Documentation student outline
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Transcript of Documentation student outline
![Page 1: Documentation student outline](https://reader035.fdocuments.in/reader035/viewer/2022062404/554b5d70b4c9051b458b4ece/html5/thumbnails/1.jpg)
Subtitle
Documentation and RecordingCommunication with the Healthcare Team
![Page 2: Documentation student outline](https://reader035.fdocuments.in/reader035/viewer/2022062404/554b5d70b4c9051b458b4ece/html5/thumbnails/2.jpg)
Document and Reporting
• Ensures quality of care• Regulatory agencies require it• Medicare reimbursement depends
upon it• Shows nursing action• Serves as a legal document
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Reporting
• Summary of activities, observations, and actions performed
• Objective and non-judgmental
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Reports
• Oral or written• Shift report• Verbal reports to physicians• Miscellaneous–Written lab reports– Dietary reports– Social workers notes– PT, OT, Speech therapies
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Types of Reports
• Change of shift– Oral, audiotape, rounds
• Telephone• Transfer• Incident– Any event not consistent with routine care of
client– Concise, objective– Not a part of the chart– Oral, audiotape, rounds
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Confidentiality
• Law protects any information gained by exam, observation, conversation, or treatment
• Information not discussed or shared with anyone not directly involved in patient’s care
• Nurses are legally and ethically obligated to keep patient information confidential
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Medical Records
• Permanent written communications• Continuing account of care status• Discussion, discharge planning,
conferences, consultations• All caregivers can benefit from
information and plan accordingly
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Purpose of Records
• Communication• Financial billing• Education• Assessment• Research• Auditing and monitoring• Legal documentation
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Documentation
• Anything written or printed that is relied upon as a record of proof for authorized persons
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Standards for Documentation
• Federal regulations-Medicare and Medicaid
• State and Federal regulations – JCAHO
• Professional standards – ANA• Facility policies- charting techniques
and responsibilities
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Legibility
• All charting should be easy to read• Reduces errors• May be used in court years after care
given
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Factual
• Descriptive, objective information• Decreases misinterpretation• Do not use “seems”, “appears”,
“apparently”, “good” “well”• Subjective information is
documented with client’s own words in quotations
• No opinions
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Complete and Concise
• Thorough, exact, brief, and NO blah, blah, blah blah
• Clear and succinct• Eliminate irrelevance• Short and to the point (long notes
difficult to read)• Too abbreviated gives impression of
being hurried and incomplete
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Timeliness
• Delay in reporting can result in serious omissions and delays in care
• Late entries may be interpreted as negligence• Certain things must be reported at time of
occurrence• Routine activities need not be charted
immediately • Military time used• No leaving until important information
recorded• Avoids errors and duplication of care
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Accurate
• Reliable and precise• Exact measurements when possible• Use only accepted abbreviations• Spell correctly
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More accuracy
• No charting for someone else• Student’s notes are countersigned by
person who assured care was given• Descriptive entries signed with full
name and status (first initial, last name, and title)
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Guidelines for Documentation and Reporting
• Certain abbreviations not acceptable• Abbreviations used
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Organization
• Logical format and order• Chronological flow of events
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Chart Components
• Data base– Assessment data
• Problems list• Care plan• Progress notes– Narrative– Flow sheets– Discharge planning summaries
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Documentation Methods
• Problem oriented medical record– S.O.A.P. or S.O.A.P.I.R– P.I.E.
• Source records• Charting by exception– Flow sheets
• Focused charting– D.A.R.
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Problem Oriented Medical Record
• Focus on patient’s problems• Follows the nursing process• Organized by problems or diagnoses• Coordinated care
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Advantages of POMR
• Easy to retrieve information and follow progress
• Easy to monitor for QA purposes• SOAP notes establish structure that
reflects what nurses do
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PIE Charting
• PIE• Daily assessment data appears on
flow sheets• Continuing problems documented
daily• Focuses exclusively on single client
problem
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Source Records
• Each discipline has a separate section of the chart for recording
• Can easily locate proper section• Examples: admission sheet,
physician's order sheet, history and physical, flow sheets, nurses notes, medication record
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Charting by exception
• Reduces repetition• Clearly defined standards of practice
and predetermined criteria• Nurses documents only significant
findings or exceptions• Preventive and wellness-focused
functions not documented
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Focus Charting - DAR
• Easily understood and adaptable to most settings
• Reflects analysis and conclusions• Does not indicate problem
assessment
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Standardized Care Plans
• Pre-printed and established guidelines for clients with similar problems
• Improved continuity• Less time to document• Inhibits unique or individualized
therapies
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Writing the Nursing Care Plan
• Prioritize problems– ABC’s–Maslow– Problems perceived by patient
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Formats
• 5 columns– Assessment data or defining characteristics– Diagnosis– Goals/outcomes– Interventions– Evaluation
• Concept Map– Same five components linked by rationales– Better indicates process of critical thinking
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Critical Pathways
• Documentation tool to integrate standards of care for multiple disciplines
• List problems, key interventions, expected outcomes, expected timelines
• Attempt to control and decrease length of stay
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Discharge Summaries
• Multidisciplinary involvement is required by HCFA
• Client leaves hospital in timely manner with the necessary resources
• Client signs original for chart and takes copy home
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Kardex
• Information• Medication• IV’s• Treatments• Diagnostic procedures• Allergies• Data • Problem list
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Computer Documentation
• Saves time in storage and retrieval• Information is permanent• Various departments can coordinate
information• Can be used at the bedside
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Protocol Charting
• Newest method• Primary use in outpatient care• Written for use as a references or
guide for care• Individualized, current, according to
intended purpose