Doc PP Lecture SON 2023 final-1.pptx

DOCUMENTION- Ch. 20 “If you didn’t chart it...then it didn’t happen…” School of Nursing-Foundations 231 1. Use standard professional guidelines for effective nursing documentation. 2. Identify measures to protect confidential patient information. Learning Outcomes 3. Identify approved abbreviations...

DOCUMENTION- Ch. 20 “If you didn’t chart it...then it didn’t happen…” School of Nursing-Foundations 231 1. Use standard professional guidelines for effective nursing documentation. 2. Identify measures to protect confidential patient information. Learning Outcomes 3. Identify approved abbreviations and symbols used for documentation and distinguish these from errorprone abbreviations and symbols. (SEE BOX 20-3 and TABLE 20-2, 20-3) 4. Describe the purposes of different types of patient health records. 5. Recognize that documentation by the nurse should be complete, accurate, current, and concise because the patient health record is a legal document. 6. Describe the nurse’s role in communicating with other health care professionals by reporting. Why is documentatio n so important??? US nurses can spend up to 25-40% of their 12shift on charting (De Groot, K. et al., 2022)  The patient record is the only permanent legal document that details the nurse’s interactions with the patient  It is the nurse’s best defense if a patient or family member alleges nursing negligence What Do You Document?  Assessments  Medication Administration  Nursing Actions  Treatments  Patient Response to Treatment  Patient Education Who’s Going to Use It? Treatment Team Patient Payors/Payers Legal System Government Agencies Accrediting Bodies =grant formal recognition to entities that meet stated criteria ie: Joint Commission (JCAHO)they mandate use of computerized data bases (Styles, Schumann, Bickford, & White, 2008, p. 5-6) Reports to improve quality of patient care, maintain current standards of care, address quality improvement measures  1. What Do We Use It For?  2. Determines severity of illness, intensity of services, and quality of care upon which payment/reinbursement is based  3. Data collection and nursing research  4. Aids in patient safety 2010 ANA Standards for Effective Charting Characteristi cs of Effective Documentati on  Accessible  Accurate  Relevant  Consistent  Auditable  Clear  Concise  Complete  Legible/readable  Thoughtful  Timely  Contemporaneous (current in time)   Subjective: direct quotes Objective Vs Subjective  Ex: Pt stated, “I don’t want that medication because it makes me nauseous”.  Ex: Pt being verbally abusive. Called transport RN a “stupid bitch”.  Ex: Pt heard yelling from room, “I am going to pull my IV out now!”  Objective: what the nurse hears, sees, feels, smells and tastes….NO!!! NEVER TASTE!!!  Poor ex: “Pt is very agitated and upset”  What are you observing to make you believe the pt is upset and agitated?  Simply stating what you think, is not enough; you must support your claims with evidence  Better ex: “Pt observed pacing the room, diaphoretic with clenched fists and screaming loudly”  Make sure your documentation reflects the nursing process and your professional responsibilities.  Record patient findings (observations of behavior) rather than your interpretation of these findings.  Avoid words such as “good,” “average,” “normal,” or “sufficient,” which may mean different things to different readers. It is best to document measurable, verifiable objective data. Documentati on Guidelines CONTENT (Box 20-1)  Avoid generalizations such as “seems comfortable today.” A better entry would be “on a scale of 1 to 10, patient rates back pain 2 to 3 today as compared with 7 to 9 yesterday; vital signs returned to baseline.”  Note problems as they occur in an orderly, sequential manner; record the nursing intervention and the patient’s response; update problems or delete as appropriate.  Document in a legally prudent manner. Know and adhere to professional standards and facility/institutional policy for documentation.  Document objectively. Avoid slang terms, stereotypes, or derogatory terms when charting. Document quotes from the patient and behaviors. Do not document your opinions or subjective feelings about a patient situation.  Refrain from copying and pasting notes in an EHR, because the data may be outdated or inaccurate. Documentati on Guidelines TIME (Box 20-1)  Document in a timely manner. Follow facility policy regarding the frequency of documentation and modify this if changes in the patient’s status warrant more frequent documentation.  If you forget to document something, record it as soon as you can, following the procedures for making late entries. Example: Late entry: Patient reported passing gas at 8:00 AM this morning but no stool yet. Notified the surgical resident, Dr. Cotter—C. Taylor, RN.  Indicate in each entry the date and both the time the entry was written and the time of pertinent observations and interventions. This is crucial when a case is being reconstructed for legal purposes.  Most facilities use military time, one 24-hour time cycle, to avoid confusion between am and pm times (see accompanying figure).  Document nursing interventions as closely as possible to the time of their execution. The more seriously ill the patient, the greater the need to keep documentation current. Never leave the unit for a break when caring for a seriously ill patient until all significant data are recorded.  Never document interventions before carrying them out.  Write a progress note for each of these instances: Upon admission, transfer to another unit, and discharge When a procedure is performed Upon receiving a patient postoperatively or postprocedure Upon communicating with health care providers regarding critical patient information (e.g., abnormal lab value result)  For any change in patient status      Check to make sure you have the correct chart before writing.  Record on the proper form or screen as designated by facility policy. Documentati on Guidelines FORMAT (Box 20-1)  With paper charts, print or write legibly in dark ink to ensure permanence. Use correct grammar and spelling. Use standard terminology, only commonly accepted terms and abbreviations, and symbols (see Box 20-3 on page 524). Alternatively, follow computer documentation guidelines.  Date and time each entry.  Record nursing interventions chronologically on consecutive lines. Never skip lines. Draw a single line through blank spaces.  Sign your first initial, last name, and title to each entry. Do not sign notes describing interventions not performed by you that you have no way of verifying. Documentati on Guidelines ACCOUNTABIL ITY (Box 20-1)  Do not use dittos, erasures, or correcting fluids. Draw a single line through an incorrect entry and write the words “mistaken entry” or “error in charting” above or beside the entry and sign. Then rewrite the entry correctly.  Identify each page of the record with the patient’s name and identification number.  Recognize that the patient record is permanent. Follow facility policy pertaining to the color of ink and the type of pen or ink to be used. Ensure that the patient record is complete before sending it to medical records.  Patients have a moral and legal right to expect that the information contained in their patient health record will be kept private. Students should be familiar with facility policy and pertinent legislation about who has access to patient records other than the immediate caregiving team, and the process used to obtain access (see HIPAA guidelines). Documentati on Guidelines CONFIDENTIALIT Y (Box 20-1)  Most facilities allow students access to patient records for educational purposes. Students using patient records are bound professionally and ethically to keep in strict confidence all the information they learn by reading patient records. Actual patient names and other identifiers should not be used in written or oral student reports.  Students should never use their cellphone in the clinical setting.  Students should never use any computer in the clinical setting for personal communication.  Students should never take photos of any patient or clinical setting.  Students should never use any patient information on any social media platform. Confidentiality & HIPPA  What information is confidential?  All information about patients is considered private and confidential  These materials are known as Protected Health Information (PHI)  Written on paper, saved on a computer, or spoken aloud  Patient/client identifiers  First + last name  DOB  Address  Telephone number  SSN  Discussing patient information in any public area  Leaving patient medical information in a public area  Leaving a computer unattended in an accessible area with medical record information unsecured Breaches in Confidential ity (HIPPA Violations)  Failing to log off a computer terminal  Sharing or exposing passwords  Copying or providing data, for yourself, coworkers, or any other party, except as required to fulfill job responsibilities  Improperly accessing, reviewing, or releasing the record of a patient for whom one has no responsibility out of concern or curiosity, or requesting another person to do so  Improperly accessing, reviewing, or releasing a patient record to use information in a personal relationship  Improperly accessing, reviewing, or releasing the patient record of a public personality for the intent of giving or selling information to the media  Improperly accessing, reviewing, or releasing confidential information of another member of the workforce who is also a patient  Improperly accessing, reviewing, or releasing confidential information that may bring harm to the organization or people associated with it Electronic Health Record (EHR) Definition: Longitudinal electronic record of a patient’s health information that is automated and streamlined into the clinician's workflow, which is able to generate a complete record of a clinical patient’s encounter in any care delivery setting, and thus supports other care-related activities, including evidence-based decision support, quality management and outcomes reporting. (HIMMS, 2010) *Legal Alert: Remember, each time you log in to an electronic health record (EHR) with your password, you create a trail that can be traced, and you are liable for everything you document—or fail ELECTRONIC HEALTH RECORD -A systematic, digitized system to improve patient care -Comprehensive records of a person’s health history -Communication for all members of the treatment team -Accounts for every treatment, diagnosis, and provider visit for billing -All components of an EHR can be used in a court of law (ati-Engage Fundamentals. Lesson 7-Documentation) S ituation B A R ackground SBAR Communicati on Tool ssessment ecommendation Can be used in a variety of ways: Hand-off communication Nurse to provider discussions SBAR is used to improve the effectiveness of communication SBAR Report Sheet Intake & Output Documentati on Activity What is intake and output? Fluids that enter the body (intake) Any food items that become liquid at room temp Water, juice, coffee, IV fluid, tube feedings Jello, ice cream, popsicles, ice chips Fluids that come out (output) Urine, emesis, blood, drainage, gastric content, liquid stools What is strict I&O? The measurement of fluids that go into the body and the fluids that come out The 2 measurements should be equal What goes in, must come out! Why do we measure it? To monitor fluid balance An abnormal finding may indicate Fluid retention (edema) Dehydration Electrolyte imbalance Organ malfunction (heart, kidneys, liver) Intake & Output