Nursing Fundamentals Chapter 9Recording & Reporting

Why do we chart?

• 1. Legal evidence as to what we’ve done. A chart or case can be subpoenaed to court. Anyone who writes in a chart is responsible for what they write. Errors in charting or scribbles or erased info. Make for a poor legal defense. A chart can be used as legal evidence for 1 year (in adults) in Ohio (medical malpractice). Children have 18 yrs.

• 2. It’s a permanent account and a record for future use. Records are kept and all are sent with the pt. For a baseline or history of illness

• 3. It allows for the sharing of information between health care workers, it’s organized and prevents the duplication of care and reduces the chances of error

Why do we chart?

• 4. Charts are used to measure quality assurance. This is to make sure pts are staying on track for insurance and payment needs. It’s also to improve quality of care and to maintain that a standard of care has been used

• 5. Accreditation of JCAHO, they make sure we are following the written standards to ensure whole, quality care

• 6.Reimbursement related to insurance, there’s always a watcher out there

Why do we chart?

• 7. Education & Research the primary resource for health education is textbooks. We can utilize real life charts to expand our knowledge base. Formal permissions must be met by the pt

What Do We Chart With?

• <<<<INK>>>>

• Pen – black or blue

• NEVER use Red ink

• NEVER use Pencil

• NEVER use liquid white-out

What to do if you make a mistake?

• NEVER erase your entry, even if it is in the wrong place or on the wrong pt

• NEVER white-out your entry

• NEVER scratch out or make many lines through an entry. ONE LINE THROUGH THE MISTAKE ONLY

• Lawyers, Drs. And others, must be able to see what you wrote

What to do when you don’t have much to write?

• Always start as far over to the left as possible and then keep writing. If you stop before the end of the paper, put a line through the rest of the paper so another person will not add to your note

Writing a note

• 0700 nurse enters room to find pt in cheerful mood-----------------------K. NyeRN

• Not this:

• 0700 pt in cheerful mood NyeRN

ERRORS

• 1000 pt arrived to hospital with daughter. Pt A&Ox3. Pt has large wound to left hip.

• (show how to make an order invalid)

• Don’t forget to write error and initials with one black/blue line

Can a patient view their own chart anytime?

Yes and No

• Since 1996 when HIPPA legislation was passed….now states that clients have the right to see their own medical and billing records.

• Pts have the right to request changes to anything they feel is inaccurate and they are allowed to be informed as to who has seen their records however…

• Many institutions have their own written policies that describe the guidelines by which pts can access their own medical records

• Policies range from institution to institution• Many facilities want the Physician or hospital

administrator to be present while the chart is being read

• NURSES SHOULD NOT BE DOING THIS

Bill of Rights

• Every patient of every race and creed has rights

• The Bill of Rights lists 12 basic rights that must be upheld (know 12 for the test)

• (See bill of rights Box 3-5 for reference)

• Cleveland Clinic Patient Rights and Responsibilities • As a patient, you have the right… • Personal Privacy/Security • •To have your personal dignity respected. • •To be free from all forms of abuse or harassment. • •To enjoy personal privacy and a safe, clean environment

and to let us know if you would like to restrict your visitors or phone calls.

• •To access protective and advocacy services. • •To know that restraints will be used only when necessary. • •To confidentiality of your identifiable health information

• Cultural and Spiritual Values • •To have your cultural, psychosocial, spiritual, and

personal values, beliefs and preferences respected. • •To have access to pastoral and other spiritual services. • Access to Care • •To receive care regardless of your race, creed, color,

national origin, gender, age, sexual orientation, disability or manner of payment.

• •To ask for a change of provider or a second opinion.

• Access to Information • •To make advance directives and have them followed. • •To have your family or a representative you choose and your own physician, if

requested, be informed of your hospital admission. • •To know the rules regulating your care and conduct. • •To know that Cleveland Clinic hospitals are teaching hospitals and that some of your

caregivers may be in training. To ask your caregivers if they are in training. • •To know the names and professional titles of your caregivers. • •To have your bill explained and receive information about charges that you may be

responsible for, and any potential limitations your policy may place on your coverage. • •To be told what you need to know about your health condition after hospital discharge

or office visit. • •To be informed and involved in decisions that affect your care, health status, services or

treatment. • •To understand your diagnosis, condition and treatment and make informed decisions

about your care after being advised of material risks, benefits, and alternatives. • •To knowledgeably refuse any care, treatment and services.

• •To say “yes” or “no” to experimental treatments and to be advised when a physician is considering you to be part of a medical research program or donor program. All medical research goes through a special process required by law that reviews protections for patients involved in research, including privacy. We will not involve you in any medical research without going through this special process. You may refuse or withdraw at any time without consequence to your care.

• •To legally appoint someone else to make decisions for you if you should become unable to do so, and have that person approve or refuse care, treatment, and services.

• •To have your family or representative involved in care, treatment and service decisions, as allowed by law.

• •To be informed of unanticipated adverse outcomes. • •To have your wishes followed concerning organ donation, when you

make such wishes known, in accordance with law and regulation.

• Communication • •To receive information you can understand. • •To have access to an interpreter and/or translation

services. • •To know the reasons for any proposed change in

the attending physicians/professional staff responsible for your care.

• •To know the reasons for your transfer either within or outside the hospital.

• Pain Management •To have pain assessed and managed appropriately. Disclosures •To request a listing of disclosures about your healthcare, and to be able to access and request to amend your medical record as allowed by law. •To know the relationship(s) of the hospital to other persons or organizations participating in the provision of your care. Recording and Filming •To provide prior consent before the making of recordings, films, or other images that may be used externally.

• Concerns, Complaints, or Grievances •To receive a reasonably prompt response to your request for services. •To be involved in resolving issues involving your own care, treatment and services. •To express concerns, complaints and/or a grievance to your providing hospital personnel. You may do this by contacting your Ombudsman office at: Ashtabula County Medical Center, 440.997.6633 Children’s Hospital, Shaker Campus, 216.444.2544 Cleveland Clinic, 216.444.2544 Euclid Hospital, 216.692.7888 Fairview Hospital, 216.476.4424 Hillcrest Hospital, 440.312.9140 Huron Hospital, 216.761.3300 Lakewood Hospital, 216.529.7049 Lutheran Hospital, 216.363.2360 Marymount Hospital, 216.587.8888 Medina Hospital, 330.721.5330 South Pointe Hospital, 216.491.6299

Types of Client Records

• Source-Oriented Records

• Problem-Oriented Records

Source-Oriented Record

• This is organized according to the source of documented information

• Contains lots of the same kind of paper (green at CCF)using as many sheets as necessary on which Drs., nurses, dieticians, P.T. and so on, can make entries about their own specific activities in relation to the pts care

• It appears that these team members are working independently of each other and their fragments of written info. Is difficult to follow at times, you have to flip back to read what others wrote.

Problem-Oriented Record

• This is organized according to the pts problems

• This type of record contains 4 major components:

• 1. Data base• 2. Problem list• 3. Plan of care (POC)• 4. Progress notes

Problem-oriented record

• The information is compiled and arranged to:

• emphasize goal-directed care

• Promote recording of pertinent information

• To facilitate communication among health care professionals

Methods of Charting

• 4 types are used across the nation, you must use your facilities type:

• 1. Narrative

• 2. SOAP

• 3. Focus

• 4. PIE

Narrative Charting

• Used in source-oriented records• Involves writing info. About the pt and their care

in chronological order• There is no format, only a story or narration of the

events that have occurred• This type of charting is time consuming to write

and read• At times, the writer of this type of note omits

pertinent info. Or includes insignificant info.

SOAP Charting

• S=subjective date• O=objective data• A=analysis of the data• P=plan of care

• Used in problem-oriented record• This type focuses on the pertinent information• This type helps to bring all teams together because everyone

involved in the care, makes entries in the same location in the chart, they are likely to read this well-written plan

Focus Charting

• Modified form of SOAP charting• Uses the word “focus” rather than problem

which can indicate negativity• A “focus” can be a pt’s current or changed

behavior, a significant event in the pt’s care, or a NANDA diagnosis

• Can enter the info. As “DAR” data, action, response, similar to the Nr. Process

PIE Charting

• P=problem

• I=intervention

• E=evaluation

• Similar to SOAP charting

• PIE charting prompts the nurse to address specific content in a charted progress note

PIE Charting

• The nurse documents her assessment on a separate form and gives the pt’s problem a corresponding number. This number is used in the progress note when referring to interventions and the pt’s response

PIE Charting

• ___________________________________• DATE Nurses Remarks Signature• ______________________________________________• 6/19 P #1 crackles heard on inspiration in bases of• ___________right and left lungs________________

• I #2 Incision splinted with a pillow. Instructed• to breathe deeply and to cough at the end of

______________________________________expiration

• E#3 Lungs clear with coughing____________

Charting by exception

• Nurse only charts IF there is a problem

• Lake Hospital and CCF do this however…..

• Be prepared to write a lot more in clinicals. We need to make sure you can chart

Computerized Charting

• Supposed to be easier to access information and it is legible however…

• Information is vague and standard. If you don’t find something that is applicable to your patient that’s already in print, WRITE A NARRATIVE NOT. Legal nurse consultants and Lawyers recommend this. Nurses don’t see the info. In print, they don’t check the block and they don’t bother to wrote a note, if it’s not written somewhere, IT’S NOT DONE

Abbreviations

• It’s difclt to shortn. Mny wrds + still let thm have mng. Nrsg notes r imprtnt we mst do a grt job all the tme.

• We are not text messaging, we are recording important information.

• This IS NOT COMPUTER OR I.M. or texting COMMUNICATION

• You could cause harm to a pt. By misinterpreting the abbreviation…

Morphine versus Magnesium

• MSO4 vs. MgSO4….big trouble if you goof

• Morphine sulfate vs. magnesium sulfate

Using Abbreviations in the institutions

• New Nurses today are getting away from using abbreviations

• Students are not being taught all of the abbreviations

• In this class, we will use some (see abbreviations sheet)

Military Time

• Military time is used in the Military today

• Other medical and health professionals use military time

• There are NEVER mistakes in what time it was when military time is used

Military time

• Is a matter of counting from 1-24 versus using 12 midnight and counting 1-2-3-4-5-till midnight again

Military Time

• Always starts at midnight

• Midnight is 0000 or 2400

• You never repeat numbers like 10am and 10pm

• You don’t use a colon ( : ) or am or pm

• 1:00 am = 0100

• 2:00 am = 0200

• 3:00 am = 0300

• 4:00 am = 0400

• 5:00 am = 0500

• 6:00 am = 0600

• 7:00-11:59 am = 0700-1159

12 NOON

• 12 noon is 12:00pm• In military time , it is 1200• 1pm = 1300 7pm = 1900• 2pm = 1400 8pm = 2000• 3pm = 1500 9pm = 2100• 4pm = 1600 10pm = 2200• 5pm = 1700 11pm = 2300• 6pm = 1800 12am or midnight

» 2400

Basically

• Military time is based on counting

• You use minutes as you would normally – 3:15 pm = 1515

• Once you pass noon, you count upward 13-23

Communication for continuity of care

• Nursing Care Plans

• Nursing Kardex

• Check lists

• Flow Sheet

• MAR- medication administration record

Nursing Care Plans

• Is a written, organized list of client problems, goals, and nursing orders for pt care

• They are sort of like a “recipe” on how to care for a pt and return them to optimal health

• We learned the NANDA diagnoses, use them often

Nursing Kardex

• Is a quick reference for current information about the pt’s care, it tells:

• Pt name tells the level of activity• Diagnosis clinic #• Lab tests that are due• Allergies• Admit date• Appointments that pt will go to such as P.T., x-ray

Check list

• Used instead of writing, one can simply check the boxes next to the activity to be done.

• Saves time on writing, if pt stays in the facility for a length of time, and not much changes, simple check mark system is acceptable

Flow sheet

• This type of documentation is used for recording frequency repeated assessment data like neurochecks

• Allows the nurse to view trends because all of the info. Is there in columns

M.A.R.

• Medication administration record

• This is the med sheets, many facilities use different forms.

• Some facilities use a yellow pencil or crayon to color over orders that are no longer in effect

What to do with all of these papers…..

• A pt’s chart becomes filled and overflowing if the pt is admitted to the institution for a length of time

• Many institutions are applying all of their forms and paperwork to computer programs

How Important is charting

• Extremely important

• Charting becomes part of the legal documents

• You must complete ALL charting before a pt leaves the floor or heads out the door

What To Do If Your Pt Leaves the Floor?

• If you haven’t charted completely before your pt leaves the floor to go to surgery or a test, what do you do?

• Use a new nursing form and add your notes there and be sure to place your new notes in a place where they can be added to the chart when the pt returns to the floor

• REMEMBER…if it wasn’t charted, then it _________________

Interpersonal Communication

• In addition to recording information in writing, verbal communication between staff members is extremely important

Change of shift report

• This is a discussion between nursing staff when one shift is ending and another shift is starting. Shift report is done in different ways according to the facility’s choice

Report

• In ICU’s the charge nurse pre-assigns pts for each individual nurses

• When you enter the report room, you find your pt assignment and then find the nurse who cared for that pt all day….not always effective

• What is the nurse you are looking for is already giving report to another nurse about her 2nd pt, you have to wait until she is done

• This form of reporting doesn’t allow for the entire staff to become familiar with all pts on floor

Report

• Some nurses sit in a faculty lounge while the charge nurse from the previous shift discusses ALL the pts in order to ALL of the staff that is coming on.

• ALL staff becomes familiar with potential problems…team approach…used a lot

I am going to give report, ready?

• Get a pen and blank paper out and hold on……………………………………….

Take report seriously

• Be prompt to work so report can start on time

• You don’t want to mosey on in at your leisure and disrupt the whole report

• Come prepared with a pen and paper or your floor’s report sheet

In this team – approach type report

• Once the report is completed, and assignment is made based on pt acuity

• It is important to not assign all of the difficult pts to one nurse or the new nurse

• Nurses usually like to focus on a few pts and continue that continuity of care by taking the same pt throughout their whole admission

• Pts like this continuity in care, they get to know that nurse and build a trusting relationship with that nurse

Conferences

• Some facilities like to round in groups including all services that could potentially care for the patient

• This could include:• Drs Nurses• P.T. O.T.• Pharmacistclergyman• Dietician social work

Grand Rounds

• Usually held in a large room• A few patient’s cases are discussed in detail• It offers advantage of group decision making, and

professional opinions are given• It puts the pt 1st, trying to meet all of their needs or

demands

• Difficult to get many services together at once, everyone is busy

Telephone report

• Some institutions will not allow LPNs to take report by phone

• RN will do this then• It is important to get the report givers name and a

phone number of where they can be reached for questions

• Some facilities will have a designated telephone report form…use it. It prompts you to ask all of the important questions

What to ask in taking report?

• Name of person giving report to me• Phone number where they can be reached• VS…always get these. Indicates how sick the pt is• A weight on the pt. Why should you have to look through

their paperwork and try to read their writing, they can just tell you this over the phone

• last time pt urinated• Condition of pt• What labs and other tests were already done• Who is with pt, you may needs a sitter and you have to

arrange this before the pt arrives

When you report is completed…

• Start to organize your thoughts on how you will prepare to care for your patients

• Discuss individually with previous nurse, the care to be given for your shift

• If you are unfamiliar with equipment or medication, spend a few minutes reviewing this with the new nurse coming to take care of the pt

• Nothing is worse than to be nervous or afraid to care for your pt

BE KIND TO ONE ANOTHER

• Reports show that nurses eat their young????????????? What does this mean?????????????

BE NICE

• EVERYONE was new once

• Nobody is perfect

• Everyone makes mistakes AND YOU WILL TOO

• Don’t be rude to each other. It’s better to educate someone rather than to put them down

Teaching-learning

• Nursing is an ongoing teaching-learning process

• You will learn new things everyday

• Be open to learning and educating others

• YOU ARE NOT ABOVE ANOTHER

THE END – be nice and help each other