documentation 1.pdf

DOCUMENTATION Ann Laban, MSN, RN Copyright © 2017, Elsevier Inc. All Rights Reserved. LEARNING OBJECTIVE The learner will discuss documentation and reporting as a means of communication within the health care team and apply the concepts in case studies and discussions COPYRIGHT...

DOCUMENTATION Ann Laban, MSN, RN Copyright © 2017, Elsevier Inc. All Rights Reserved. LEARNING OBJECTIVE The learner will discuss documentation and reporting as a means of communication within the health care team and apply the concepts in case studies and discussions COPYRIGHT © 2017, ELSEVIER INC. ALL RIGHTS RESERVED. 2  MULTIDISCIPLINARY COMMUNICATION WITHIN THE HEALTH CARE TEAM Records or chart: – Confidential permanent legal document  Reports: – Oral, written, audiotaped exchange of information  Consultations – A professional caregiver providing formal advice to another caregiver Referrals – Arrangement for services by another care provider COPYRIGHT © 2017, ELSEVIER INC. ALL RIGHTS RESERVED. 3 THE CHART: A LEGAL DOCUMENT Legal documentation (Pg358)  Timely, Accurate, Legible  Erasing Correction fluids Document only for yourself Correcting errors Documentation of discussion with providers 4 THE CHART: A LEGAL DOCUMENT Mistakes in documentation that commonly result in malpractice include Failing to record pertinent health or drug information. Failing to record nursing actions. Failing to record medication administration. Failing to record drug reactions or changes in patients’ conditions. Incomplete or illegible records. Failing to document discontinued medications. 5 PURPOSES OF PATIENT RECORDS Auditors  People appointed to examine patients’ charts and health records to assess quality of care Peer Review  An appraisal by professional co-workers of equal status Quality Assurance/Assessment/Improvement An audit in health care that evaluates services provided and the results achieved compared with accepted standards COPYRIGHT © 2017, ELSEVIER INC. ALL RIGHTS RESERVED. 6 PURPOSES OF THE MEDICAL RECORD Reimbursement Auditing/monitoring Education Research Communication COPYRIGHT © 2017, ELSEVIER INC. ALL RIGHTS RESERVED. 7 PURPOSES OF THE MEDICAL RECORD Reimbursement: Diagnosis Related Groups (DRGs) – A system that classifies patient by age, diagnosis, and surgical procedure; producing 300 different categories used in predicting the use of hospital resources, including patient length of stay This is the basis for cost reimbursement rates for Medicare and Medicaid – Many private insurance companies use similar illness categories when setting hospital payment rates COPYRIGHT © 2017, ELSEVIER INC. ALL RIGHTS RESERVED. 8  PURPOSES OF THE MEDICAL RECORD Auditing and Monitoring Nursing care Patient care Accrediting agencies ◦ Education/Research Medical student Nursing student COPYRIGHT © 2017, ELSEVIER INC. ALL RIGHTS RESERVED. 9 PURPOSES OF THE MEDICAL RECORD Communication Interdisciplinary team Safe care Timely care Patient Centered Care COPYRIGHT © 2017, ELSEVIER INC. ALL RIGHTS RESERVED. 10 STANDARD The Joint Commission The Joint Commission accredits and certifies more than 21,000 health care organizations and programs in the United States. Joint Commission surveyors visit accredited health care organizations a minimum of once every 39 months. This visit is called a survey.  All regular Joint Commission accreditation surveys are unannounced. 11 STANDARDS Know standards of your organization Documentation needs to conform to standards of the National Committee for Quality Assurance (NCQA) and TJC to maintain institutional accreditation and minimize liability ◦ Assessment ◦ Nursing process Medical record components COPYRIGHT © 2017, ELSEVIER INC. ALL RIGHTS RESERVED. 12 NURSES’ DOCUMENTATION Application of the Nursing Process Document standard of care for every nursing tasks Teaching Discharge instruction Nurse’s Notes – The form on the patient’s chart on which nurses record their observations, care given, and the patient’s responses COPYRIGHT © 2017, ELSEVIER INC. ALL RIGHTS RESERVED. 13 THE SHIFT TO ELECTRONIC DOCUMENTATION HITECH established provisions to promote the meaningful use of health information technology (HIT) to improve the quality and value of health care Experts believe that implementing EHRs across the health care delivery system will decrease costs and improve the quality of patient care COPYRIGHT © 2017, ELSEVIER INC. ALL RIGHTS RESERVED. 14  THE SHIFT TO ELECTRONIC DOCUMENTATION Difference between EHR and EMR ◦ EMR- Digital version of paper chart ◦ EHR - Life long record of the patient for all encounter EHR (pg 359) ◦ Attributes ◦ Components ◦ Advantages COPYRIGHT © 2017, ELSEVIER INC. ALL RIGHTS RESERVED. 15 GUIDELINES FOR QUALITY DOCUMENTATION Factual Accurate Complete Current Organized 16 GUIDELINES FOR QUALITY DOCUMENTATION AND REPORTING Understanding and knowledge of common abbreviations and medical terms Most facilities have a published list of generally accepted medical abbreviations and terms approved for use in charting. COPYRIGHT © 2017, ELSEVIER INC. ALL RIGHTS RESERVED. 17 CONFIDENTIALITY Nurses are legally and ethically obligated to keep client information confidential. Nurses are responsible for protecting records from all unauthorized readers.  HIPAA act requires disclosure or requests regarding health information COPYRIGHT © 2017, ELSEVIER INC. ALL RIGHTS RESERVED. 18  QUICK QUIZ! 1. Information regarding a patient’s health status may not be released to non–health care team members because: A. legal and ethical obligations require health care providers to keep information strictly confidential. B. regulations require health care institutions to document evidence of physical and emotional well- being. C. reimbursement issues related to patient care and procedures may be of concern. D. fragmentation of nursing and medical care procedures may be identified. 19 METHODS OF CHARTING Traditional Chart ◦ Chart is divided into specific sections or blocks. ◦ Emphasis is placed on specific sheets of information. ◦ Typical sections are: ◦ Admission sheet, physician’s orders, progress notes, history and physical examination data, nurse’s admission information, care plan and nurse’s notes, graphics, and laboratory and x-ray reports. COPYRIGHT © 2017, ELSEVIER INC. ALL RIGHTS RESERVED. 20 METHODS OF CHARTING Narrative Charting ◦ The traditional method ◦ Recording of patient care in descriptive form ◦ Includes the basic patient need or problem data, whether someone was contacted, care and treatments provided, and the patient’s response to treatment ◦ Written in an abbreviated story form 21 METHODS OF CHARTING COPYRIGHT © 2017, ELSEVIER INC. ALL RIGHTS RESERVED. 22 METHODS OF CHARTING (pg 363) Problem-oriented medical record (POMR) ◦ Database ◦ Problem list ◦ Care plan ◦ Progress notes ◦ Uses SOAP/PIE COPYRIGHT © 2017, ELSEVIER INC. ALL RIGHTS RESERVED. 23 METHODS OF CHARTING (pg 363) SOAP ◦ Subjective, objective, assessment, plan SOAPIE ◦ Subjective, objective, assessment, plan, intervention, evaluation PIE ◦ Problem, intervention, evaluation Focus charting (DAR) ◦ Data, action, response COPYRIGHT © 2017, ELSEVIER INC. ALL RIGHTS RESERVED. 24 METHODS OF CHARTING S = Subjective data (what the patient says) O = Objective data (what is observed or measured) A = Assessment P = Plan (short- and long-term plans) I = Intervention (nursing action) E = Evaluation (assessment of interventions) R = Revisions (changes to plan of care) COPYRIGHT © 2017, ELSEVIER INC. ALL RIGHTS RESERVED. 25 METHODS OF CHARTING 26  METHODS OF CHARTING PIE/APIE ◦ similar to SOAP ◦ based specifically on the nursing process A = Assessment (objective and subjective information) P = Problem (nursing diagnosis) I = Intervention (what the nurse did to correct, improve, or change the problem) E = Evaluation (subjective and objective results of intervention). 27 METHODS OF CHARTING COPYRIGHT © 2017, ELSEVIER INC. ALL RIGHTS RESERVED. 28 METHODS OF CHARTING Focus Charting Format ◦ Data – Action - Response This format uses the nursing process and the more positive concept of the patient’s needs rather than the medical diagnoses and problems. Instead of problem lists  a modified list of nursing diagnoses Is used as an index for nursing documentation. COPYRIGHT © 2017, ELSEVIER INC. ALL RIGHTS RESERVED. 29 METHODS OF CHARTING Charting by exception (CBE) (focus charting) ◦ Focuses on documenting deviations ◦ Patient meets all standards ◦ WNL COPYRIGHT © 2017, ELSEVIER INC. ALL RIGHTS RESERVED. 30 METHODS OF CHARTING COPYRIGHT © 2017, ELSEVIER INC. ALL RIGHTS RESERVED. 31 METHODS OF RECORDING Charting by exception (CBE) (Focus Charting) ◦ Pertinent data are charted at the beginning of each shift ◦ During the shift, only additional treatments given or withheld, changes in patient condition, and new concerns are charted. ◦ Uses flow more detailed flow sheets COPYRIGHT © 2017, ELSEVIER INC. ALL RIGHTS RESERVED. 32 METHODS OF CHARTING COPYRIGHT © 2017, ELSEVIER INC. ALL RIGHTS RESERVED. 33 COMMON RECORD KEEPING FORMS Make medical record documentation easy and quick, yet comprehensive. Prevent duplication. It is unnecessary to chart a narrative note each time a medication or a bath is given or vital signs are assessed. Eg: graphic sheet, I&O sheet, Skin assessment Braden scale Fall assessment COPYRIGHT © 2017, ELSEVIER INC. ALL RIGHTS RESERVED. 34 GUIDELINES FOR DOCUMENTATION Correct spelling, Grammar, Punctuation, Good penmanship The registered nurse (RN) has primary responsibility for the initial admission nursing history, physical assessment, and development of the care plan based on the nursing diagnoses identified COPYRIGHT © 2017, ELSEVIER INC. ALL RIGHTS RESERVED. 35 GUIDELINES FOR DOCUMENTATION The correct patient name, date, and time. Use only approved abbreviations and medical terms. Fill all spaces; leave no empty lines. Chart consecutively, line by line. Do not indent left margin. Chart after care is given, not before. COPYRIGHT © 2017, ELSEVIER INC. ALL RIGHTS RESERVED. 36 GUIDELINES FOR DOCUMENTATION Chart as soon and as often as possible and per unit charting schedule. Only your own care, observation and teaching Never chart for someone else Use direct quotes when appropriate Describe as you see it Chart only what you hear, see, feel, and smell.  Chart facts; avoid judgmental terms and placing blame COPYRIGHT © 2017, ELSEVIER INC. ALL RIGHTS RESERVED. 37 GUIDELINES FOR DOCUMENTATION  Sign entry with full legal name and title.  Write only what you observe, not opinions.  When the patient leaves a unit, chart the time and method of transportation on departure and return. Chart all ordered care as given or explain deviation. Note patient response to treatments and response to analgesics or other medications. COPYRIGHT © 2017, ELSEVIER INC. ALL RIGHTS RESERVED. 38 GUIDELINES FOR DOCUMENTATION Use only hard-pointed Permanent black ink pens No erasures or correcting fluids are allowed on charts If charting error is made, draw one line through the faulty information, mark error, initial if required, and make the correct entry. COPYRIGHT © 2017, ELSEVIER INC. ALL RIGHTS RESERVED. 39 GUIDELINES FOR DOCUMENTATION Late entry Follow each institution’s policy and procedures for charting. If order is questioned, record that clarification was sought. “Status unchanged” or “ had a good day.” Telephone calls made to a provider Telephone and verbal orders COPYRIGHT © 2017, ELSEVIER INC. ALL RIGHTS RESERVED. 40  CHANGE OF SHIFT REPORT Nurse-to-nurse report A meeting between healthcare providers at the change of shift Off going and oncoming shift Exchange of vital information about the for the patient Bedside report- Patient centered care COPYRIGHT © 2017, ELSEVIER INC. ALL RIGHTS RESERVED. 41 CHANGE OF SHIFT REPORT COPYRIGHT © 2017, ELSEVIER INC. ALL RIGHTS RESERVED. 42 DOCUMENTATION AND REPORTING Kardex ◦ Card system used to consolidate patient orders and care needs in a centralized, concise way – Kept at the nursing station for quick reference ◦ A medical information system used by nursing staff as a way to communicate important information on their patients. ◦ quick summary of individual patient needs that is updated at every shift change. COPYRIGHT © 2017, ELSEVIER INC. ALL RIGHTS RESERVED. 43 OTHER DOCUMENTATION FORMS AND EXAMPLES Nursing Care Plan ◦ Preprinted guidelines used to care for patients with similar health problems ◦ Developed to meet the nursing needs of a patient ◦ Based on nursing assessment and nursing diagnosis COPYRIGHT © 2017, ELSEVIER INC. ALL RIGHTS RESERVED. 44 OTHER DOCUMENTATION FORMS AND EXAMPLES Incident Report Form that is filled out with any event not consistent with the routine care of a patient Used when patient care was not consistent with facility or national standards of expected care Give only objective information Do not give unnecessary details  Do not mention the incident report in the nurse’s notes – legality purposes COPYRIGHT © 2017, ELSEVIER INC. ALL RIGHTS RESERVED. 45 OTHER DOCUMENTATION FORMS AND EXAMPLES Discharge Summary ◦ Information is provided that pertains to the patient's continued health after discharge. ◦ Discharge summary forms make the summary concise and instructive. COPYRIGHT © 2017, ELSEVIER INC. ALL RIGHTS RESERVED. 46 INTERPROFESSIONAL COMMUNICATION The quality of patient care depends on your ability to communicate with other members of the health care team. When a plan is not communicated to all members of the health care team Care becomes fragmented, tasks are repeated, and delays or omissions in care often occur. COPYRIGHT © 2017, ELSEVIER INC. ALL RIGHTS RESERVED. 47 DOCUMENTATION AND CLINICAL (CRITICAL) PATHWAYS The nurse and other team members use the pathways to monitor a patient’s progress and as a documentation tool Grand rounds Communication allows staff from all disciplines to develop integrated care plans for a projected length of stay for a specific case type. COPYRIGHT © 2017, ELSEVIER INC. ALL RIGHTS RESERVED. 48 DOCUMENTATION IN THE HOME HEALTH CARE SETTING Medicare has specific guidelines for establishing eligibility for home care. Medicare guidelines for establishing a patient’s home care cost reimbursement serve as the basis for documentation by home care nurses. Documentation is the quality control and justification for reimbursement from Medicare, Medicaid, or private insurance. Nurses need to document all their services for payment. COPYRIGHT © 2017, ELSEVIER INC. ALL RIGHTS RESERVED. 49 DOCUMENTATION IN THE LONG-TERM HEALTH CARE SETTING Governmental agencies are instrumental in determining standards and policies for documentation. Documentation in the long-term care setting supports an interprofessional approach to the assessment and planning process for all patients. COPYRIGHT © 2017, ELSEVIER INC. ALL RIGHTS RESERVED. 50  ACCESS TO RECORDS The original health care record or chart is the property of the institution or physician. The patient usually does not have immediate access to his or her full record. Patients have gained access rights to their records in most states but only if they follow the established policy of each facility. A lawyer can gain access to a chart with the patient’s written permission. 51 SPECIAL ISSUES IN DOCUMENTATION Confidentiality ◦ Confidentiality of the patient’s record. ◦ The Patient’s Bill of Rights and the law ◦ Shearing of patient information ◦ The nurse should not read a record unless there is a clinical reason and should hold the ◦ Information regarding the patient in confidence. 52 SPECIAL ISSUES IN DOCUMENTATION Many institutions have mainframe computers for data processing tasks.  Most billing is now stored and processed on this type of computer. Many progressive hospitals have installed computers that can handle physician orders; pharmacy, laboratory, and diagnostic imaging orders; central supply requests; care planning; documentation; and billing. The most efficient computer systems have bedside or handheld terminals for data entry. 53 SPECIAL ISSUES IN DOCUMENTATION The password used to enter and sign off computer files should not be shared with another caregiver Never leave the computer terminal unattended after being logged on. Follow the correct protocol for correcting errors.. Do not leave information about a patient displayed on a monitor where others can see it. COPYRIGHT © 2017, ELSEVIER INC. ALL RIGHTS RESERVED. 54 SPECIAL ISSUES IN DOCUMENTATION Follow the agency’s confidentiality procedures for documenting sensitive materials. Printouts of computerized records should be protected. COPYRIGHT © 2017, ELSEVIER INC. ALL RIGHTS RESERVED. 55 PRIVACY, CONFIDENTIALITY, AND SECURITY MECHANISMS Electronic documentation has legal risks. Most security mechanisms for computerized information systems use a combination of logical and physical restrictions to protect information. Physical security measures include placing computers or file servers in restricted areas or using privacy filters for computer screens visible to visitors or others without access. COPYRIGHT © 2017, ELSEVIER INC. ALL RIGHTS RESERVED. 56 HANDLING AND DISPOSING OF INFORMATION You must safeguard any information that is printed from the record or extracted for report purposes De-identify all patient data Special considerations for faxing COPYRIGHT © 2017, ELSEVIER INC. ALL RIGHTS RESERVED. 57  Quick Quiz! 2. Anurse has just admitted a patient with a medical diagnosis of congestive heart failure. When completing the admission paper work, the nurse needs to record: A. an interpretation of patient behavior. B. objective data that are observed. C. lengthy entry using lay terminology. D. abbreviations familiar to the nurse. COPYRIGHT © 2017, ELSEVIER INC. ALL RIGHTS RESERVED. 58  Quick Quiz! 3. Anurse records that the patient stated his abdominal pain is worse now than last night. This is an example of: A. PIE documentation. B. SOAP documentation. C. narrative charting. D. charting by exception. COPYRIGHT © 2017, ELSEVIER INC. ALL RIGHTS RESERVED. 59  Quick Quiz! 4. A patient you are assisting has fallen in the shower. You must complete an incident report. The purpose of an incident report is to: A. exchange information among health care members. B. provide information about patients from one unit to another unit. C. ensure proper care for the patient. D. aid in the hospital’s quality improvement program. COPYRIGHT © 2017, ELSEVIER INC. ALL RIGHTS RESERVED. 60