Institutional records - Sagar.V.Joshi - Fourth Yr Basic BSc Nsg - CHN Dept

8/7/2019 Institutional records - Sagar.V.Joshi - Fourth Yr Basic BSc Nsg - CHN Dept

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NURSING

DOCUMENTATION

NURSING ADMINISTRATION

J. J . COLLEGE OF NURSING

Sagar. Joshi

4th Yr Basic BSc Nursing.


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Objectives

At the end of this presentation, the

participants should be able to;

Define source oriented medical record Define problem oriented medical record

List items to be included in the medical record

Discuss reasons for keeping medical records

Explain the PSOAP acronym for keeping records


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It is always easier to find your way if you have a road map!


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Which data are we recording in

practice?


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Why to keep records?

Helps in medical decisions

(is the size of a lymph node or nodule

increasing with time?) Helps to share responsibility with thepatient

Legal obligation. Protects the patient as well as doctor in

front of the court


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Has economic benefits

Useful to produce health statistics Provides epidemiological data

Assists practice management

Useful in QI activities

Is a communication tool


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Types

According to the method;

Source oriented

Problem oriented


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Source oriented medical recordData taken from the source are recorded as they are

(Source: patient, relative, laboratory etc.)

Easy and fast to record Flexible

Omitting information is highly possible

Difficult to access the information


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Problem oriented medical record Structure is defined in advance.

The patient with problem is in the focus

It is systematic Data is easily accessible

Not flexible. Recording information is difficult

and time consuming


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Which data to record?

Personal info: age, sex, occupation, training, family...

Risk factors: tobacco, alcohol, life styles...

Allergies and drug reactions

Problem list

Disease history: diseases, operations. . .

The disease process: main problem, history, exam, lab.

Management plan: advice, education, medication. . . Progress notes: in the P S O A P format


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PSOAP

ProblemEverything the patient reports and doctorsfindings which are regarded as problems

Subjective

History of the problem; what the patient feelsor thinks about the problem

ObjectiveDoctors findings related with the problem

AssessmentEvaluation of the problem; the diff. diagnosis

PlanPrescription, consultation, advice, control

visit...


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Visits

21 February 1996: dyspnea, coughing and fever. Dark defecation.

PE: BP 150/90, pulse 95/min, Fever: 39.3o

C.Ronchi +, no abdominal tenderness.

Medications: 64 mg Aspirin/day.

Possible acute bronchitis and cardiac decompensation.

Possible bleeding due to Aspirin.

Rx: Amoxicilline 500 mg 2x1, Aspirin 32 mg/day.

4 March 1996: no cough, slight dyspnea, defecation normal.

PE: light rhonchi, BP 160/95, pulse 82/min.

Rx: Aspirin 32 mg/day.

Lab21 February 1996: ESR 25 mm, Hb 7.8, Fecal occult blood +.

4 March 1996: Hb 8.2, Fecal occult blood :-.X-ray

21 February 1996: Chest x-ray: no atelectasis, light cardiac decompensation

findings

Patient -Source-Oriented Medical Record

Source Oriented Medical Record


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Problem 1: CoughingProblem 1: Coughing

21 February 1996S:dyspnea, coughing, fever.

O:pulse 95/min, Fever: 39.3 oC.

Rhonchi+. ESR 25 mm.

Chest x-ray: no atelectasis, light cardiac

decompensation findings.A:Acute bronchitis.

P:Amoxicilline 500 mg 2x1.

4 March 1996

S:no coughing, slight dyspnea.

O:pulse 82/min. Slight rhonchi.A:minimal bronchitis findings.

Problem Oriented Medical Record

Problem 2: DyspneaProblem 2: Dyspnea

21 February 1996S:Dyspnea.

O:Rhonchi+, BP 150/90 mmHg.

Chest x-ray: no atelectasis, slight

cardiac decompensation findings.

A:Slight decompensation findings.

4 March 1996

S:slight dyspnea.

O:BP: 160/95, pulse 82/min.

A:No decompensation.


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Problem 3: Dark colored defecationProblem 3: Dark colored defecation

21 February 1996

S:Dark feces. Using Aspirin 64 mg/day.

O:No abdominal tenderness, rectal exam revealed no blood, Hb 7.8

mg/dl. Fecal occult blood +

A:Possible intestinal bleeding due to Aspirin.P:Decrease Aspirin dose to 32 mg/day.

4 March 1996

S:Defecation normal.

O:Fecal occult blood -A:No intestinal bleeding symptoms.

P:Continue Aspirin dosage 32 mg/day


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DOCUMENTATION

Any printed or written record of activities.

Recording and reporting are the major wayshealth care providers communicate.

The clients medical record is a legal

document of all activities regarding client

care.


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COMMUNICATION

Documentation confirms the care provided to

the client and clearly outlines all important

information regarding the client.


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PRACTICE AND

LEGAL STANDARDS

The legal aspects of documentation

require:

Writing legible and neat

Spelling and grammar properly used

Authorized abbreviations used Time-sequenced factual and descriptive

entries


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PRACTICE

STANDARDS INCLUDE:

State Nursing Practice Acts

Joint Commission on Accreditation of

Healthcare Organizations (JCAHO)

Confidentiality

Informed consent

Advance Directives


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REIMBURSEMENT

The federal government requires monitoring

and evaluation of quality, appropriateness of

care provided.

Documentation of intensity of services and

severity of illness reviewed.

Failure to document can result in

reimbursement denied.


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EDUCATION

Health care students use medical record as

tool to learn about disease processes, nursing

diagnoses, complications and interventions.

Students can enhance critical-thinking skills

by examining the records and following

health care teams plan of care.


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RESEARCH

The clients medical record is used by

researchers to determine whether a client

meets the research criteria for a study.

Documentation can also indicate a need for

research.


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NURSING AUDIT

Method of evaluating the quality of care

Includes:

Safety measures

Treatment interventions and responses

Expected outcomes

Client teaching Discharge planning

Adequate staffing


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PRINCIPLES OF EFFECTIVE

DOCUMENTATION

1. Document accurately, completely, and

objectively, including any errors.

2. Note date and time.

3. Use appropriate forms.

4. Identify the client.

5. Write in ink.

6. Use standard abbreviations.


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PRINCIPLES OF EFFECTIVE

DOCUMENTATION (continued)

7. Spell correctly.

8. Write legibly.

9. Correct errors properly.

10. Write on every line.

11. Chart omissions.12. Sign each entry.


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SYSTEMS OF DOCUMENTATION

Narrative charting

Source-oriented

charting Problem-oriented

charting

PIE charting

Focus charting

Charting by exception

Computerized

documentation

Critical pathways


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NARRATIVE CHARTING

Traditional method of nursing documentation.

Chronologic account in paragraphs describing

client status, interventions and treatments, and

clients response.

The most flexible system.

Usable in any clinical setting.


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SOURCE-ORIENTED CHARTING

Narrative recording by each member of the

health care team on separate documents.


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PROBLEM-ORIENTED CHARTING

SOAP, SOAPI, AND SOAPIER S: subjective data

O: objective data

A: assessment data

P: plan

I: implementation E: evaluation

R: revision


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PIE CHARTING

P: problem

I: intervention

E: evaluation


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FOCUS CHARTING

System using a column format to chart Data,

Action, and Response (DAR).


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CHARTING BY EXCEPTION

Only significant findings (exceptions) are

documented in a narrative form.

Presumes that unless documented

otherwise, all standardized protocols have

been met and no further documentation is

needed.


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COMPUTERIZED

DOCUMENTATION

Reduces time taken, increases accuracy.

Increases legibility.

Stores, retrieves information quickly.

Improves communication among health care

departments.

Confidentiality and costs can be problems.


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CRITICAL PATHWAY

Also known as Care Maps.

Comprehensive pre-printed standard plan

reflecting ideal course of treatment for

diagnosis or procedure, especially with

relatively predictable outcomes.

Additional forms are needed to complementthe pathway.


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NURSES PROGRESS NOTES

Document clients condition, problems,

complaints, interventions, and clients

response to interventions.

Include MAR, vital signs records, flow

sheets, and intake and output forms.


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DISCHARGE SUMMARY

Client status on admission and discharge

Brief summary of the clients care

Intervention and education outcomes

Resolved and unresolved problems

Client instructions about medications, diet,food-drug interactions, activity, treatments,

follow-up, and other needs


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DOCUMENTATION TRENDS

Nursing Minimum Data Set (NMDS)

Nursing Diagnoses

Nursing Interventions Classification (NIC)

Nursing Outcomes Classification (NOC)


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INFORMATION

FOR SHIFT REPORT Name, room and bed,

age, gender

Physician, admissiondate, and diagnosis

Diagnostic tests or

treatments performed in

past 24 hours (results if

ready)

General status, any

significant change

New or changedphysicians orders

IV fluid amounts, last

PRN medication

Concerns about client


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WALKING ROUNDS

Members of the

care team walk

to each clientsroom and

discuss progress

and care witheach other and

with the client.


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TELEPHONE ORDERS

Date and time

Order as given by the physician

Signature beginning with t.o. (telephone

order)

Physicians name

Nurses signature

Physician must countersign


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INCIDENT REPORT

May also be called a variance.

Informs administration of incident, allows risk

management personnel to consider ways to

prevent future similar occurrences.

Alerts insurance company to potential claim

and possible need to investigate.


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Follow-up Charts

It is practical to use follow-up charts for

chronic diseases

DM,

Hypertension

Obesity


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Rules in keeping medical records (NCQA)

1. Each page in the record contains the patients name or ID number.2. Personal biographical data include the address, employer, home and

work telephone numbers and marital status.

3. All entries in the medical record contain the authors identification.

Author identification may be a handwritten signature, unique

electronic identifier or initials.

4. All entries are dated.

5. The record is legible to someone other than the writer.

6. *Significant illnesses and medical conditions are indicated on the

problem list.

7. *Medication allergies and adverse reactions are prominently noted

in the record. If the patient has no known allergies or history of

adverse reactions, this is appropriately noted in the record.

http://www.ncqa.org/LinkClick.aspx?fileticket=dmQOrIgyvMQ%3D&tabid=125&mid=766&forcedownload=true


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National Committee for Quality Assurance

(NCQA)

8. * Past medical history (for patients seen three or more times) is easilyidentified and includes serious accidents, operations and illnesses.For children and adolescents (18 years and younger), past medicalhistory relates to prenatal care, birth, operations and childhoodillnesses.

9. For patients 12 years and older, there is appropriate notationconcerning the use of cigarettes, alcohol and substances (for patientsseen three or more times, query substance abuse history).

10. The history and physical examination identifies appropriatesubjective and objective information pertinent to the patients

presenting complaints.

11. Laboratory and other studies are ordered, as appropriate.12. * Working diagnoses are consistent with findings.

13. * Treatment plans are consistent with diagnoses.

14. Encounter forms or notes have a notation, regarding follow-up care,calls or visits, when indicated. The specific time of return is noted in

weeks, months or as needed.


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NCQA15.Unresolved problems from previous office visits are addressed in

subsequent visits.

16.There is review for under - or over utilization of consultants.17.If a consultation is requested, there a note from the consultant in the

record.

18.Consultation, laboratory and imaging reports filed in the chart areinitialed by the practitioner who ordered them, to signify review.

(Review and signature by professionals other than the orderingpractitioner do not meet this requirement.) If the reports are presentedelectronically or by some other method, there is also representation ofreview by the ordering practitioner. Consultation and abnormallaboratory and imaging study results have an explicit notation in therecord of follow-up plans.

19.* There is no evidence that the patient is placed at inappropriate riskby a diagnostic or therapeutic procedure.

20.An immunization record (for children) is up to date or an appropriatehistory has been made in the medical record (for adults).

21.There is evidence that preventive screening and services are offered inaccordance with the organizations practice guidelines.


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Legal Problems

Not recorded = Not done !


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Record everything you do (including phone

consultations)

Apply guidelines (e.g.: NCQA)

Don't use erasable pencils

Dont use humiliating expressions

In order to prevent legal

problems:


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Do not use vague expressions such as the patientfeels well

If you need to make changes just strike through andrecord also the date of change

If you stated that the patient is not cooperative givethe reason

If patient rejects a procedure or test, mention it andgive the reason why you requested it


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-: Bibliography :-

1. B.T.Basvanthappa.

2. Wikipedia.org/Institutional Records.

3. Encyclopedia Encarta.

4. Britannica.

5. Google search.

6. Amazon.com

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THANK

YOU

:)

Institutional records - Sagar.V.Joshi - Fourth Yr Basic BSc Nsg - CHN Dept

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