between the nursing staff and other healthcare providers
9
Otten/403
Evaluation
For the purposes of review, the medical record should:
 Be written to facilitate an assessment of the care provided
 Serve as a method of tracking the client’s response to treatment
 Be a means for evaluating the quality of care
1
0
Otten/403
Relationship Monitoring
 Nurse/client relationship is a therapeutic relationship
built on a series of interactions.
 Notes detailing observations and monitoring of the
client’s interactions are an important component of
nursing care.
1
1
Otten/403
Reimbursement
 The medical record provides proof of services.
 Absence of such documentation may result in
termination of funding or treatment.
1
2
Otten/403
Legal Documentation
 All aspects of the medical record may be
important for legal documentation
 Notations need to be—
◦ written in permanent ink/computer-entered
◦ specific about date and time (military time)
◦ signed by the person making the entry
1
3
Otten/403
Legal Documentation
 An error must be—
 crossed out with one line
 still legible
 identified as an “error”
 initialed by the author
 White-outs are not acceptable
1
4
Otten/403
Accreditation
 JCAHO standards: “Nursing care data related to patient
assessments, nursing diagnoses, and/or patient needs, nursing
interventions, and patient outcomes are permanently integrated into
the medical record.”
 Progress notes must be completed on schedule and in a way
that facilitates data retrieval
1
5
Otten/403
 Notes must give the reader a clear picture of
what occurred with the client
 To ensure clarity, use descriptive (or
observational) statements
 Avoid use of judgmental language
1
6
Otten/403
Judgmental Language
 Statements of opinion
 Open to varying interpretation
 Lack supporting data
1
7
Otten/403
Judgmental Language
Types of judgmental statements include phrases
that:
 Make reference to undefined time periods
 Refer to undefined quantities
 Refer to qualities
 Fail to specify any objective basis for the judgment made
1
8
Otten/403
Undefined Periods of
Time
 Statements that refer to
undefined periods of time
without clarification may
leave the statement unclear
and judgmental.
1
9
Otten/403
Watch for words such as:
 some
 a lot
 enough
 many
 a great deal
 very little
 too much
Qualities
 Slang words are unclear
and should not be
contained in a
professionally written
note.
2
0
Otten/403
Watch for words such
as:








hyped-up
loose
spaced-out
pushy
cool
bummed
tanked-up
crazy
Watch for words
such as:
 friendly
 attentive
 aloof
 unhappy
 excited
2
1
Otten/403
 apathetic
 enthusiastic
 bored
 proud
Descriptive Language
 Contains observations only
 Avoids statements that are evaluative or judgmental
 Contains measurable periods of time
 Contains measurable quantities
 Provides a basis or rationale for qualities named in the
note
2
2
Otten/403
Content of Note/Entry
 As specific and accurate as possible
 Correct grammar and spelling
 Legible writing
 Abbreviations used cautiously or not at all
2
3
Otten/403
Content of Note/Entry
 Concise, short, succinct sentences or phrases
 Redundancy avoided
 Consistent in style and format
2
4
Otten/403
Findings to document at time of
occurrence
 Critical changes in VS
 Meds and treatments
 Prep for a test or surgery
 Critical change in status
 Admission—nursing hx must be completed on admission to
the nursing unit
 Discharge
 Transfer
 Death
2
5
Otten/403
Format of note entry may vary—
 Block notes, with a single entry covering an entire shift
 Narrative--storylike
 POMR--Problem-oriented medical record system
 Focus charting—viewing the client from a positive
rather than a problem-oriented perspective
2
6
Otten/403
 SOAP—subjective, objective, assessment, plan
 DAR—data, action, response
 PIE—Problem, intervention, evaluation
 Standardized forms
 Flow sheets
2
7
Otten/403
Most common documentation
omissions
 Administration of drug
 Effect of treatment
 Recording of bowel movements
2
8
Otten/403
Change of shift report
 Nurses report information about their assigned clients to the
nurses working on the next shift
 Provide continuity of care among nurses who are caring for a
client
 Oral in person, tape, walking/rounds
2
9
Otten/403
Telephone report
 Change in condition
 Lab reports
 Dx test info
3
0
Otten/403
Unclear communication leads to errors
Mixed messages:
“Start the coumadin today at 5”
“Give a GI cocktail to the patient in room 4”
Distractions interrupting follow through
Order documentation
3
1
Otten/403
SBAR
 Clear communication accepting responsibility for what is




3
2
sent and received
Organized communication
Anticipate the team member’s needs & workload
Shared model
Leads to action by empowering others with specific
information
Otten/403
What if…you are the captain on the ship
and you are called in the middle of the
night
 Captain, I’m sorry I had to call you, well I wasn’t
going to but the Sergeant said I should, well this isn’t
my fault, but I thought I saw something and then I
heard a noise. What do you want me to do?
3
3
Otten/403
SBAR
S: Captain, this is the watch man, we are cruising at 30 knots
and I believe the starboard hull hit an iceberg
B: We are in northern waters and there are many icebergs
present
A: I believe we are taking on water
R: I recommend we should carefully load the life boats and
abandon ship
3
4
Otten/403
SBAR
Situation: I am calling about Mrs. Smith because she has a
fever and is not tolerating po’s
Background: Mrs. Smith is POD 2 for a TAHBSO and has a
temp of 101.6, BP 105/60, P 103, R 24 and is c/o abd pain
increasing since yesterday and has received 2 mg of MS every
2 hrs today. Abd exam shows mild rebound, tenderness and
guarding
3
5
Otten/403
SBAR
Assessment: I am concerned about a perforation
Recommendation: I would like you to come by and examine
her as I am concerned she may need to return to the OR
3
6
Otten/403
SBAR: Situation
 My name is ________________
 I am calling about <Pt. and location>
 Admitted for <diagnosis>
 The problem is ______________
 Vital signs are _______________
 Baseline VS are ----------------
3
7
Otten/403
B
S AR: Background
 Remember the person you are speaking to may know nothing
about the patient
 Restricted work hours
 Cross-coverage
 The patient was admitted (when) for (diagnosis)
 This problem has already been evaluated with these tests:
__________________
 Meds, allergies, IV fluids, latest labs
3
8
Otten/403
A
SB R: Assessment
 I think the problem is: (cardiac, respiratory, neuro,
infectious)
or
 I don’t know what is wrong, bus she/he is getting worse
or
 The patient appears unstable
3
9
Otten/403
R: Recommendation
SBA
 I suggest you:
 Transfer to ICU
 Work up for an infection
 Come to see the patient immediately
 Get a __________ order (med, ABG, lab)
 Tell me what to watch for and when to call you back.
4
0
Otten/403