Medical Records PDF

make notes for a 16 year old to understand, include all information but in a brief format. include all the information I need to know at a digestible amount. Nursing or multidisciplinary plan of care Identifies client problems, goals, and directions for care based on an analysis of collected data Gr...

make notes for a 16 year old to understand, include all information but in a brief format. include all the information I need to know at a digestible amount. 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, and 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 providers, 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 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 Hard copy paper forms are placed in a chart (a binder or folder that promotes the orderly collection, storage, and safekeeping of a person’s medical record). The paper forms in the chart are color-coded or separated by tabbed sheets. An EHR stored on a computer is accessed by using a password and selecting the desired form from a menu. EHRs can be printed if a hard copy is desired. All personnel involved in a client’s health care contribute to the medical record by charting, recording, or documenting (the process of entering information). Uses for Medical Records Besides serving as a permanent health record, the collective information about a client provides a means to share information among health care providers, thus ensuring client safety and continuity of care. Occasionally, medical records also are used to investigate quality of care in a health agency, demonstrate compliance with national accreditation standards, promote reimbursement from insurance companies, facilitate health education and research, and provide evidence during malpractice lawsuits. Permanent Account The client’s medical record is a written, chronologic account of a person’s illness or injury and the care provided from the onset of the problem through discharge or death. The record is filed and maintained for future reference. Previous health records are often requested during subsequent admissions so that the client’s health history can be reviewed. Sharing Information Because it is impossible for all health care providers to meet and exchange information on a personal basis at the same time, the medical record becomes central to communication (i.e., sharing information among personnel). The documentation serves as a way to inform others about the client’s status and plan for care. Sharing information prevents duplication of care and helps reduce the chance of error or omission. For example, if a client requests medication for pain, the nurse checks the client’s current record to determine when the last pain-relieving drug was administered. Accurate and timely documentation prevents medication from being administered too frequently or withheld unnecessarily. Maintaining immunization records is another example of how documentation promotes continuity; the record ensures the administration of subsequent immunizations according to an appropriate schedule. To maintain a high level of care, hospitals and other health care agencies use medical records to promote quality assurance (QA), continuous quality improvement (CQI), or total quality improvement (TQI) (an agency’s internal p. 114 p. 115 process for self-improvement to ensure that the level of care reflects or exceeds established standards). One QA method involves investigating the documentation in a sample of medical records. If the analyzed data indicate less-than-acceptable compliance with standards of care, the committee recommends corrective measures and reevaluates the outcomes later. Accreditation The Joint Commission (TJC) is a private association that has established criteria reflecting high standards for client safety and institutional health care. Representatives of TJC periodically inspect health care agencies to determine whether they demonstrate evidence of quality care. The documentation in randomly selected medical records is just one component examined during an accreditation visit. To support a health care agency’s accreditation, nursing documentation should include: Initial assessment and reassessments of physical, psychological, social, environmental, and self-care status; education; and discharge planning Identification of nursing diagnoses or client needs Planned nursing interventions or nursing standards of care for meeting the client’s nursing care needs including the education and training provided to the client and fall precaution strategies (The Joint Commission, 2012) Nursing care provided Client’s response to interventions and outcomes of care, including pain management, discharge planning activities, and the client’s or caregiver’s ability to manage continuing care needs If documentation is substandard, accreditation may be withheld or withdrawn. Reimbursement The costs of most clients’ hospital and home care are billed to third-party payers such as Medicare, Medicaid, and private insurance companies. Auditors (inspectors who examine client records) survey medical records to determine whether the care provided meets the established criteria for reimbursement. Undocumented, incomplete, or inconsistent documentation of care may result in a denial of payment.Education and Research Published references are primary resources for health education. Examining the medical records of clients with specific disorders, however, provides a valuable supplement that enhances learning and future problem-solving. Client records also facilitate research. For example, some types of clinical investigations are difficult to conduct because few participants are in a particular locale or test facilities are limited. Consequently, stored, microfilmed, or EHR documents serve as an alternative resource for scientific data. Nevertheless, to protect confidentiality, only authorized persons are allowed access to client records (see discussion on protecting health information). Formal permission must be obtained from the client, the health agency’s administrator, or other authority whenever a client’s record is used for a purpose other than treatment and record keeping. Legal Evidence The medical record is considered a legal document. Therefore, entries in medical records must follow legally defensible criteria (Box 9-1). Portions of the medical record can be subpoenaed as evidence by the defense or prosecuting attorney to prove or disprove allegations of malpractice. It is especially important to document safety precautions taken to protect the client, individuals who were notified about concerns and issues, and outcomes of the communication. Each person who makes entries in the client’s medical record is responsible for the information he or she records and can be summoned as a witness to testify concerning what has been documented. Any written documentation that cannot be clearly read or that is vague, scribbled through, whited out, written over, or erased makes for a poor legal defense. BOX 9-1Criteria for Legally Defensible Charting When making an entry in a client’s medical record, the nurse should Ensure that the client’s name appears on each page. Never chart for someone else. Use the specified color of ink and ballpoint pen, or enter data on a computer. Date and time stamp each entry as it is made. Chart promptly after providing care. Make entries in chronologic order. Identify documentation that is out of chronologic sequence with the words “late entry.” Write or print legibly. Use correct grammar and spelling. Reflect the plan of care. Describe the outcomes of care. Record relevant details. Use only approved abbreviations. Never scribble over entries or use correction fluid to obliterate what has been written. Draw a single line through erroneous information so that it remains readable, add the date, initial, and then document the correct information. Record facts, not subjective interpretations. Quote the client’s verbal comments. Write “duplicate” or “recopied” on documentation that is not original; include the date, time, initials, and reason for the duplication. Never imply criticism of another’s care. Document the circumstances for notifying a physician, the specific data reported, and the physician’s recommendations. Identify specific information provided when teaching a client and the evidence that indicates the client has understood the instructions. Leave no empty spaces between entries and signature. Sign each entry by name and title. Discuss how the nurse could improve each of the following documentation samples: 01/11 0800 Ate well. 1400 Hygiene provided and ambulated. 1500 Depressed all day. S. Rogers. Client Access to Records Historically, clients were not allowed to see their medical records. Since the passing of federal legislation regarding client confidentiality in 1996 known as the Health Insurance Portability and Accountability Act (HIPAA), with further revisions in 2001 and 2002, clients now have the right to see their own medical and billing records, request changes to anything they feel is inaccurate, and be informed about who has seen their medical records (U.S. Department of Health and Human Services, 2013). The latest version includes a revised definition of what constitutes a data breach (HIPAA Journal, 2013) and HIPAA rules for cloud computing (HHS.gov, 2017). Consequently, many institutions have written policies that describe the guidelines by which clients can access their own medical records. Policies range from complete, unrestricted access within 30 days of the client’s written request to arranging access in the presence of the client’s physician or hospital administrator. Nurses must follow the established agency policy. Types of Client Records Client records in most agencies contain similar information. They are generally organized in either a source-oriented or a problem-oriented format. Source-Oriented Records The traditional type of client record is a source-oriented record (records organized according to the source of documented information). This type of record contains separate forms on which physicians, nurses, dietitians, physical therapists, and other health care providers make entries about their own specific activities in relation to the client’s care. One of the criticisms of source-oriented records is that it is difficult to demonstrate a unified, cooperative approach for resolving the client’s problems among caregivers. Frequently, the fragmented documentation gives the impression that each health care provider is working independently of the others. Problem-Oriented Records A second type of client record is the problem-oriented record (records organized according to the client’s health problems). In contrast to source-oriented records that contain numerous locations for information, problem-oriented records contain four major components: the database, the problem list, the plan of care, and the progress notes (Table 9-2). The information is compiled and arranged to emphasize goal-directed care to promote the recording of pertinent information and to facilitate communication among health care providers. TABLE 9-2Common Components of a Problem-Oriented Record COMPONENT DESCRIPTION Database Contains initial health information Problem list Consists of a numeric list of the client’s health problems Plan of care Identifies methods for solving each identified health problem Progress notes Describes the client’s responses to what has been done and revisions to the initial plan METHODS OF CHARTING Nurses use various styles to record information within the client’s record. Examples include narrative charting, SOAP charting, focus charting, PIE charting, charting by exception, and electronic computerized charting. Narrative Charting Narrative charting (the style of documentation generally used in source-oriented records) involves writing information about the client and client care in chronologic order. There is no established format for narrative notations; the content resembles a log or journal (Fig. 9-1). Narrative charting is time-consuming to write and read. The health care provider must sort through the lengthy notation for specific information about care and progress that correlates with the client’s problems. Depending on the skill of the person writing a narrative entry, he or she may omit pertinent documentation or include insignificant information. SOAP charting (the documentation style more likely to be used in a problem-oriented record) acquired its name from four essential components included in a progress note: S = subjective data O = objective data A = analysis of the data P = plan for care Some agencies have expanded the SOAP format to SOAPIE or SOAPIER (I = interventions, E = evaluation, R = revision to the plan of care; Table 9-3). Any variations in the SOAP format tend to focus the documentation on pertinent information that is required by TJC. SOAP charting also helps demonstrate interdisciplinary cooperation because everyone involved in the care of a client makes entries in the same location in the chart. Focus Charting Focus charting (a modified form of SOAP charting) uses the word focus rather than problem because some believe that the word problem carries negative connotations. A focus can be the client’s current or changed behavior, significant events in the client’s care, or even a North American Nursing Diagnosis Association International (NANDA-I) nursing diagnosis. Instead of using the SOAP format to make entries, focus charting follows a DAR model (D = data, A = action, R = response; Fig. 9-2). DAR notations tend to reflect the steps in the nursing process. p. 116 p. 117 FIGURE 9-1 Sample of narrative charting. TABLE 9-3SOAPIER Charting Format LETTER EXPLANATION EXAMPLE OF RECORDING S = Subjective information Information reported by the client S—“I don’t feel well” O = Objective information Observations made by the nurse O—Temperature 102.4°F A = Analysis Problem identification A—Fever P = Plan Proposed treatment P—Offer extra fluids and monitor body temperature I = Intervention Care provided I—750 mL of fluid intake in 8 hours; temperature assessed every 4 hours E = Evaluation Outcome of treatment E—Temperature reduced to 101°F R = Revision Changes in treatment R—Increase fluid intake to 1,000 mL per shift until temperature is ≤100°F p. 117 Example of DAR charting. PIE Charting PIE charting (a method of recording the client’s progress under the headings of problem, intervention, and evaluation) is similar to the SOAPIE format. The PIE style prompts the nurse to address specific content in a charted progress note. When nurses use the PIE method, they document assessments on a separate form and give the client’s problems corresponding numbers. They use the numbers subsequently in the progress notes when referring to interventions and the client’s responses (Fig. 9-3). Charting by Exception Charting by exception is a documentation method in which nurses chart only abnormal assessment findings or care that deviates from a standard norm. Proponents of this method say that charting by exception is more efficient. It provides quick access to abnormal findings because it does not describe normal and routine information. FIGURE 9-3 Sample of PIE charting. Electronic Charting Electronic charting (documenting client information via computer) is a component of informatics. Informatics refers to the collection, storage, retrieval, and sharing of recorded data. Nursing informatics involves a combination of computer skills, knowledge of informatics, and information literacy (Thede, 2012). Electronic charting is most efficient for nurses when documentation is done at the point of care (POC) on a bedside computer (Fig. 9-4) or on a computer on wheels (COW). Having a terminal at the nursing station is a less desirable option because this removes the nurse from the source of the data; however, this may be the only alternative when there are limited computers for charting available. Centralized terminals generally are connected to large information systems (e.g., local area networks or LANs) that link departments in the institution (e.g., pharmacy, laboratory, admissions office, accounting); therefore, they are less specific for nursing use. Although each computer system varies, electronic charting is generally done by using a computer and keyboard, or touching the monitor screen with a finger or device such as a light pen to select from a list of menu options. Some systems allow a combination of keyboarding and touch-screen technology. 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. It eliminates trivia. Omissions are fewer because the computer prompts the nurse to enter specific information. It saves time because it eliminates delays in obtaining a physical chart. FIGURE 9-4 Portable computers allow for point-of-care documentation. (From Craven, R. F., & Hirnle, C. J.. Fundamentals of nursing [6th ed.]. Philadelphia, PA: Lippincott Williams & Wilkins.) p. 118 p. 119 FIGURE 9-5 Sample of computerized charting. It reduces overtime costs for incomplete end-of-shift charting. Multiple health care providers can use the medical record simultaneously from many different work stations. Documentation formats prompt the nurse to enter data required by TJC such as pain and fall assessments. Entries are automatically credited to the user. Legibility and spelling are no longer issues. Reduces medication errors because the system alerts and prompts the physician regarding miscalculations of drug doses, medication interactions, or the client’s allergies Allows obtaining test results quickly so that interventions can be implemented in a more timely manner Frees nurses from transcribing physicians’ orders and making phone calls for the purpose of clarification Firewalls and passwords prevent breaches in confidentiality by protecting unauthorized access to confidential information. Electronic records are periodically backed up on systems outside of the agency of origin and are therefore protected from destruction should there be a fire or other type of disaster. Computerized documentation and EMRs have additional advantages for institutions, but there are also disadvantages, such as: Systems are expensive to purchase. Systems vary with institutions necessitating extensive training of new hires. Competency in using the system requires significant time. IT support staff are required. Passwords must be changed regularly. Downtime during system upgrades and power or electronic failures can interrupt and delay documentation and access to the full record. p. 119 p. 120 Temporary paper charting must be substituted when the system is down. There are fewer narrative entries due to structured options that are limited to multiple lists. Information is scattered among various files. They can promote double charting (repetitious entry of same information). Confidentiality of information may be compromised if computer screens are left unattended, viewed by others at the bedside, accessed by unauthorized users, or if printouts are not secured or destroyed at the end of a shift. Pharmacologic Considerations Built-in safeguards are a feature of electronic medication administration records (MARs). Screen pop-ups require the entry of data before the MAR screen can be viewed. This is designed to ensure that vital assessments such as blood pressure, pulse, or blood glucose levels are done before administering select medications, alerting the nurse and reducing the chance of serious consequences of incorrect medication administration. PROTECTING HEALTH INFORMATION Congress enacted the first HIPAA legislation to protect the rights of U.S. citizens to retain their health insurance when changing employment. To do so required transmitting health records from one insurance company to another. Transmission of the information resulted in the disclosure of personal health information to nonclinical individuals, a process that essentially jeopardized the individual’s confidentiality and right to privacy. Subsequently, the original HIPAA legislation was expanded in 2001 and 2002 to enact further measures to protect the privacy of health records and the security of that data. All health care agencies have been mandated to comply with the newest HIPAA regulations. HIPAA regulations require health care agencies to safeguard written, spoken, and electronic health information in the following ways: Submit a written notice to all clients identifying the uses and disclosures of their health information such as to third parties for use in treatment or for payment for services. Obtain the client’s signature indicating that he or she has been informed of the disclosure of information and his or her right to learn who has seen the records. The law also indicates that agencies must limit released information from a health record to minimum disclosure, or information necessary for the immediate purpose only. In other words, it is inappropriate to release the entire health record when only portions or isolated pieces of information are needed. BOX 9-2Exemptions for Beneficial Disclosures Reporting vital statistics (births and deaths) Informing the U.S. Food and Drug Administration of adverse reactions to Disclosing information for organ or tissue donation Notifying the public health department about communicable diseases Notifying an identified person of a credible threat for imminent harm Health care agencies must obtain specific authorization from the client to release information to family or friends, attorneys, and other parties for uses such as research, fundraising, and marketing. The client retains the right to withhold health information for any of these. There are some exceptions when health information can be revealed without the client’s prior approval. Box 9-2 identifies examples of beneficial disclosures (exemptions when agencies can release private health information without the client’s prior authorization). Gerontologic Considerations State laws related to mandatory reporting of elder abuse and neglect, including self-neglect, take precedence over HIPAA regulations. Workplace Applications In an effort to limit casual access to the identity of clients and health information, HIPAA legislation has created several changes that affect the workplace. Some examples of these regulations include: The names of clients on charts can no longer be visible to the public. Clipboards must obscure identifiable names of clients and private information about them. Whiteboards must be free of information Computer screens must be oriented away from public view. Flat screen monitors are more difficult to read at obtuse angles. Conversations regarding clients must take place in private places where they cannot be overheard. This has led to a trend of providing private rooms for all hospitalized clients so that personal health information cannot be overheard by someone else sharing the room. Facsimile (fax) machines, filing cabinets, and medical records must be located in areas off-limits to the public. p. 120 p. 121 A cover sheet and a statement indicating that faxed data contain confidential information must accompany electronically transmitted information. Light boxes for examining X-rays or other diagnostic scans on which the client’s name appears must be in private areas. Documentation must be kept of those who have accessed a client’s record. Data Security Maintaining confidentiality is more difficult with computerized data keeping. Because multiple people who enter and retrieve information from computer files can access electronically stored data, it has been difficult to monitor use or to limit access to only authorized people within and outside a health care institution. As a result of HIPAA legislation, health agencies are adopting the following methods to ensure the protection of electronic data: Assigning an access number and password to authorized personnel who use a computer for health records. These are kept secret and changed regularly. Using automatic save, use of a screensaver, or return to a menu if data have been displayed for a specific period. Issuing a plastic card or key that authorized personnel use to retrieve information. Locking out client information except to those who have been authorized through a fingerprint or voice activation device. Blocking the type of information that personnel in various departments can Storing the time and location from which the client’s record is accessed in case there is an allegation concerning a breach in confidentiality. Encrypting any client information transmitted through the internet. DOCUMENTING INFORMATION Each agency sets its own documentation policies. In addition to identifying the method for charting, such policies generally indicate the type of information recorded on each chart form, the people responsible for charting, and the frequency for making entries on the record. Box 9-3 lists the general content of nursing documentation. Current standards of TJC require that the medical records of clients cared for in acute care agencies (e.g., hospitals) must identify the steps of the nursing process (assessment, diagnosis, planning, implementation, and evaluation of outcomes). Because consistency in charting is important for legal purposes, nurses must follow the agency’s documentation policy. Deviating from the charting policy reduces a nurse’s legal protection if the record is subpoenaed (see Chapter 3). Nurses or those to whom they delegate client care are responsible for documenting: Assessment dataa 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 Referrals to other health care agencies aIn acute care settings, The Joint Commission requires a registered nurse to document the admission nursing assessment findings and develop the initial plan of care. The registered nurse may delegate some aspects of the initial data collection to the practical or vocational nurse. Using Abbreviations Abbreviations shorten the length of documentation and the time required for this task. Brevity, however, must never take priority over completeness and accuracy. It is better to write at length than to omit information or make vague entries. Many abbreviations have common meanings; however, nurses cannot assume that all abbreviations are interpreted the same universally. Some may have one meaning in one locale or agency but may mean something different or be unfamiliar in another. To avoid confusion among caregivers and misinterpretation if the chart is subpoenaed as legal evidence, each agency provides a list of approved abbreviations and their meanings. When documenting, nurses must use only those abbreviations on the agency’s approved list. TJC has identified specific abbreviations that should not be used in order to protect the safety of clients (available via TJC’s website; see the resources on or by searching the term “National Patient Safety Goals 02.02.01” in a search engine). In addition, the Institute for Safe Medication Practices (ISMP, 2013) has added a list of abbreviations, symbols, and dose designations that should be avoided to prevent medication errors. There may be future deletions of dangerous abbreviations, acronyms, symbols, and dose designations as TJC monitors and evaluates compliance. Currently, the ban on using unapproved abbreviations does not apply to health IT systems such as EMRs, but TJC recommends that they be eliminated from newly appropriated or upgraded systems (The Joint Commission, 2014). Some common abbreviations are listed in Table 9-4; more can be found in the Appendix. ABBREVIATION MEANING abd. abdomen a.c. before meals ad lib as desired AMA against medical advice amt. amount approx. approximately b.i.d. twice a day BM bowel movement BP blood pressure bpm beats per minute BRP bathroom privileges cˉ with C Centigrade CCU coronary care unit c/o complains of dc discontinue ED emergency department et and H2O water I & O intake and output IM intramuscular IV intravenous kg kilogram L liter L and Lt left lb pound NKA no known allergies NPO nothing by mouth NSS normal saline solution O2 oxygen OB obstetrics OOB out of bed OR operating room per by or through P pulse p.c. after meals p.o. by mouth postop. postoperative preop. preoperative pt. patient PT physical therapy q every q.i.d. four times a day q.s. quantity sufficient R respirations R and Rt right without SS soap suds stat immediately t.i.d. three times a day TPR temperature, pulse, respirations UA urinalysis via by way of WC wheelchair WNL within normal limits Wt. weight Indicating Documentation Time The nurse identifies the date and time of each entry in the record; this happens automatically with electronic documentation. Some hospitals use traditional time (time based on two 12-hour revolutions on a clock), which is identified with the hour and minute, followed by AM or PM. Other agencies prefer military time (time based on a 24-hour clock), which uses a different four-digit number for each hour and minute of the day (Fig. 9-6 and Table 9-5). The first two digits indicate the hour within the 24-hour period, and the last two digits indicate the minutes. The use of military time avoids confusion because no number is ever duplicated, and the labels AM, PM, 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 AM and is stated as “oh seven PM is 1300. Minutes are given as 1 to 59. See Skill 9-1. FIGURE 9-6 The military clock uses one 24-hour time cycle instead of two 12-hour cycles (e.g., 9:00 AM is 0900 and 9:00 PM is 2100). TABLE 9-5Examples of Military Time Conversions TRADITIONAL TIME MILITARY TIME Midnight 0000 or 2400 12:01 AM 0001 1:30 AM 0130 Noon 1200 1:00 PM 1300 3:15 PM 1515 7:59 PM 1959 10:47 PM 2247 p. 122 p. 123 Stop, Think, and Respond 9-2 Convert the following from traditional time to military time: 6:30 PM Midnight 8:45 AM 9:05 PM 4:15 AM COMMUNICATION FOR CONTINUITY AND COLLABORATION Although the medical record serves as an ongoing source of information about the client’s status, nurses use other methods of communication to promote continuity of care and collaboration among the health care providers involved in the client’s care. These methods are in written or verbal forms. Written Forms of Communication Examples of written forms of communication include the nursing care plan, the nursing Kardex, checklists, and flow sheets. A nursing care plan is a written or printed list of the client’s problems, goals, and nursing orders for client care. It promotes the prevention, reduction, or resolution of health problems. The principles and style for writing a diagnostic statement, goals, and nursing orders are described in Chapter 2. Presently, TJC’s standards require that the record show evidence of a plan of care. Many agencies require a separate nursing care plan as a means of demonstrating compliance. Nurses revise the plan of care as the client’s condition changes. Most nursing care plans are handwritten on a form that the agency develops (Fig. 9-7). Some agencies use preprinted care plans, computer-generated care plans, standards of care, clinical pathways, or cite the plan of care within progress notes. Because the nursing care plan is part of the permanent record and thus is a legal document, it is compiled and maintained following documentation principles. All entries and revisions are dated. The written components are clear, concise, and legible. The information is never obliterated; only approved abbreviations are used. Each addition or revision to the plan is signed. Nursing Kardex The nursing Kardex is a quick reference for current information about the client and his or her care (Fig. 9-8). The Kardex forms for all clients are centrally located in a folder at the nursing station to allow caregivers to flip from one client’s data to another. The Kardex has the following uses: FIGURE 9-7 Sample nursing care plan. p. 123 p. 124 FIGURE 9-8 A computer-generated Kardex. (Holmes, H. N. [Ed.].. Documentation in action [pp. 231–232]. Philadelphia, PA: Lippincott Williams & Wilkins, used with permission.) Locate clients by name and room number. Identify each client’s physician and medical Serve as a reference for a change-of-shift report. Serve as a guide for making nursing assignments. Provide a rapid resource for current medical orders on each client. Specify the client’s code or do-not-resuscitate (DNR) status. Check quickly on a client’s diet. Alert nursing personnel to a client’s scheduled tests or test preparations. Inform staff of a client’s current level of activity. Identify comfort or assistive measures a client may require. Provide a tool for estimating the personnel-to-client ratio for a nursing unit. The information in the Kardex changes frequently, sometimes several times in a day. The Kardex is not a part of the permanent record. Therefore, nurses can write information in pencil and erase. Checklists A checklist is a form of documentation in which the nurse indicates the performance of routine care with a check mark or initials. It is an alternative to writing a narrative note. Nurses use paper checklists or a designated file on a computer primarily to avoid documenting types of care that are regularly repeated such as bathing and mouth care. This charting technique is especially helpful when the care is similar each day and the client’s condition does not differ much for extended periods. Flow Sheets A flow sheet is a form of documentation with sections for recording frequently repeated assessment data. It enables nurses to evaluate trends because similar information is located on one form. Some flow sheets provide room for recording numbers or brief descriptions. Interpersonal Communication In addition to using written resources (e.g., the medical record) to exchange information, communication also takes place during personal interactions among health providers. Some examples include: Client assignments Team conferences Rounds Telephone calls Change-of-Shift Report A change-of-shift report is a discussion between a nursing spokesperson from the shift that is ending and the arriving p. 124 p. 125 personnel (Fig. 9-9). It includes a summary of each client’s condition and current status of care (Box 9-4). FIGURE 9-9 Nurses begin their shifts by receiving reports on their clients. (From Lippincott Professional Development, July–November 2012.) To maximize the efficiency of change-of-shift reports, nurses should: Be prompt so that the report can start and end on time. Come prepared with a pen and paper or clipboard. Avoid socializing during reporting sessions. Take notes. Clarify unclear information. Ask questions about pertinent information that may have been omitted. Some agencies scan and record the report, which saves time because there are no interruptions or digressions. In addition, nurses can replay portions of the digital recording if information needs to be repeated. A recorded report, however, does not allow direct questions, elaboration, or clarification with the person who recorded the report. BOX 9-4Change-of-Shift Report A change-of-shift report usually includes the following: Name of physician Medical diagnosis or surgical procedure and date 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 Special body position and level of activity, if applicable Scheduled diagnostic tests Test results, including those performed by the nurse, such as blood glucose levels Changes in medical orders, including newly prescribed drugs Intake and output totals Type and rate of infusing intravenous fluid Amount of intravenous fluid that remains Settings on electronic equipment such as amount of suction Condition of incision and dressing, if applicable Color and amount of wound or suction drainage Client Care Assignments Client care assignments are made at the beginning of each shift. Assignments are posted, discussed with team members, or written on a worksheet (Fig. 9-10). Each assignment identifies the clients for whom the staff person is responsible and describes their care. Meals and break times may also be scheduled, as well as special tasks such as checking and restocking supplies. Team Conferences Conferences are commonly used to exchange information. Topics generally include client care problems, personnel conflicts, new equipment or treatment methods, and changes in policies or procedures. Team conferences often include the nursing staff, staff from other departments involved in client care, physicians, social workers, personnel from community agencies, and, in some cases, clients and their significant others Client Rounds Rounds (visits to the bedside of clients on an individual basis or as a group) are used as a means of learning firsthand about clients (Fig. 9-12). When done as a group, the client is a witness to and often an active participant in the interaction. Observing and conversing in the client’s presence provides an opportunity to survey the client’s condition and determine the status of equipment used in his or her care. It also tends to boost client confidence and security in their care. Since the passage of HIPAA regulations, however, agencies avoid this type of communication if another client shares the room or if the client has not authorized family members or friends who may be visiting to have access to his or her health information. Telephone Nurses use the telephone to exchange information when it is difficult for people to get together or when they must communicate information quickly. When using the telephone, the nurse: Answers as promptly as possible Speaks in a normal tone of voice Identifies him or herself by name, title, and nursing unit Obtains or states the reason for the call Discreetly 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 SBAR format (Table 9-6) has been recommended as a model for effective communication (Institute for Healthcare Improvement, 2014; Narayan, 2013). SBAR refers to: p. 125 p. 126 FIGURE 9-10 Sample of a nursing assignment sheet. p. 126 p. 127 S (Situation): What is the situation about which you are calling? B (Background): Pertinent background information related to the situation A (Assessment): What is your assessment of the situation? R (Recommendation): Explain what is needed or wanted. If the nurse believes that the physician has not responded in a safe manner to the information given, he or she notifies the nursing supervisor or the head of the medical department. FIGURE 9-11 A team of personnel hold a conference to discuss the care of a client. (Rosdahl, C. B., & Kowalski, M. T.. Textbook of basic nursing [10th ed.]. Philadelphia, PA: Lippincott Williams & Wilkins.) FIGURE 9-12 Rounds help acquaint oncoming staff with the client. TABLE 9-6SBAR Format S Situation: What is the situation you are calling about? Identify yourself, unit, patient, and room number. Briefly state the problem, what it is, when it happened or started, and how severe. B Background: Pertinent background information related to the situation could include: The admitting diagnosis and date of admission List of current medications, allergies, IV fluids, and labs Most recent vital signs Lab results: the date and time test was done and results of previous tests for comparison Code status Other clinical information A Assessment: What is your assessment of the situation? R Recommendation: What is your recommendation about what should happen next? For example, there may need to be notification that a patient has been admitted, that a patient needs to be seen immediately, or that an order must be changed. KEY POINTS Reasons for client charts and medical records Permanent account Sharing information Quality assurance Reimbursement Education and research Legal evidence Methods of charting Narrative SOAP Focus PIE Charting by exception Electronic HIPAA: Regulations that require health care agencies to safeguard written, spoken, and electronic health information Review abbreviations list for approved medical abbreviations and “do not use” lists. Review and understand the conversion of traditional time to military time: The military clock uses one 24-hour time cycle instead of two 12-hour cycles (e.g., 9:00 AM is 0900 and 9:00 PM is 2100, adding 12 hours to the 12-hour cycle time). Written forms of communication Nursing care plans Nursing Kardex Checklists Flow sheets Interpersonal communication Change-of-shift report Client care assignments Team conferences Client rounds Telephone p. 127 p. 128