Transcript Slide 1

Documentation
Improving Your Charting
The chart remains as the only
evidence of the nursing care
you have given!!!
If it was not charted it was
not done!!!
But I swear it did it!!
There are many factors required to be
assessed for each and every patient:
• Patient needs
• Care necessary to meet those needs
• What needs to be done in respect to continuing
care after patient is discharged.
Nursing charting must contain:
• Physical/psychosocial assessment to
determine the need of care and the
frequency for additional assessments
• Assessment of patient nutritional
assessment
• Assessment of functional abilities/status to
determine the need for post-discharge
planning and rehabilitation
The charting must reflect:
• Age specific and appropriate assessment and
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interventions
On-going assessment of educational needs
Involvement of family and/or significant others
when appropriate
Adjustments in the plan of care with changes in
condition or diagnosis
Continual assessment of discharge planning
needs
All entries should reflect:
• The care you have given
• Adherence to MD orders or plan of care
• Care should be consistent with standards
of care (“Best Practice”)
i.e. Your charting will be measured against
what any other educated and prudent
nurse would have delivered to the same
patient in the same care situation
Finding Time to Chart
• Flow sheets help minimize the time
required to document “routine” care
however,
Charting must also be individualized
So, how do you find the time to do this??
Multi-task !
• While assisting a patient to the BR who needs
help getting back to bed….
• Combine care delivery with history taking,
teaching, assessment. (Bed Bath)
• While giving medications you can teach your
patient about what they are receiving.
• What other ideas do you have??
Your Initial Assessment
Examples:
Identify pressure ulcers in detail when
admitting a patient:
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location, size, depth, drainage characteristics,
integrity of tissue margins.
If this is not done, it must be assumed that the
ulcer developed during the course of this hospital
visit!!
Patient at fall risk:
• If a patient was to fall and fracture a hip, you
have no evidence that steps were taken for the
patient’s safety to prevent falls if you don’t
document that you:
– Instructed the patient NOT to get up to the bathroom
without using the call light (and the call light was at
the bedside)
– Ensured that the bed was left in the lowest position
Patient refusing medications:
• Document the exact reason why the patient refused
medication or treatment:
Example: Mr. Dysphasia states, “I cannot swallow pills”
You chart: “Instructed patient regarding importance of taking
potassium replacement, with understanding verbalized.
Call to Dr. Jones to notify of patients refusal and
request liquid alternative”
NOT “Patient refused.”
A complete chart contains:
• Identification of patient (stamp / sticker)
• Date and time of assessment or
intervention
• Assessment of problem, knowledge deficit
requiring teaching, patient concern etc.
– Assessment contains subjective and
objective information
A complete chart contains:
• Statement of problem or knowledge deficit
• Measurable goals: outcomes
• Implementation measures: interventions
taken to correct the problem or knowledge
deficit
• Evaluation of patients response to
interventions
• Your signature!
What about flow sheets??
* Excellent for recording repetitive data:
Vital signs, I/Os, routine care
Don’t forget to chart patient’s
response to interventions:
If pain is rated as 8/10, and you
give a pain medication, be sure to:
• Document their pain level or response
(i.e. asleep) 30min-1 hour afterward.
Common reasons for lawsuits
involving nursing care :
• Failure to question inappropriate physician’s
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orders
Failure to adequately monitor a patient
Failure to protect the patient from an avoidable
injury
Failure to document care that was given in an
adequate manner
Failure to properly administer medications
Failure to take a complete and appropriate
nursing history
Common reasons for lawsuits
involving nursing care :
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Failure to follow orders correctly and timely
Failure to perform procedures properly
Failure to protect patient confidentiality
Failure to assess an emergency situation
properly and initiate appropriate resuscitative
measures
Functioning outside the scope of nursing
practice
Failure to request help when the nurse is unable
to meet the needs of a patient
Common reasons for lawsuits
involving nursing care :
• Failure to notify the physician of test
results
• Failure to follow hospital policy and
procedure when restraining patients
Why make such a big deal??
• Charting is a professional responsibility
• Medical record may be scrutinized by insurance companies
or Medicare or Medical and evaluated for errors
• Length of stay justification
• Quality of care assessment through chart review by
accreditation organizations
• Risk management reviews chart to evaluate safety concerns
• To protect hospitals/nurses in the event of a lawsuit.
What about handwriting??
• How you write is as important
as what you write!
Up to 25% of medication errors are
related to illegible handwriting!
•PRINT PRINT PRINT
•SLOW DOWN
•NUMBERS MUST BE WRITTEN
CLEARLY
2 not 2.0
0.2 not .2
You Should Never…
• Never leave blank spaces for others to “catch up”
• Never destroy or change any part of the medical
record after it has been created.
• Never chart in advance—watch out for flow
sheets!
You Should Never..
• Chart for others
• Chart the observations that others have
made.
Ex. “patient fell on the floor” (NO)
“patient found on the floor next to
bed” (YES)
• Never chart in a way that could be
determined as a negative assault on the
patient’s character.
i.e. “patient was a drunk and
obnoxious jerk”
• Instead chart specific behaviors:
i.e. “The patient refuses to have
x-rays performed, refused
assessment, was observed to have a very
unsteady gait while ambulating in the
waiting room and urinated in the trash
can in the waiting room.”
Dangerous Abbreviations
* Know where the list is located
on your unit and in the
Org. Wide manual.
DO NOT USE THEM!
* There is also a list of Acceptable
Abbreviations in the OWM.
Performance Improvement
Regulatory Agencies, Occurrence
Reports, Risk Management
Performance Improvement
• All nursing departments have a planned, systematic and
ongoing monitoring and evaluation program to assess
the quality of care delivered to patients
• The Performance Improvement Coordinator as well as
the unit managers, are responsible and accountable for
assuring this process is in place and that consistent
standards are used to monitor and evaluate patient care
Performance Improvement
• Performance Improvement data is presented to the
staff during their staff meetings.
– This is an opportunity for all to review the data, analyze
the scores, and provide ideas for how improvements can
be achieved.
• The findings from the Performance Improvement
activities are used to formulate continuing education
programs for the staff.
Regulatory Agency Umbrella
CMS
AOA
JCAHO
CDPH
CMS
• Centers for Medicare & Medicaid Systems
• Reimbursement for Medi-Cal and Medicare
patients
• Reimbursements effected by performance
• Improved Performance = Increased
Reimbursement
What does CMS do with info about
our performance?
• We are mandated to submit our
performance
• CMS publicly reports our performance
compared with other hospitals
• CMS pro-rates our reimbursement based
on our performance and “grades” us on
a scale with other hospitals
• Rewards for being in top 10%
CDPH Evaluation
• California Department of Public
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Health
For State of California licensure
Investigates complaints and
deficiencies
Deficiencies can incur fines
OSHA: Occupational Safety &
Health Administration
• Federal and State
• Primary concern: YOU
• Safe work place
How do Regulatory Agencies decide
on what to focus on?
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Focus on QUALITY
Focus on PATIENT SAFETY
Focus on BEST PRACTICE
Focus on PATIENT SATISFACTION
Input from:
– Institute for Healthcare Improvement
– National Quality Forum
Why Participate?
• Because QUALITY, BEST PRACTICES &
Patient Safety are IMPORTANT!
• And because we are rewarded for good practice
What do we focus on here?
• Best Practices around patients with:
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Pneumonia
Heart Failure
AMI
Surgical patients
• Quality in all the services we provide:
– from food to diagnostic tests
• Patient Satisfaction
• All inpatients and outpatients are surveyed
What do we focus on here?
• Patient Safety
– Culture of Safety
• Recognition of unsafe conditions and environments
• Recognition of situations that could result in a
problem or undesired outcome
• Talking about what we can do to make our
workplace safer
– Communication!
Core Measures
• What is it?
– Best Practices identified by CMS as contributors to
better outcomes, decreased length of stay and
decreased occurrence of readmission
• The diagnoses include:
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Heart Failure
Pneumonia
Acute Myocardial Infarction
Surgical Care Improvement Project
Occurrence Report
• Used for reporting
unanticipated events
such as:
– Equipment failures
– Patients leaving AMA
– Falls
• If you notice a potential
problem:
– Isolate the problem
(the piece of
equipment, etc)
• Report the problem to
your supervisor or the
department that can fix
the problem
Risk Management
• Uses Occurrence Report information
• Patient/Family complaints
– If you hear a family or patient complaining,
address the complaint if you can
– If you can not address the complaint, report it
to someone who can
• “ABUSE”
• “HARRASSMENT”
– RED FLAGS!
Cultural
Awareness
Cultural Awareness
• Why learn about cultural awareness?
Cultural Awareness
• Help patients receive more effective care.
• Improve your job performance and your
job satisfaction.
• Meet expectations of regulatory agencies.
Cultural Awareness
• What is Cultural
Awareness?
Cultural Awareness
• Considering every patient’s culture when
giving care.
• Treating every patient, family member,
visitor and co-worker as an individual.
BACK CARE
BODY MECHANICS and
LIFTING TECHNIQUES
A Healthy Back
• Composed of 24 movable bones called
vertebrae
• Disks act like cushions
• Muscles and ligaments
support the back
• Injury or disease = PAIN
A Balanced Back
• Cervical, Thoracic, and Lumbar curves
must be aligned
• Ears shoulders and hips stacked
• A healthy back is also protected and
supported by well conditioned muscles
Preventive Back Care
• Always warm up
• Exercise the muscles that support your
back
• Stretch to improve flexibility
• Posture is important
TASK ANALYSIS
• Fancy name for “PLANNING AHEAD”
• Break task into steps
• Think it through
PLANNING AHEAD.....
• Can I do the task by myself in a safe
manner?
• If not, determine the number of people it
will take.
• What equipment or materials are needed
to do the job?
Use Your
POWER ZONE!
• Floor to shoulders,
directly in front of the body
• The maximum Power Zone is from the knees to
the waist
• You have 5-7 times the load capacity when using
the Power Zone
Keep it “Locked In”
• Keep your back muscles “Locked In” while
lifting
• 10x disk pressure when
“Bowed Out”
• Head and shoulders up
BACK SAVING TIPS
• Always lift with your legs
• Support lower back
• “Nose between the toes!”
• Be aware of trip or slip hazards
• Push, don’t pull
• Exercise
Thank you for reviewing the
MRCH Student Nurse Orientation
We welcome you to our hospital team!
Please complete the post test, and bring it with you on the
day of your hospital orientation