Documentation & Reporting PDF

Documentation & Reporting  Intended Learning Outcomes At the end of this lecture, every student will be able to: ▪ Define nursing documentation. ▪ List purposes of nursing documentation. ▪ Identify Principles of nursing documentation. ▪ Discuss benefits of nursing documentation. ▪ Apply documenta...

Documentation & Reporting  Intended Learning Outcomes At the end of this lecture, every student will be able to: ▪ Define nursing documentation. ▪ List purposes of nursing documentation. ▪ Identify Principles of nursing documentation. ▪ Discuss benefits of nursing documentation. ▪ Apply documentation of nursing actions following the guidelines. ▪ Analyze Consequences of inaccurate nursing documentation.  Documentation & Reporting Introduction: Documentation is not separate from care and it is not optional. It is an integral part of registered nurse(RN) practice, and an important tool that RNs use to ensure high-quality client care.  Documentation & Reporting Definition Any written or electronically generated information about a client that describes the care or service provided to that client. “Client” refers to individuals, families, groups, populations or entire communities who require nursing expertise.  Documentation & Reporting Nursing documentation clearly describes: An assessment of the client’s health status, nursing interventions carried out, and the impact of these interventions on client outcomes. Information reported to a physician or other health care provider.  Documentation & Reporting Purpose for documentation: ▪Communication: Provides efficient and effective method of sharing information. ▪Legal Documentation: It is admissible as evidence in a court of law. ▪Research: Provides valuable health-related data for research. ▪Statistics: Provides statistical information that can be utilized for planning people’s future needs. ▪ Education: Serves as an educational tool for students in health discipline.  Documentation & Reporting Purpose for documentation: ▪ Quality Assurance. Monitors the quality of care received by the client and the competence of health care givers. ▪ Planning Client Care. Provides data which the entire health team uses to plan care for the client. ▪ Reimbursement. Provides the basis for decisions regarding care to be provided and subsequent reimbursement to the agency, to cover health- related expenses.  Documentation & Reporting Benefits of Nursing Documentation: An account of judgment. Critical thinking used in the nursing process. Accurate, timely documentation reflects care provided. It also reflects the application of : Nursing knowledge. Nursing skills & judgment. Established accountability. Conveys the unique contribution of the nursing to health care.  Documentation & Reporting Documentation Principles: Good documentation has 6 important characteristics. ▪ Factual ▪ Accurate ▪ Complete ▪ Timely ▪ Concise ▪ Legible  Documentation & Reporting Factual: ▪ Descriptive objective information about what the nurse sees, hears, feels, smells and think. ▪ Use of inference (‫)استنتاج‬without supporting ▪ data is not acceptable. ▪ Vague terms like appears, seems or ▪ apparently are not accepted. ▪ Subjective data is documented in client’s exact ▪ words within quotation marks.  Documentation & Reporting Accurate: ▪ Use of exact measurement establishes accuracy ▪ e.g. Intake 450 ml of water than writing adequate amount of water. ▪ Clients name and identifying information are written on each page. ▪ Before making any entry in the chart make sure that it is correct. ▪ Chart only your observations and actions to be accountable.  Documentation & Reporting Complete ▪ Document all necessary information. ▪ It should give a clear picture of what took place. ▪ Complete pertinent assessment data such as vital signs, wound drainage, client complaints, who was notified and what interventions are carried out are recorded. ▪ Any condition change. ▪ Patient’s responses especially unusual, undesired or ineffective response. ▪ Communication with patient’s family.  Documentation & Reporting Timely (date & time): ▪ Document date & time of each recording ▪ Record time in conventional manner (e.g. 9:00am or 6:00pm or according to the 24 hours clock) ▪ Avoid recording in advance (this practice is illegal falsification of the records contributes to errors and confusion and threatens patient safety.  Documentation & Reporting Concise: Recording need to be brief as well as complete to save time in communication. Client’s name and the word client can be omitted.  Documentation & Reporting Legible : Using black pen, clear enough to be readable particularly handwriting. Any mistakes occur while recording draw a line through it and write above or next to original entry with your initial or name.  Documentation & Reporting Draw a line through the blank space so that no additional information can be added. Using black pen, clear enough to be readable particularly handwriting. Any mistakes occur while recording draw a line through it and write above or next to original entry with your initial or name.  Documentation & Reporting General Documentation Guidelines: ▪ Ensure that you have the correct client record or chart. ▪ Document as soon as the client encounter is concluded to ensure accurate recall of data. ▪ Never write procedures to be done until they have been done. ▪ Make sure your writing is neat, clear and legible. ▪ Correct spelling is essential for accuracy. ▪ Date and time of each entry. ▪ Sign each entry with your full legal name.  Documentation & Reporting General Documentation Guidelines(cont.) ▪ Do not leave space in between entries. ▪ If an error is made while documenting, use a single line to cross out the error, then date, time and sign the correction. ▪ Never change another person’s entry even if it is incorrect.(don’t use the correction fluid) ▪ Use quotation marks to indicate direct client responses. ▪ Use permanent ink(blue or black).  Documentation & Reporting General Documentation Guidelines(cont.) ▪ Use concise phrases, begin each phrase with a capital letter each new topic on a separate line. ▪ Avoid any judgmental words about patient ,family or staff in your documentation. ▪ Identify the source of information. ▪ Document all telephone calls that you received that are related to client’s case. Questions  Documentation & Reporting When to document: ▪ With the patient’s initial admission ▪ Daily documentation ▪ After provision of nursing care ▪ When there is a change in patient’s condition ▪ When there is an emergency situation ▪ On patient discharge  Documentation & Reporting Initial admission assessment : Documentation will include: ▪ The time of admission, or transfer of patients, patients' complaints, vital signs, height, weight and allergies. ▪ Initial admission notes should consist of the general observation of the patient (assessment). ▪ Use only approved abbreviations in the documentation.  Documentation & Reporting Daily documentation : ▪ Shift time and date of observation as well as the care given. ▪ The time of patients return from operating or recovery room, the patients' condition; the dressings if dry or wet. ▪ Chart the colors, and quantity of drainage, type, amount, and rate of intravenous fluids; condition of the insertion site. ▪ Chart medication (five rights).  Documentation & Reporting Document nursing care : ▪ Document the exact time of procedures, patients condition after the procedure, vital signs and patients' education or instructions for being NPO, X-ray, ------ ▪ Record specific care given ▪ Record patients' complains / nursing intervention ▪ a- Complain of pain and its characteristics, ▪ b- Record notifying the doctor, and the prescribed medications ▪ c- If analgesics were given, record its effect.  Documentation & Reporting Document when there is a change in the patient’s condition : ▪ Any change in patients' condition. ▪ Each time a physician visits the patient. ▪ When a patient refuses medications or treatment, include notifying the physician on duty. Document when there is an emergency situation: ▪ Document factual information, as well as specific times and interventions.  Documentation & Reporting On discharge : ▪ Document the general condition of patients at discharge time / date of discharge for each patient. ▪ Document instructions given for medications, diet, dressing, and referral to clinics. ▪ Relationship of significant other accompanying patients at time of discharge.  Documentation & Reporting Do not do the following in nurses' notes: ▪ Writing inappropriate abbreviations. ▪ Routine tasks i.e. bed making, emptying urinals, etc. ▪ Omitting your name after writing nurses progress notes.  Documentation & Reporting Methods(Styles or Formats) of Nursing Documentation: ▪ Narrative documentation. ▪ Problem-Oriented Medical Record (POMR). ▪ Subjective, objective, assessment, plan (SOAP)documentation. ▪ Assessment, plan, intervention, evaluation (APIE) documentation. ▪ Focus Charting: data, action, response(DAR) documentation.  Documentation & Reporting Methods(Styles or Formats) of Nursing Documentation: ▪Narrative documentation: ▪ Is the traditional method for recording nursing care provided. It is a story-like format to document information specific to client conditions and nursing care. ▪ Data are recorded in the progress notes without an organizing framework. It often requires the reader to sort through information to locate the data required.  Documentation & Reporting Methods(Styles or Formats) of Nursing Documentation: ▪ Problem-Oriented Medical Record (POMR) : ▪ Recording data about the health status of the patient in form of problem solving format. ▪ POMR preserves the data in an easily accessible way that encourage ongoing assessment and revision of the health care plan by all members of health care team. ▪ All data base is collected before beginning of identifying the patient problem.  Documentation & Reporting Advantages of Problem-Oriented Medical Record (POMR) method: ▪ Gives emphasis to client’s perceptions of their problems. ▪ Requires continuous evaluation and revision of the care plan. ▪ provides greater continuity of care among health-care team members. ▪ Enhances effective communication among health-care team members ▪ Increases efficiency in gathering data  Documentation & Reporting Methods(Styles or Formats) of Nursing Documentation: ▪ Subjective, objective, assessment, plan (SOAP): One of the most prominent features of this problem- orientated method of documentation is the structured way in which progress notes are written by all health-care team members, using the SOAP, SOAPIE or SOAPIER format. Subjective the client’s observations Objective the care provider’s observations and tests Assessment the care provider’s understanding of the problem Plans goals, action, advice  Documentation & Reporting Methods(Styles or Formats) of Nursing Documentation: ▪ Intervention, Evaluation, Revision (IER): Intervention when an intervention was identified and changed to meet client’s needs. Evaluation how outcomes of care are evaluated. Revision when changes to the original problem come from revised interventions, outcomes of care or time lines this is used to denote changes.  Documentation & Reporting Methods(Styles or Formats) of Nursing Documentation: Problems, Intervention, Evaluation (PIE) The PIE notes are numbered or labeled according to the client’s problems. Resolved problems are dropped from daily documentation after the RN’s review. Continuing problems are documented daily. Problems Intervention Evaluation  Documentation & Reporting Methods(Styles or Formats) of Nursing Documentation: Focus Charting: Focus Charting (sometimes referred to as DAR) This method of documentation consists of notes that include data, both subjective and objective; action or nursing interventions; and response of the client. Data Action Response  Documentation & Reporting what exactly nurses document? Patient care related documentation: ◼ The “Notes” ◼ Admission and Discharge ◼ The “Orders” ◼ Legal Documentation and Consent Administrative Documentation ◼ Routine admission ◼ Birth and Death certificates ◼ Insurance or billing (‫ )الفواتير‬paperwork  Documentation & Reporting Patient care related documentation: The Notes: ▪ An abbreviated notation of the facts similar to the “notes” one might take during a lecture and refer to while studying before a test. ▪ Allows colleagues and other medical personnel a chance to review the case. ▪ Allows oneself a chance to review initial presentation and evaluation. Ms. Fukai, a 23 y/o o/w healthy Japanese , presented today for ℅ acute onset R ear pain following daily swimming in the local pool over the previous week. Pt. has exp’d 36 hrs ↑’ing R otalgia assoc. w/ ↑’ing mucoid d/c. Afebrile and w/o any signs or symptoms of illness. Denies trauma/diving. Meds: Eucerin, occasional topical hydrocortisone 2% ointment Allergy: NKDA PMH/PSH/FH: Atopic dermatitis well controlled on current tx. o/w N/C Soc Hx: No tobacco, occasional EtOH (