Chapter 04 - Documentation, communication PDF

Chapter 4—Documentation and Interprofessional Communication Copyright © 2015 Wolters Kluwer Health | Lippincott Williams & Wilkins  Learning Objectives ❖ 1. Describe the multiple purposes of the patient medical record. ❖ 2. Discuss the significance of accurate and timely documentation. ❖ 3...

Chapter 4—Documentation and Interprofessional Communication Copyright © 2015 Wolters Kluwer Health | Lippincott Williams & Wilkins  Learning Objectives ❖ 1. Describe the multiple purposes of the patient medical record. ❖ 2. Discuss the significance of accurate and timely documentation. ❖ 3. Describe the relationship between reporting patient assessment data and ensuring patient safety. ❖ 4. Compare and contrast various methods of documenting assessment data in the patient’s record, such as SOAP, PIE, and DAR. ❖ 5. Develop a concise, clear communication using a template such as SBAR. ❖ 6. Discuss ethical and legal considerations when documenting and reporting assessment information in the patient record. Copyright © 2019 Wolters Kluwer All Rights Reserved Documentation and Interprofessional Communication ❖ Essential: prompt reporting, recording of patient assessment data ❖ Communication failures: root cause o 75% of sentinel events (2016) o A sentinel event is a patient safety event that results in death, permanent harm, or severe temporary harm ❖ Documentation o Verbal and written o Used by all health care team members to plan/provide care o Paper to electronic form Copyright © 2019 Wolters Kluwer All Rights Reserved Patient Medical Record #1 ❖Purposes o Legal document o Communication and care planning o Quality assurance o Financial reimbursement o Education o Research Copyright © 2019 Wolters Kluwer All Rights Reserved  Patient Medical Record #2 ❖ Components o Nursing admission assessment o History/physical examination (H&P) by primary health care provider o Primary provider’s orders o Plan of care (POC) or clinical pathway o Flow sheets ▪ Vital signs; intake and output (I&O) ▪ Routine assessments Copyright © 2019 Wolters Kluwer All Rights Reserved Patient Medical Record #3 ❖Components—(cont.) o Focused assessment documentation o Medication administration record (MAR) o Laboratory, diagnostic test results o Progress notes: to members of the health care team o Consultations o Discharge or transfer summary Copyright © 2019 Wolters Kluwer All Rights Reserved Patient Medical Record #4 ❖ Electronic medical record o Clinical agencies have computerized part/all records ▪ eMAR ▪ Computerized provider order entry o Permits use of automated clinical surveillance tools ▪ Detects assessment data indicating problems ▪ Requires timely input of assessment data Copyright © 2019 Wolters Kluwer All Rights Reserved  Principles Governing Documentation #1 ❖ Confidentiality: keeping patient’s health information private o Health Insurance Portability and Accountability Act (HIPAA) ▪ Rule requires protection of specific health information. ▪ Be mindful of breaking HIPAA ❖ Accuracy and completeness o Must precisely reflect assessment data o Legally accepted abbreviation use (no shorthand) o Chief Complaint: quote the client and use their own words. o Corrections Copyright © 2019 Wolters Kluwer All Rights Reserved Principles Governing Documentation #2 ❖ Accuracy and completeness—(cont.) o Logical organization o Timeliness ▪ Batch charting discouraged (waiting till the end of your shift) ▪ Point-of-care documentation Prompt, accurate documentation o Clear, Complete, Concise Copyright © 2019 Wolters Kluwer All Rights Reserved Medical Record Components #1 ❖ Nursing admission assessment (also known as nursing H&P) o Acute care: performed within 24 hours o Skilled nursing facility (SNF): performed within 3 days o Comprehensive patient information : ▪ Physical; psychological ▪ Functional; social ; spiritual o Forms basis for individualized POC Copyright © 2019 Wolters Kluwer All Rights Reserved Medical Record Components #2 ❖ Flow sheets ❖ Plan of care/clinical pathway ❖ Progress note (case note) ❖ Narrative notes o SOAP(IE) notes: subjective; objective; analysis; plan; interventions; evaluation o PIE notes: problem; interventions; evaluation o DAR note: data; action; response o CBE (charting by exception): outside normal limits, assessment data require additional documentation Copyright © 2019 Wolters Kluwer All Rights Reserved PIE Note Copyright © 2019 Wolters Kluwer All Rights Reserved DAR Note Copyright © 2019 Wolters Kluwer All Rights Reserved Question #1 ❖Is the following statement true or false? The Health Insurance Portability and Accountability Act mandates accuracy and completeness of medical records. Copyright © 2019 Wolters Kluwer All Rights Reserved Answer to Question #1 False Rationale: The Health Insurance Portability and Accountability Act (HIPAA, 1996) that gives patients greater control over their medical records became effective in 2003. HIPAA regulates all areas of information management, including reimbursement, coding, and security of records. The HIPAA Privacy Rule requires an agency to make reasonable efforts to limit the use of, disclosure of, and requests for protected health information to the minimum necessary to accomplish the intended purpose. Copyright © 2019 Wolters Kluwer All Rights Reserved Verbal Communication #1 ❖ Verbal handoff potential communication barriers o Lack of Structured format Policies/standards for communication o Responsibility/contract ambiguity o Relationship hierarchy questions o Ethnic background differences o Poor clinical decision making regarding pertinent data o Differing communication styles of nurses, doctors Copyright © 2019 Wolters Kluwer All Rights Reserved Verbal Communication #2 ❖ Reporting o Qualities of effective reporting ▪ Organized; complete; concise; respectful SBAR model: situation; background; assessment; recommendations Clear accurate assessment data o Reporting to primary health care provider ❖ Telephone communication ❖ Patient rounds; conferences ❖ Critical thinking; clinical judgment Copyright © 2019 Wolters Kluwer All Rights Reserved SOAP and SBAR Copyright © 2019 Wolters Kluwer All Rights Reserved