Documenting and Reporting in Nursing | PDF Guide

Documenting and Reporting Chapter 17 Candance Tooley MSN, RN  Learning Outcomes 1. Explain the purposes of documentation. 2. Compare and contrast electronic and written documentation. 3. Identify a variety of documentation formats and their purposes. 4. Follow docu...

Documenting and Reporting Chapter 17 Candance Tooley MSN, RN  Learning Outcomes 1. Explain the purposes of documentation. 2. Compare and contrast electronic and written documentation. 3. Identify a variety of documentation formats and their purposes. 4. Follow documentation guidelines to record accurately the health status of the patient, nursing interventions, and patient outcomes in written and electronic formats. 5. Identify approved abbreviations to use in documenting in clinical environments. 6. Discuss the key elements of giving a verbal patient report. 7. Explain the process for verifying or questioning a medical prescription. Steven Stellanski is a 16-year-old male who has just been released from the postanesthesia care unit (PACU) after an emergency appendectomy. You are assigned to his care on your unit. Steven is groggy but moaning in pain. Meet Your “Help me, help me,” he whispers. He is holding his abdomen and grimacing. The PACU nurse tells you that Steven has Down syndrome and functions at an elementary school–age level. Patient Steven’s vital signs are as follows: tympanic membrane temperature 99.9°F (37.7°C); pulse, 104 beats/min; respirations, 24 breaths/min; and blood pressure 104/68 mm Hg. An intravenous (IV) bag of lactated Ringer’s solution is infusing at 125 mL/hr. The dressing on Steven’s right lower abdomen is dry and intact. An indwelling catheter is draining pale yellow urine. The provider has prescribed a patient-controlled analgesia (PCA) pump that will deliver morphine sulfate at 1 mg every 15 minutes, up to 4 mg per hour. Steven is to remain NPO (nothing by mouth) for now. His postoperative dressing is to be changed tomorrow morning, and the nurses are to institute progressive ambulation as tolerated.  Nurses must be able to communicate patient care clearly, concisely, comprehensively, and accurately through verbal reporting to others and documenting in written and/or  Accurate Bias-free Complete Detailed Easy to read Factual Documentati Grammatical on ABC’s Harmless (legally) I am responsible  Documentation Is The Most Important Task You Will Do! Medical records (chart/health record) are the collection of documented events that occurs during an admission regarding a pt.’s health and progress from everyone that provides/provided - It is permanent and can care. be used as evidence in court. - To share information among health care workers to provide continuity of pt. care to ensure their safety. - Permanent Record- is a chronologic account of a person's illnesses/injury, the care provided and the pt.’s response to treatments/interventions from admission to discharge or death. - Always kept for future reference such as readmits to  Other uses of a Medical Record cont. Quality Improvement- Medical records can be used to evaluate the quality of care, patient safety, and to verify that healthcare providers meet licensure requirements. The Joint Commission (TJC)c establishes criteria that reflects what a facility should be doing to demonstrate they are providing quality care for a pt. Audit of a facilities departments and medical records occur to determine if the company is complaint, if they are not, then TJC can withdraw their approval or give the facility a set time to get things back in order. TJC requires the following nursing documentation evidence to justify accreditation: Initial assessment and reassessments of physical, psychological, social, environmental, and self-care; education; discharge planning and the client's or significant other's ability to manage continuing care needs. Identification of nursing diagnoses or client needs. Planned nursing interventions or nursing standards of care for meeting the client's nursing care needs.  Other uses of a Medical Record cont. Reimbursement and Utilization Review- various agencies such as insurance companies, the government, 3rd party payers, and billing departments use to determine cost of care. Companies will request documentation proving that care/supplies billed for was actually done/used. Undocumented, incomplete, or inconsistent documentation may result in denial of payment. Education and Research- Used by students to prepare for clinical, in research to further  Other uses of a Medical ProfessionalRecord cont Standards of Care- American Nurses Association (ANA) Scope and Standards of care have documentation in most of the standards. Document relevant data accurately and in a manner accessible to the interprofessional team (Standard 1—Assessment). Document diagnoses, problems, and issues in a manner that facilitates the determination of the expected outcomes and plan (Standard 2—Diagnosis). Document expected outcomes as measurable goals (Standard 3—Outcomes Identification). Document the plan using standardized language or recognized terminology (Standard 4—Planning). Document implementation and any modifications, including changes or omissions, of the identified plan (Standard 5—Implementation). Document the coordination of care (Standard 5A—Coordination of Care). Document the results of the evaluation (Standard 6—Evaluation). Document nursing practice in a manner that supports quality and performance improvement initiatives (Standard 14—Quality of Practice).  Other uses of Medical Records Legal Record - evidence in court to determine if treatments/interventions were carried out in an appropriate and timely manner. The lawyers look at baseline status, changes in status, analysis of the changes, actions taken, and client's response. Medical records are legal documents. It can be used as evidence in court for malpractice or negligence. You are responsible for what you document. Anything that cannot be read,  Standardized Nursing Language Keeps nursing visible- demonstrates the value of what we do. Using the same terminology ensures nursing care is visible and easier to follow from admission to discharge. Supports Nursing Research- Documentation systems that use a format can easily analyze large amounts of data to support evidenced based practices. Electronic Health Records (EHR’s) - use a standardized language.  Documentation Methods Source Oriented ⮚ Traditional Medical Record ⮚ Tabs for each discipline ❑ Advantages- easily locate information from various departments. ❖ Disadvantages - data is scattered, fragmented, and hard to find the answer without having to read through several tabs. - difficult to track treatments and the outcomes of a particular problem. Example- pt. admitted with CHF and retaining fluids causing her to have SOB (Shortness of Breath) so you would need to read nurses, respiratory therapist, and provider notes in addition to the  Electronic Health Records (EHR) Computerized charts located at the nurse's station, in the patient rooms, handheld, or on wheels (COW). Computerized charting has many advantages: ⮚ Enhanced communication and collaboration. ⮚ Increased access to information. ⮚ The information is always legible. ⮚ It automatically records the date and time of the documentation. ⮚ The abbreviations and terms are consistent with agency-approved lists. ⮚ Omissions are fewer because the computer prompts the nurse to enter specific information. ⮚ It saves time because it eliminates delays in obtaining the chart. ⮚ Electronic data require less storage space and are quickly retrievable by any health care member at the same time. ⮚ Improved quality of care. (embed protocols) ⮚ Decreased medical errors. Alarms when medical entry items are picked up. ⮚ Support the collection of data for evidenced based practice. ⮚ Confidential information is safe with tracking systems for when and who accessed the record, password requirements, and screen protectors/savers.  Electronic Health Records (EHR) Disadvantages - computer illiterate/intimated users. - most have a form that pops up to document on but does not have what you want to say which requires you to go to another section to explain in narrative form. - Computers can be hacked! Access/password that is changed every 90 days. DO NOT SHARE PASSWORD. - the initial expense of purchasing computer system and training personnel to use it. - during a power failure or electronic malfunction, nurses must resort to written documentation until the emergency backup access reactivates the computer system. - Sometimes not integrated across departments or has limited access to some information that may be needed so has to find someone to access it for them.  Documentation Methods Chartingcont. by Exception (CBE): - The expected norms are defined on the form. CBE assumes that all standards have been met to say the patient is responding normally and the body system is normal. - Only significant problems or abnormalities are documented. ▪ Advantage- decreases amount of time required to chart with repetition of routine care. It is easily read and understood with just problems noted. ▪ Disadvantages- omissions of pertinent information due to nurse's perception of normal and if assessment is being documented by baseline or physiologic status. Must know organizations  Formats for Nursing Notes Narrative- Writing information out in a chronological order- looks like a journal. - This is better form of documentation but time consuming. Flowsheets- document recurring tasks (I/O, wgts, ADL’s, vital signs, post-op). Graphics helped you to monitor trends in vital signs, intake/output, etc. Problem Oriented Medical Record- organized by patient problems, data base with objective and subjective data, care plan, and progress notes- examples are SOAP, PIE, and DAR.  Documentat Using the Nursing ion Process and Clinical Judgement model ensures you cover all the pertinent areas.  Nurses are the only ones that provide 24/7 care to the patient. At the end of a shift the nurse leaving tells the nurse coming on about the patient using an SBAR, but you can’t tell everything! So, it is your responsibility to maintain an accurate record in order to provide a complete “picture” for members of the healthcare team. Effective patient care should be continuously evaluated, done in a systematic manner, and at least every 2 Formats for Nursing Use of abbreviations: - The Joint Commission “do not use Notes abbreviations“ and recommendations.  Activity Use of Abbreviations Recall the case of Steven Stellanski (Meet Your Patient). Following is a brief admission note using a narrative documentation format. Underline any words or entries that you do not understand: 4/11/XX 1600 Pt received on unit from PACU. VSS. TM temp 99.9°F (37.7°C), P 104, and BP 104/68. LOC unstable. Arouses when name called but quickly drifts off to sleep. PERRLA. Moaning, grimacing, holding abd, whispers “Help me. Help me.” LR at 125 mL/hr infusing in R forearm. IV site patent. Urinary catheter in place, draining pale yellow urine. Abd dsg dry & intact. Morphine sulfate PCA prescribed. Will initiate. ——————————— Ron Allen, R. N  Forms used… Name of Tab Content Admission data Provides information such as the client's name, date of birth, address, phone number, religion, insurer, admitting physician, admitting diagnosis, person to contact in case of emergency, emergency phone number Advance directive Provides instructions about the client's choices for care should he or she be unable to make decisions later History and physical examination Contains the physician's review of the client's current and past health problems, results of a body system examination, medical diagnosis, and tentative plan for treatment Physician's orders Identifies laboratory and diagnostic tests, diet, activity, medications, intravenous fluids, and clinical procedures (instructions for changing a dressing, inserting tubes, and so forth) on a day-by-day basis Physician's or multidisciplinary progress notes Describes the client's ongoing status and response to the current plan of care, and potential modifications in the plan Nursing admission data base Documents baseline information concerning the client's health patterns and initial physical assessment findings Nursing or multidisciplinary plan of care Identifies client problems, goals, and directions for care based on an analysis of collected data Graphic sheet Displays trends in the client's vital signs, weight, daily summary of fluid intake and output Daily nursing assessment and flow sheet Indicates focused physical assessment findings by individual nurses during each 24-hour period and the routine care that was provided Nursing notes Provides narrative details of subjective and objective data, nursing actions, response of the client, outcomes of communication with other health care personnel or the client's family Medication administration record Identifies the drug name, date, time, route, and frequency of drug administration as well as the name of the nurse who administered each medication Laboratory and diagnostic reports Contains the results of tests in a sequential order Discharge plan (begins on admission) Indicates the information, skills, and referral services that the client may need before being released from the agency's care Teaching summary Identifies content that was taught, evidence of the client's learning, and need for repetition or reinforcement  Forms used in Nursing Medication Administration Records (MAR) used to document when medications were given: scheduled, unscheduled (on call), PRN (as needed), STAT (give immediately), single dose (one time), IVF (intravenous fluids), etc. Be alert for allergies! Other documentation required for medications: - Injections- location - Specific assessment- heart rate, BP, glucose levels, etc. - Dosage range orders- such as titration of an IV heart medicine. - If patient refuses medication- circle time/date square for that med on MAR and document in nursing notes. In computer select not given and that patient refused. - Omitted/delayed medications- pt. at dialysis or another appointment, change in status, etc. Make sure to note did not give in nurses note and why. If given later sign off on MAR but also put in nurses' notes.  Forms used in Nursing Pt. care 24 hour summary- quick reference for current pt. information. Kept updated with all pt. changes in medical orders. Integrated Plan of Care - an individualized written list of client’s assessment, planning, implementation and evaluation. Revised as condition changes.  Guidelines: Incident (Occurrence) Reports 1. Clearly identify the client, date, and time, and location. - document out-of- ordinary occurrences that may 2. Briefly describe the incident in involve patient, family, visitor, employee, medication objective terms and accurately. errors, falls, needlesticks, unsafe staffing, loss of 3. Quote the client or persons involved if patients belongings, lack of care supplies, possible. inadequate response to an emergency situation, etc. 4. Identify any witnesses in the event, equipment involved, and - Sent to risk management for evaluation. Is not environmental conditions. punitive but to evaluate problems and change 5. Avoid drawing conclusions or placing processes. blame. 6. Notify physician for orders. Document actions taken and the client's - People that found situation and supervisor in response to the interventions. charge must be listed. - Not kept on chart – but if lawyer asks for it then it must be provided.  Home Health Care Documentation Regulated by Health Care Financing Administration(HCFA) - Medicare/Medicaid Patient must meet certain criteria to be accepted for HH. - Certificate of Homebound status - A plan of care - Ongoing assessment for continued need of services. Outcome and Assessment Information Set (OASIS) Admission form extensive to determine this certification. RN fills out initial paperwork then RN or LPN can perform follow-up visits. Must document using the nursing process.  Long-Term Care (LTC) Documentation Must meet certain criteria to be admitted. Paperwork must be completed for LTC acceptance and reimbursement. Documentation different than hospitals. You document daily for services (wound care) then once a week (weekly summary) on a patient unless problems occur then will document daily until problem resolved. LTC documentation is regulated by the U.S. Government which varies based on level of care and resident payment method (Medicare and Medicaid require more detailed documentation). LTC must fill out an extensive assessment form called the Minimum Data Set for Resident Care and Screening (MDS) on admission and every three months. LTC weekly summary must include documentation on elimination, activity levels, communication, support systems, nutrition, prostheses (glasses, dentures, hearing aids, etc.) LTC medication Administration records are monthly and not daily like in acute care.  Report - Off Form Change of Shift Report/hand over - person leaving shift tells the person coming on about patient. Need a standard report form SBAR (Situation, Background, Assessment, and Recommendations.) commonly used in hospital. - Notes need to be all inclusive and clear to guide day. - Be on time and have pen/paper ready. - Cover important details. Clarify anything unclear and ask questions about pertinent information not covered. - Report can be taped, face to face, or can have walking rounds. - Keep notes during shift with accurate times to assist in documenting care and during report to the next shift. Transfer - MBAR (Medications, Background, Assessment, and recommendations) Report given when a pt. is transferred to another unit or facility. Provides detailed information on health history, orders, care needed, MD A change of shift report usually includes: Name of client, age, and room number Name of physician Medical diagnosis or surgical procedure and date Relevant past history Range in vital signs/Abnormal assessment data Characteristics of pain, medication, amount, time last administered, and outcome achieved Type of diet and percentage consumed at each meal Intake and output totals Special body position and level of activity, if applicable Scheduled diagnostic tests; consultations Test results, including those performed by the nurse. Changes in medical orders including newly prescribed drugs Type and rate of IVF and the amount of fluid that remains Settings on electronic equipment such as amount of suction Condition of incision and dressing Teaching performed  Miscellaneous 12/17/XX 0815 MVerbal (VO)/Telephone Orders (TO)- Only obtained if there is an emergency or provider is not somewhere they can enter orders. Have a second nurse as a witness, repeat the order, and spell unfamiliar names. 1. Enter order into EHR, state read back and verify (RB&V), select physician then sign. You name will be the one entering the order. 2. When writing on a paper prescription form, first document the date and time, how you received the prescription, “TO” or “VO” followed by the prescribing provider’s name and then your name, and RB&V). The following is an example of a telephone prescription: orphine 2 mg IV push ×1 for pain now. TO Dr. Clayton Kent/Sarah Hogan, RN; read back for verification and validated/ RB&V - Questions about a prescription- follow policy- if illegible call MD.  Workpla ce Names on charts can’t be visible to public. Clipboards –private/closed/upside down. Whiteboards- room numbers- no linkage to diagnosis/treatment/procedure. Computer screens not visible (privacy filters) or log-out when you walk away. DO NOT leave portable devices in public. Create a secure password- at least 8 characters with a mix of numbers, upper and lowercase letters, and a symbol if allowed. Do not use personal data. Change password every 6 months. DO NOT share passwords with others. Discuss pt. only in private area where can not be overheard. Fax machines (call to ensure intended person by fax machine) documents must have a cover sheet for saying confidential and to destroy if received in error and call the person that sent the fax. Filing cabinets/medical records, and x-ray boxes in areas off limit to public. Telephone Etiquette: - used to exchange information in emergency or when difficult to get together to discuss clients need, condition, etc. - Answers as promptly as possible - Speaks in a normal tone of voice - Identifies himself or herself by name, title, and nursing unit - Obtains or states the reason for the call - Discretely identifies the client being discussed to avoid being publicly overheard - Spells the client's name if there is any chance of confusion - Converses in a courteous and business-like manner - Repeats information to ensure it has been heard accurately  Documenti document, and how frequently! ng Know your facilities policy on method used, responsibility for what and who is to MINIMUM of EVERY TWO HOURS IF STABLE! Make sure you have the right chart! Assessment data/Client care needs Routine care such as hygiene measures Safety precautions that have been used Nursing interventions described in the care plan Medical treatments prescribed by the physician Outcomes of treatment and nursing interventions Client activity Medication administration Percentage of food consumed at each meal Visits or consults by physicians or other health professionals Reasons for contacting the physician and the outcome of the communication Transportation to other departments, like the radiography department, for specialized care or diagnostic tests, and time of return Client teaching and discharge instructions  Guidelines for Documenting continued Know if the facility uses traditional or military time. - Traditional time listed with am, pm, midnight, or noon behind the time. - The use of military time avoids confusion because no number is ever duplicated, and the labels a.m., p.m., midnight, and noon are not needed. Military time begins at midnight (2400 or 0000). One minute after midnight is 0001. A zero is placed before the hours of one through nine in the morning; for example, 0700 refers to 7:00 a.m. and is stated as “oh seven hundred.” After noon, 12 is added to each hour; therefore, 1 p.m. is 1300. Minutes are given as 1 to 59. Convert 6:30 p.m.the following from traditional Midnight time to9:05 8:45 a.m. military p.m. time: 4:15 a.m. NOTE: EHR documents in real time so if you are late documenting ensure that you change the date and time to the occurrence!!  Guidelines for Paper Health Records To ensure your written paper documentation is effective, the forms used must be efficient, comprehensive, and relevant to the client’s healthcare needs. The forms should guide you to document appropriately according to your organization’s policies and procedures. 1. Ensure you have the correct form (e.g., I&O sheet, graphic record) before you begin writing. 2. Check that the medical record and documentation forms are clearly marked with the client’s name and identification number. 3. Write legibly, neatly, and in an organized manner. This enables others to read your entries and use them to make clinical decisions. Sloppy or illegible handwriting creates errors or, at least, leads to poor communication. 4. Always use black or blue ink (facility policy) for handwritten notes. Inks other than black or blue are not legible when a patient record is photocopied. Do NOT use green or red pen. 5. Do not leave blank lines in the narrative notes. If you need to leave space for clarity, draw a straight line through the area and begin on the next line. Open areas leave an opportunity for later tampering. 6. Draw a line through the incorrect documentation and initial it. Never use a correction fluid, “ink over,” or otherwise cover up written notes. 7. Sign all your paper documentation entries with your first name, last name, and  Guidelines for Documenting Remember continued to be brief, concise, and to the point. No need to use grammatically correct sentences and unnecessary words but do need to use proper tenses of time! No need to document pt., resident, client, because you should ONLY be talking about the person the chart belongs to. Do use proper punctuation- Start sentence with capital letter and end with a period. Be accurate- - Factual and specific- no vague comments. - Use correct medical terminology. - Check spelling. - Do not document opinions, assumptions, or interpretations. - Document what you see, hear, smell, read, or feel. - Use quotations mark for comments from patient or family, etc. ex: States "I hurt” - Never discard any page of the medical record. Recopy it if something split on  ANA Social Media Social media helps to increase the visibility of the nursing profession and the critical role that nurses are playing in our health care systems and communities worldwide. The American Nurses Association (ANA) has created a set of principles to help nurses while safeguarding themselves, the profession, and their patients: 1.Be aware of your audience. Make sure that the content of your posts is appropriate for the people who will be seeing it and may share it with others. 2. Maintain your professionalism. Avoid posting anything that could be considered unprofessional or inappropriate, such as photos or videos of patients. 3. Know your social media policy. Familiarize yourself with your employer’s social media policy and adhere to it across all the social media platforms that you choose to use. 4. Secure your social media profiles. Review and set-up the respective privacy settings for the social media platforms that you choose to use. 5. Share credible information only. The dissemination of credible and reliable information protects the health and well-being of the public. 6. Engage with respectful content. Do not share content that is harmful, disparaging, Defensive documentation the practice of keeping thorough, accurate, and timely records of patient care. It's a vital responsibility that can help protect nurses from legal action and malpractice lawsuits The Nurses Service Organization (NSO) states common nursing documentation errors include: 1. Incomplete or missing documentation: Failing to document medications, treatments, or changes in a patient's condition 2. Incorrect information: Recording information in the wrong chart, using the wrong abbreviations, or making transcription mistakes 3. Subjective data: Using inappropriate terms like "demanding" or "irritating" to describe a patient 4. Improperly recording orders: Transcribing orders incorrectly or failing to document discontinuation of a medication 5. Sloppy handwriting: Handwriting that is illegible or difficult to read 6. Late entries: Failing to record information immediately or very soon after it occurs 7. Following organizational policies and regulations