Psychiatric Nursing: Documentation

Documentation in Psychiatric Nursing Practice

• Documentation enhances practice and patient care.
• Patient care documents create communication between health professionals.
• Documentation can be used for nursing audit and legal requirements.
• Documentation improves the quality of service and facilitates research.
• Psychiatric nurses collect patient information to aid accurate diagnosis and therapeutic care.
• Nursing documentation serves various purposes for healthcare delivery and accountability.
• Communication - Records help health professionals communicate.
• Planning client care - Health professionals use client records to plan care, and include any specific treatments and/or medication a client is give and why.
• Auditing health agenicies - Audits review client records for quality assurance purposes.
• Accrediting Agencices - Accrediting body reviews client records to ensure health facilities are meeting set standards.
• Research - Records provide data for research.
• Education - Patient Records are used as educational tools and provide a view of the client, their illness, treatment, and factors that affect treatment outcomes.
• Reimbursement - Documentation aids facility reimbursement, clinical records must contain correct DRG codes.
• Legal Documentation - Client records are admissible in court as evidence. Records can be inadmissible if the client objects because the care provider is confidential.
• Health Care Analysis - Records determine health agency needs and various service costs.

POR - Problem oriented recording

• POMR is a method shifts medical doc, organizing patient data around specific problems rather than by the source of info.

Four Basic Components

• Database - Complete patient history, exam results, and diagnostic tests, provide a baseline of patient information.
• Problem List - Serves as an index to the chart of progress notes - Problems listed as they are identified; list is updated as problems are identified or resolved.
• Plan of Care - initial plans developed and documented for each problem identified. Plans split into diagnostic (tests needed), therapeutic (treatment plans), and patient education (info provided to pt).
• Progress notes - Progress notes detail updates & ongoing care/progress for each problem - Uses SOAP (subjective, objective, assessment, and plan) format;

PIE Documentation Model

• Information grouped into three categories: problems, interventions, and evaluation of nursing care
• Problems (P): Lists patient's health issues or nursing diagnoses
• Interventions (I): What actions have been taken to address problems identified
• Evaluation (E): Documents patient response and effectiveness of care provided

Client Care Asseessment flow sheet

• Flow sheets provide structured pt asseessments according to needs and funcitonality of pt
• Progress notes document ongoing patient care in narrative form in relation to problems

Focus Charting

• This is a documentation method designed and organized by patient needs and concerns;

Components of focus charting

• Client centered focus - method is intented to keep the focus on patient concers and care is tailored to patients needs & circumstances;
• Three Cololmns for recording
  • Date and time - logs when care is given and timing of interventions
  • Focus - specifies the main issue being addressed, like a concidtion, symptom, or goal
  • Progress notes - details action taken and response, organized in DAR (data, action, reposnse) format.
• DAR Format - data, action, response and records patient reactions and notes any changes in the pateints condition

Charting by Exception

• Documentation system that focuses on recording only abnormal or significant findings - highlights critical information to be addressed

Components of charting by exception

• Flow Sheets - Used to document routine and normal findings in standardized format
• Standards of Nursing Care - Provide guidelines for pt assessments- based on established practices.
• EHR provides bedside access, used during rounds reducing accuracy delays

Computerized Documentation

• Storing Client Databases - Nurses input and store patient info (demographics, medical history, allergies, meds).
  • Upon admission, pt personal info, medical hisotry, and initial assessment are added to the system.
• Adding New Data - Info added as care progresses and updates with ongoing assessments, results, and observations
  • Updates include vital signs, symptoms, changes to the patient's condition.
• Creating and Revising Care Plans - Nurses develop care plans based on real-time patient data for customizations.
  • Care plans may include blood sugar monitoring, dietary adjustments, and meds
• Documenting patient progress - All aspects of patient care are documented (interventions, pt responses, outcomes).
  • Records meds given and reaction, noting effects side or improvments.

Narrative Recording

• Nurses write detailed, chronological accounts of a pt's condition, care provided, and related response - captures nuance of care delivery

Source-Oriented Record

• Traditional client record where each person/department documents in a separate section of the chart

Process Recording

• Detailed written documentation when a nurse interracts with a pt to analyze/reflect on their cummunication skills and overall delivery
• Records verbal/nonverbal cues, and personal thoughts allowing for critical eval.

SOAPIE/SOAPIER

• Structured method of documenting, standing Subjective, Objective, Assessment, Plan, intervention, Evaluation," or "Subjective, Objective, Assessment, Plan, Intervention, Evaluation, and Revision."

F-DAR

• Used to focus on pt concerns, organize record and chart through date/hour, progress notes, action and response.

SBAR

• SBAR (Situation, Background, Assessment, and Recommendation) is a tool for clinicians to communicate critical information with one another
  • Situation - State current situation.
  • Background - Give relevant pt Info.
  • Assessment - State professional conclusion using background and situation.
  • Recommendation - State the support needed.

ADPIE

• ADPIE (assessment, diagnosis, planning, intervention, evaluation).
  • Assessment: Objective and subjective data supporting the identified problem.
  • Diagnosis: Leads interventions in line w/ the North American Nursing Diagnosis Association (NANDA).
  • Planning: Specific order to manage patient and goals of care.
  • Intervention: Action the nurse takes in relevance to the problem and its depence on other nurses and independent collaborators.
  • Evaluation: evaluates client response to interventions

Kardex

• A Kardex is a desktop file system that gives a brief overview of each patient and is updated every shift - cheat sheet for easy reference.

Principles in Nursing Documentation

• High-quality documentation is accessible
• High-quality documentation is consistent
• High-quality documentation is clear and concise
• High-quality documentation is thoughtful and completed in timed
• Nurses need education and training in technical elements of documentation
• Nurses need to be familiar with all organizational policies related to documentation.
• Protection systems need to be built into documentation following industry standards
• Entries must be accurate, valid, and complete
• Entries must be authenticated with data and time.
• Standardized terminologies should be included

Responsibilities of a nurse in Documentation

• Understanding accountability for documenting care provided
• Documenting care process and concerns shared with other health providers
• Noting information in Chronological order
• Comprehensive doc. when Pt is ill, high risk or is complex issue
• Documents error changes.
• Safeguard pt privacy

Legal and Ethical Issues in Psychiatric Nursing

• Clients can refuse treatment, speak freely, and have visitors unless documented safety is imperative.
• Patient's Bill of Rights includes access to certain information, treatment plans, and fair reviews.
• Individuals become danger when they have mental illnesses so they loose the right to leave while still having human rights

Release from Hospital

• Voluntary clients can leave unless they are a danger to themselves or another - If psychiatrist determines client is dangerous, paperwork can file client for commitment until hearing.

Mandatory Outpatient Treatmetn (MOT)

• Requires individuals to continue involuntarily treatment after hospital.
• Also known as conditional release, requires the courts order with severe mental illness
• Conservatorship + Guardianship are legal processes used for individuals who cannot care for ones self

Leave restrictive environmtn

• Patients have the right to be treated less strict as possible; Not be hospitalized, in restraints or seclusion unless nesscary. For adult, need face to face evaluation for those in restraint w/ the doctor. Childer are re-ordered every two hours

Confidentiality

• HIPAA of 1996 protects personal health information.

Duty to Warn Third Parties

• The duty to warn, established by the Tarasoff vs, Regents of the University of California: Mental health workers must warn about a situation

Insanity Defense

• When someone accused, is not guilty, to due their behaviour. M´Nagten

Nursing Liabilities

• Nurses provide safe, competent, legal, and ethical cares + follow standards + guidelines

Torts

• wrongful act that leads to injury, loss, or damage and unintentional or intentional

Unintentional Tors

• Negligence is when one fails in acting reasonably which may cause harm
• Malpractice is professional negligence (harm/death of a patient)

The elements to win malpractice:

• One was legally needed (nurse + patient)
• Breach the Duty
• Harm/Demage
• Causation: The breach directly caused

Intentional torts

• Are actions that cause harm the includes: Assault, battery, and False imprisionments

Steps to avoid liability:

• Always consult with law and practice, collaborate, act safe. put clients needs first, develop interpersonal skills, document and avaluate

Ethical Issues

• Deals with human conduct, right/wrong actions and good/bad motives

Utilitarianism Decision

• "the greatest good for the greatest number," which are based on person actions

Ethical Principles in Nursing

• Autonomy- Patient have a right to be respected when making their own decisions
• Beneficence- Act on what the patient needs
• Nonmaleficence: Do no harm-intentinally or unintentially
• Justices- Treat patient equal
• Veracity- Be truthful + Honest
• Fideltiy- honor commitments or responsibilities

Autonomy, Informed Consent

• Nurse respects pt through encouraging autonomy pt rights and consent + making choices aboiut healthcare

Ethical Delimmas in Mental Health Nursing

• Dilemman that arrise when principles conflict or whens ther no clear action exists - may limit rights to the individual
• Forced Med.- should a clent take meds when strickened. if not do they need permission

Client Empowerment vs Provider- Shoul prof make decisions if no good

###Confidentiality vs Public Safety _ Should dr's report reckless. w/ mental health

Seclusion for disruption- is it eithical to re,ove loud climet so other notbotherd. is

##Legal vs Ethical

Legal - Clear cut laws and based decision ethical depends own belief and options, what best

###Ethical Decision Making Nursing

• The Nurse often face delimmas at practice, workplace, and broad. They must adhere to balance Rights and Public.
• The code and ethical provides ethic emphazising compassion, rights, acoountability, and collaboration.
• Ethical Decision making involves getting legal constraints, reaching consensus.
• Nurses must appyl responsibily and pt based care in complex

Grief and Loss

• Loss is natural/essential for human growth
• Grief: emotional response to loss
• Grieving/Bereavement refers ot experiencing that greef.

Types of Losses

• Physhiologic loss- Is lost of body like amputation
• Safety -loss sae enviirmonet - domestic, abuse, or even public so schools
• loss of seurity, such as lost of lovws or fmily
• Loss of Self esteem- from death of a break and relationships challlging with self and worth
• Loss to self artial when dream areunatuainble event like illnes

Grieving the Losses - Affect the losses

• losses often effect mulltple levls os Masclw'y ,leadinh got complex emotonal process and healing Stages includes
• Kubler- Ross stages of grieving
  • Denial- When im shock to avoid its realities
  • Anger- can can ditect them in the future when feel helpless un fair
  • bargining and will may try to prevent and even change the ineveitable situation Depression- Feeling sadness and when recognize the permanent losses and the nature and loss'l Acceptance - Coming ot term with senses with findning pease but integeated into are ready to foward

##Theory B -John Bowlby

• Attachment theory - where humans form bonds broken it into four phaes

Numbness/denial

• When feel in shock, where person is connected ot feelings
• Protest: Person begin to reconguzr losses + acoompained with any angers which with in tense

Cognitie/emotional

• Feeling disoragnaztion unable to ormal

Reoragamzition integrit

• Pt begin ro rearrange live and adapt

Engele stages model

• individual is going through pt with loss
• Shock/disbelief- may refuse to acknowledge the loss
• develop - feelings are anger or sadness when loss and beign wth is happening- Restution - helps indiivudal the loss
• Revolution - Becomes preoccupied with the lost o
• Marbi Horwitzs- The model focus psychologycal of grieving, (1. Outary

2. Denial and intuition
3. Working t
4. Copmpetion

Tasks and the grieving

• Raudib known the six ,

• Rcogniize loss as real

• Reat- emotinwl to loss

• collect to re-enric- Memory loss Relmquidh- world ha changed

• readjuast

Wordens Task

• Wording a task grief thpough by interacrt

1. Action

2 - Pain 3. Adjusitng Chang

4- Emotion

• dimension expersion
• Coqnitive and Challignes a person

Make senes to it and why so young"

"" To keep lose one or sentment and intralodialogue

Emotional responses for grief

• Is when an indivudalis when intense, such anger, sadness, guilt, and anxy, often directed at those passed. With anger for the action

Spiritual response - Inerwtinned with belief which can help give pitoo life

• indivudal e[eprence spiritual struggle (Disillusiment or angers ) nurses play criutcalr ole to to expefde and their pain through the spirital transtiantion

###behavoural respones to greif

• numbest Crying or searchibng for the decersesed/
• Irratuabiltys hositulity / show behaviours such Avioding place sharecd witth the deck When working.
• Psychologtical responce- headance and loss
• Culutura - Religious. Sprituale guidnes in mouring - Buddhsim chritan Islam help.
• Universal reaction - the cutlure is based on greef
• Cultre rutiulas: Us ot canda and mmgrait o cutlural thourght

1 - African Ameria- Mouring and hyumans or christ

2-Muslim: islam farbid and and buiral wash bodu to postin acrodung to the muslims man of gender or the gender

3- Haitian America- follow vordm. vodun cally on spriritis

4-.Chines American- annacing, preparitioon and burnic and reciding and spiritua - ofterung placey the spirti food

55--Japene Amer- B buddisim 0 the batb and drwess, and

• Fillippino - Bwac and death aounnce d

6 viremase amerian - bath , and place and play signal

7- Hispanic - cathil with.pray and avodi

8 - Native Amercaim- vaay Spiriutr in

9 - Othodox - Nevr alone -

10 The nurse rolis and culutrely Senstiive

Varatons and Greivion encorage pratice

Examples

• Asm the Hispanic
• offer if jewish.

Modern Greiving Rutuas

• Aid Quitt symobl/ Empty chair