Nursing Documentation (Fall 2024) PDF

Domain: Nursing Documentation Concept: Clinical Decision Making Fall 2024 Exemplar: Documentation 1 2 Documentation Standards...

Domain: Nursing Documentation Concept: Clinical Decision Making Fall 2024 Exemplar: Documentation 1 2 Documentation Standards Domain: Nursing Hospital policies for documenting are based on standards set by: Concept: Clinical Decision Making A process nurses use to evaluate and Medicare and Medicaid select the best actions to meet desired The Joint Commission goals American Nurses Association State Nurse Practice Acts Exemplar: Documentation 3 4 Ethical and Legal Guidelines Ethical and Legal Guidelines Access to the record is restricted to professionals involved ANA Code of Ethics: “…the nurse has a duty to in the care of patient maintain confidentiality of all patient information.” (Provision 3.1, p. 12) Protected health information (PHI) Identifiable health information that is transmitted or maintained HIPAA: Protects the privacy and security of health Includes written, verbal, electronic info records Do not share personal passwords or walk away from computer when logged on Nursing students: Held to the same standard 5 6 1  Ethical and Legal Guidelines Purposes of Health Care Records ◼Documentation of patient care ◼Communication among the healthcare team Do not look at the charts of any patient not assigned to you unless directed by clinical professor ◼Research Do not identify patient name or give info that could identify ◼Education patient in student worksheets or CONVERSATIONS ◼Auditing health agencies Do not leave facility with your nursing notes with patient ◼Legal documentation info—put in shredder ◼Healthcare analysis 7 8 Nursing Documentation Documentation Systems Admission Nursing Assessment Problem-Oriented Medical Record Nursing Care Plans Data arranged according to patient problems Flow Sheets Database, problem list, plan of care, progress Intake and output, MAR, Assessments notes Easy identification of problems, repeated Progress notes documentation can be tedious Nursing Discharge Types of charting: PIE, Focus charting, Chart by exception, Critical pathways, Narrative notes (progress notes) 9 10 Charting by Exception (CBE) A documentation system in which only significant findings or deviations from norms are recorded Includes flow sheets Emphasize standards of care Available at the bedside 11 12 2  CBE Charting CBE Charting HEENT: Lungs: Wheezing right and left lungs Advantages: CV: Elimination of lengthy repetitive notes GI: Reports changes in patient condition GU: Easier to read and pick out problem areas MS: Disadvantages: Neuro: May not pick up subtle changes in condition Should be used with narrative note for charting abnormal findings in detail CBE presumes that all systems are assessed!!! 13 14 Critical Pathways Emphasizes quality and cost-effective care given in pre-determined length of time Critical pathways used to document care If goals are met, no further charting needed A goal not met is called a variance—an unexpected occurrence Example: Infection after surgery 15 16 Narrative Charting Nursing Process Progress notes that include routine care, normal findings, and patient problems Assessment Written in an abbreviated story form Nursing Diagnosis/Patient Problem/Analysis May be used with CBE to chart abnormal findings Plan Use nursing process to organize data Implement Evaluate 17 18 3 Narrative Example Documentation Standards 0730: During initial assessment, patient was found to be confused-not oriented to place or situation but knows her name and who is president. Temp 38.5 C, RR 28, HR 98, BP 130/80. ◼Ongoing assessment Husband at bedside who states patient can get confused when she is febrile. Patient medicated with acetaminophen and fluids offered. Will continue to monitor. Ann Smith, RN ◼Patient teaching and patient response to teaching 0830: Temp down to 37.8 C. Drinking fluids. Patient now states ◼Response to medications, treatments, interventions she is in the hospital but is still confused about why she is here. Husband at bedside. Ann Smith, RN ◼Relevant statements made by the patient 0930: Patient afebrile, sitting up in bed and eating breakfast. Oriented x 4. Ann Smith, RN 19 20 High Quality Documentation High Quality Documentation Clear, concise, complete Factual--What you see and hear, not your opinion Follows logical order Reports data and conclusions Accurate—Be precise—be clear who gave the care Reports variances Accurate Complete—Change in patient condition, patient responses to treatment, communication with family Accepted abbreviations Timely—ASAP after events, note time of events if charting later, never document in advance—illegal falsification of records 21 22 Common Documentation Errors Common Documentation Errors Failure to record pertinent health info Failure to record medications given Failure to record changes in patient’s condition Failure to record drug interactions Failure to record nursing actions Failure to record required restraint documentation Failure to record the reporting of critical lab results to provider Failure to record skin assessment and pressure ulcer prevention 23 24 4  Your Documentation Testifies Let your Did you provide a safe environment? documentation Did you take the safety precautions with restraints? reflect professional Did you observe responses to meds, treatments? standards of Did you provide infection control? nursing care!!! 25 26 ISBAR I—Dr. Collins, this is Kim, the RN taking care of Mrs. Jones in room 204 A tool for nurses to communicate patient needs or S—She is c/o abdominal pain changes in patient’s condition with B—She had an appendectomy 2 days ago physicians/interdisciplinary team members A—She was crying and holding her abdomen, even after giving her pain med. Her temp is normal, but BP, HR and Identify RR are elevated. C/O pain 10/10. I gave her acetaminophen, but she states it did not help. Situation R—I recommend a stronger pain medication. Or, are there Background any orders you want to write? Assessment Recommendation 27 28 References Myers, V. (2014). Defending yourself through documentation, American Nurse Today, 9(2). RN.com (2015). Professional nurse documentation. 29 5