NF 7 Documentation of Nursing Care.pdf

Unit III Communication in Nursing c hap t e r 7 Documentation of Nursing Care http://evolve.elsevier.com/Williams/fundamental Objectives Upon completing this chapter, you should be able to do the following: Theory 1. Identify three purposes of documentation (charting). 2. Correlate the nursing p...

Unit III Communication in Nursing c hap t e r 7 Documentation of Nursing Care http://evolve.elsevier.com/Williams/fundamental Objectives Upon completing this chapter, you should be able to do the following: Theory 1. Identify three purposes of documentation (charting). 2. Correlate the nursing process with the process of documentation. 3. Discuss maintaining conidentiality and privacy of paper and electronic medical records. 4. Compare and contrast the six main methods of documentation. 5. List the legal guidelines for documenting on medical records. 6. Explain the approved way to correct errors in medical records. Clinical Practice 1. Correctly make entries on a daily care low sheet. 2. Demonstrate a systematic way of documenting that ensures all pertinent information has been included. 3. Document the characterization of signs or symptoms in a sample documentation situation. 4. Apply the general documentation guidelines in the clinical setting. 5. Navigate electronic medical records and document care correctly. Key Terms case management system charting (p. 87) charting (p. 86) charting by exception (p. 86) computer-assisted charting (p. 86) computerized provider order entry (CPOE) (p. 92) electronic health record (EHR) (p. 90) Concepts Covered in This Chapter • • • • • • • • • • • Care coordination Communication Health literacy Patient-centered care Accountability Health care systems Patient care technology Patient education Informatics Health care quality Quality improvement PURPOSES OF DOCUMENTATION Documentation provides a written record of the history, treatment, care, and response of the patient while under medical and nursing care. It justiies claims for reimbursement, may be used as evidence of care in a court of law, 84 focus charting (p. 86) medical record (p. 84) PIE charting (p. 89) problem-oriented medical record (POMR) charting (p. 86) protocols (PRŌ-tō-kŏlz, p. 90) source-oriented (narrative) charting (p. 86) shows the use of the nursing process, and provides data for quality-assurance studies. Each person who provides care for the patient adds documentation to the medical record (sometimes referred to as a chart). The medical record contains all orders, tests, treatments, and care that occurred while the person was under the care of the health care provider. The medical record is a communication tool for the professionals involved in patient care. Health team members use documentation to communicate what has been done, how the patient responded, and the current plan for care. Many different forms are used for documentation, and the most common forms are shown in the chapters speciic to their content; for example, an intravenous (IV) low sheet (parenteral infusion record) is shown in Chapter 36. The Joint Commission sets the standards for documentation. Common types of forms in patients’ medical records are listed in Table 7.1. Insurance companies and Medicare rely on documentation to determine actual length of stay, procedures performed, and diagnoses established and to Documentation of Nursing Care Table 7.1 CHAPTER 7 85 Forms Used for Hospital Documentation FORM General Forms TYPE OF INFORMATION Face sheet Patient data, including the patient’s name, address, phone number, next of kin, hospital identiication number, religious preference, place of employment, insurance company, occupation, name of admitting health care provider, and admitting diagnosis. Provider orders The provider’s directives for patient care. Graphic sheet Record of serial measurements and observations, such as temperature, pulse, respiration, blood pressure, and weight. Nursing care plan Care plan for the patient, including nursing diagnoses, goals and expected outcomes, and nursing interventions. Nursing notes Documentation of the nursing process (i.e., assessment, nursing diagnosis, planning, implementation, and evaluation); a record of interventions implemented and the patient’s response to them. Care low sheet Form on which check marks or short entries are made to indicate dietary intake, type of bath, wound dressing changes, oxygen in use, health care provider visits, equipment in use, level of activity, and so forth. Medication administration record (MAR) Documentation of all medications ordered, doses given, and doses not taken by the patient. History and physical examination forms Primary care provider’s record of the patient’s medical history and indings of the current physical examination. Nurse’s admission history and assessment Nurse’s current history, including usual habits, medications usually taken, and physical assessment indings at admission. Progress sheet Primary care provider’s notes regarding the patient’s progress. Laboratory reports Results of laboratory tests. Radiology reports Results of X-ray examinations. Admission forms Information on patient identiication, conditions for admission, and consent for general medical and nursing care. Intake and output (I&O) record Serial record of 24-hr intake and output. Miscellaneous Forms Ancillary staff sheets Records of treatments by physical therapists, occupational therapists, respiratory therapists, and so forth. Consultation sheet Record of another health care provider called in to consult by the primary care provider. Diabetic low sheet Record of blood glucose determinations and amounts of insulin administered. Discharge form Information about instructions given regarding wound care, medications, rest, activity restrictions, needed exercises, diet, and signs and symptoms to report to the primary care provider; also includes when to see the provider next. Discharge planning sheet Records by social services, home health agencies, case managers, and clinical nurse specialists regarding the discharge plans and patient’s needs. Fall risk assessment Information regarding the patient’s potential fall risk; particularly used for frail patients, older adults, or patients with neuromuscular impairments. Frequent observations sheet Used when frequent measurements of vital signs or neurologic assessments are needed (e.g., after surgery or after head trauma). Intravenous (IV) low sheet Record of IV luids and additives infused, type of IV catheter in use, date tubing was changed, and date dressing was applied. Pain assessment Record of pain level, when assessed, measures to reduce it, and effectiveness of treatment. Preoperative checklist List used to verify that the patient is ready to go to surgery. Skin risk assessment Data from thorough skin assessment on admission; evaluation of risk factors for skin breakdown; diagrams showing areas of redness, breaks in the skin, or pressure injuries. Surgical or treatment consent form Patient authorization for surgery or treatment. Time-out form Patient veriication, site-mark veriication, and time out performed before surgical procedure. Transfer form Information pertinent for the transfer of the patient to another unit or facility. 86 UNIT III Communication in Nursing calculate charges due for reimbursement. Each piece of equipment in service must be documented. Medical records must display data that support the medical and nursing diagnoses. Evaluation data indicating that the treatment was successful or unsuccessful must be present to justify the duration of the hospital stay. Documentation of this type is also necessary for accreditation of the health care agency. Medical records are also used for research data collection. For example, statistics may be compiled for the number of cases of pneumonia treated, the average age of the patients, and treatment results, to see which treatments are most effective. The medical record is a legal record and can be used as evidence of events that occurred or treatment that was given. When documentation is thorough, the record provides a way to show that standards of care have been met. Documentation, also called charting, is used to track the application of the nursing process. The nurse writes down observations made about the patient, notes the care and treatment that was delivered, and adds the patient’s response. Documentation shows progress toward the expected outcomes listed on the nursing care plan. Documentation is useful for supervisory purposes to evaluate staff performance. QSEN Considerations: Quality Improvement Medical Record Audits Documentation in the medical record is audited as part of the health care agency’s quality-improvement program. Evidence that care adheres to accepted standards should be present in the nurse’s notes. The results of audits of the medical records tell nurse managers where improvement may be needed. DOCUMENTATION AND THE NURSING PROCESS The nursing care plan or interdisciplinary care plan provides the framework for nursing documentation. Documenting in the medical record is organized by nursing diagnosis or problem. An initial assessment is recorded for each shift. Standard areas of assessment are usually noted on low sheets, and a note is added if an abnormality exists. Nursing diagnoses or problems are entered on the care plan, which is created soon after the admission assessment is complete. The plan is reviewed and updated every 24 hours. Implementation of each intervention is documented on a low sheet or within the nursing notes. The speciics of what was done and how, plus the patient response, are documented. Evaluation statements are entered in the nurse’s notes, and they indicate progress toward the stated expected outcomes and goals. Evaluation data must be documented showing that expected outcomes have been achieved before a nursing diagnosis is marked “resolved” or deleted from the care plan. When expected outcomes are not being met, the care plan is altered to better represent the patient’s needs. Think Critically If evaluation data are not showing progress toward expected outcomes, what part of the nursing care plan needs to be altered? Where in the medical record would this be done? THE MEDICAL RECORD The medical record contains data on a patient’s stay in the health facility or while under the care of a health care provider. Each type of facility has a particular set of forms used to record information about the patient. As a legal record, the medical record’s contents are conidential; this means you can only give out information with the patient’s written consent because the medical record contains personal information regarding the patient. Only health professionals caring directly for the patient, or those involved in research or education, should have access to the medical record. Protecting the patient’s privacy is of prime importance. Do not discuss patient information with others not directly involved in the patient’s care. The medical record is the property of the health facility or agency, not of the patient or primary care provider. Patients do have a right to information contained in the medical record under certain circumstances (see Chapter 3). Keeping the patient and the family informed in a clear and timely manner usually satisies their need for information. After the patient has been discharged, the medical record is sent to the medical records or health information department for safekeeping. It can be retrieved if the patient is admitted to service again within a 10-year span. Electronic records may be kept for longer periods, ranging from 10 years to indeinitely, depending on the state where the patient resides (Shepard, 2015). Think Critically What would you say to your neighbor, who sees you working on the unit on which her sister’s husband is a patient, if she asks you to check and see what her brother-in-law’s primary care provider has documented about his condition? METHODS OF DOCUMENTATION (CHARTING) Different methods of documentation are used in various health care agencies. The six main methods of documentation are (1) source-oriented (narrative) charting, which is organized by “source” or author of the documentation entry; (2) problem-oriented medical record (POMR) charting, which focuses on the problems the patient experiences as a result of being ill; (3) focus charting, which centers on the patient from a positive perspective; (4) charting by exception, which focuses on deviations from predeined norms, using preset protocols and standards of care; (5) computer-assisted Documentation of Nursing Care 10/10 11-7 FLOWSHEET ADLs—cont’d Ambulate 10/11 7-3 FR 10:00 Activity response FR 14:00 tolerated well tolerated well FR 16:00 FR 08:00 tolerated well tolerated well RJK 20:00 FR 10:00 tolerated well tolerated well FR 14:00 Feeding 87 Doe, John B. Neverland Hospital From 10/10/17 to 10/11/17 Room 645-1 ADM 10/09/17 Age 63Y Sex M MD Sawbucks, Jackson ID 4620958 MR 102756 3-11 done RN done self CHAPTER 7 RJK 22:00 self assist FR 08:00 self assist FRI 12:00 Diet regular FR 08:00 regular FR 12:00 Ate % 80% FR 08:00 80% FR 12:00 Hygiene assist bath perineal care skin care back rub linen change Standard prec yes FR 10:00 yes RJK 20:00 FR 08:00 yes yes RJK 22:00 FR 10:00 SKIN Skin assmnt 11-7 7-3 WNL WNL WNL FR 08:00 RJK 00:00 Braden sc 21 INC/WDS UPPER L shoulder Wound type 3-11 RJK 00:00 21 11-7 FR 08:00 RJK 20:00 21 7-3 incision incision RJK 22:00 3-11 incision RJK 00:00 RJK 20:00 FR 08:00 Wound appearance dry clean RJK 00:00 dry clean FR 08:00 dry clean dry intact checked FR 08:00 dry intact checked RJK 20:00 L shoulder Wound dressing dry intact checked RJK 00:00 IV LINES R subclavian Line type RJK 20:00 11-7 7-3 triple 3-11 triple triple RJK 00:00 Rutken, Frances (FR) RN FR 08:00 RJK 20:00 Kahn, Roland J. (RJK) LPN FIGURE 7.1 Computer activity low sheet. (Created by Susan C. deWit [SCD] RN; Carolyn Sims [CJS] LPN.) charting, where data are input to the computer; and (6) case management system charting, which tracks vari- ances from the clinical pathway. Whatever method of documentation is used, you are required to document the patient’s progress periodically during the shift or at the time of a home health visit. The medical record entries are either in your notes or on low sheets (Fig. 7.1). Flow sheets track routine assessments, treatments, and frequently given care. The speciic time frame required for documentation is found in the agency’s policy and procedure manual. Some agencies require one note per patient contact; others require documentation every 1 to 3 hours during the shift. 88 UNIT III Communication in Nursing Date 6/25/18 Time 2015 2020 2045 Problem #1 Nurse’s Notes States has “sharp throbbing” pain at a 7 on a 1-10 pain scale. Started at 2000 when amb down hall. T 99, P 88, R 24, BP 146/82. Unrelieved by change in position or rest.----R. Hill, LVN Meperidine 75 mg IM RUOQ. R. Hill, LVN Resting quietly in bed. P 86, R 20, BP 146/78. States pain “has decreased considerably.” R. Hill, LVN FIGURE 7.2 Example of source-oriented (narrative) charting. Table 7.2 Major Components of the Problem-Oriented Medical Record AREA Database CONTENTS Initial assessment, general health history, indings of the physical examination, results of diagnostic and laboratory tests, psychosocial information, nursing assessment, and patient’s response to the illness or problem. Problem list A list of problems derived from the information in the database. The list is continually updated with resolved problems deleted and new problems added. Problems are listed in the chronologic order in which they were identiied, not by priority. Both actual and potential problems are listed. Plan A three-part plan of care is devised based on the identiied problems. For each problem, there is a plan for diagnostic studies, a therapeutic plan, and a patient education plan. The primary care provider orders therapies for medical problems, and the nurse orders care for nursing problems. Progress notes Contain the assessments, plans, and orders of the physicians, nurses, and other therapists involved in the patient’s care. Notes are organized by problem number from the problem list, and each problem is addressed in the SOAP format: S: Subjective data that include symptoms and patient’s description of the problem O: Objective data based on health care team’s observations, physical examination, and diagnostic tests A: Assessment or analysis of the meaning of the data obtained P: Plan to resolve the problem It is not essential to write a progress note on each problem every day. Discharge summary A summary of the problems the patient had, how they were resolved, and the plan for care after discharge. SOURCE-ORIENTED OR NARRATIVE CHARTING These records are organized according to the source of information. There are separate areas for physicians (focusing on medical problems), nurses (focusing on nursing diagnoses), dietitians, and other health care professionals to document their assessment indings and plan the patient’s care. Narrative notes are phrases and sentences written without any standardized structure, content, or form. Narrative documentation used in source-oriented records requires documentation of patient care in chronologic order. Assessments usually follow a body systems format. The content is similar to a set of dated and timed journal entries (Fig. 7.2). Advantages of the source-oriented (narrative) method: • It gives information on the patient’s condition and care in chronologic order. • It indicates the patient’s baseline condition for each shift. • It includes aspects of all steps of the nursing process. Disadvantages of the source-oriented method: • It encourages documentation of both normal and abnormal indings, making it dificult to separate pertinent from irrelevant information. • It requires extensive documentation time by the staff. • It discourages physicians and other health team members from reading all parts of the medical record because of the lengthy descriptive entries in it. PROBLEM-ORIENTED MEDICAL RECORD CHARTING POMR charting focuses on patient status, emphasizing the problem-solving approach to patient care and providing a method for communicating what, when, and how things are to be done to meet the patient’s needs. The POMR contains ive basic parts: the database, the problem list, the plan, the progress notes (in which all members of the health care team document), and the discharge summary (Table 7.2). The precise form these records take varies greatly between agencies, but the essentials of documentation are the same. As this documentation method evolved, the original SOAP format for progress notes (for Subjective information, Objective data, Assessment data, and Plan) was modiied to Subjective, Objective, Assessment, Plan, Implementation, Evaluation (SOAPIE) and Documentation of Nursing Care Date 7/18/18 Time 0800 Problem #2 Pain, Abd S. O. A. P. CHAPTER 7 89 Nurse’s Notes States having RUQ pain radiating to right shoulder. Is “like a knife is poking me.” States is a 6 on a scale of 1-10. “It started after I ate the bacon.” States feels nauseous, but no vomiting.------------------------------------------------------------Pale, diaphoretic and shaky. Splinting abd c hands. T 100° F, P 112, R 22, BP 134/88. Abd pain. Institute NPO status; medicate when IM order received. Notify physician.-------------------------------------J. Sims, RN A Date 6/25/18 Time 1620 Problem #1 Hypertension S. O. 1625 A. P. I. 1700 E. Nurse’s Notes States feeling “warm and restless.”----------------------------Face flushed; skin hot to touch. T 103° F, P 120, R 26, BP 160/90.--------------------------------------------------------------Hyperthermia r/t wound infection. Medicate for ↑ temp.----------------------------------------------Acetaminophen 500 mg PO c full glass of H2O. Gown changed. Heat turned down, blanket removed.----------------T 101.6°F, P 95, R 24; temp falling. States is feeling better. Skin cooler to touch.----------------------------M. Bailey, LPN B FIGURE 7.3 (A) Example of POMR charting. (B) Example of SOAPIE charting. SOAPIER. The additional letters stand for Implementation, Evaluation, and Revision. It is not necessary to use each component of the SOAPIER format each time you make an entry. If there are no subjective data, the S can be omitted or labeled “none.” If there is no revision, the R can be left out (Fig. 7.3). Advantages of the POMR method of documentation: • It provides documentation of comprehensive care by focusing on patients and their problems. • It promotes the problem-solving approach to care. • It improves continuity of care and communication by keeping data relevant to a problem all in one place so that it is more available to all who are providing care. • It allows easy auditing of patient medical records in evaluating staff performance or quality of patient care. • It requires continual evaluation and revision of the care plan. • It reinforces application of the nursing process. Disadvantages of the POMR method of documentation: • It results in loss of chronologic documentation. • It is more dificult to track trends in patient status. • It fragments data because of the increased number of low sheets required. Problem Identification, Interventions, and Evaluation Charting Another offshoot of this method is PIE charting, which stands for Problem identiication, Interventions, and Evaluation. This type of documentation follows the nursing process and uses nursing diagnoses while placing the plan of care within the nurses’ progress notes. It differs from SOAP notes because it does not use a traditional nursing care plan or require narrative documentation of the assessment data as long as they are normal. The problems, patient education, and discharge needs are listed under the P of the PIE format. Nursing diagnoses are kept on a problem list (P), and each entry is marked with the problem number and title. With this method, the daily assessment information is placed on special low sheets, and duplication of the information is avoided. Interventions performed are documented under I. The outcomes of the interventions are evaluated and documented under E (Fig. 7.4). When assessment data are abnormal, an A is added (APIE). FOCUS CHARTING Focus charting is similar to the POMR system, but it substitutes focus for the problem, eliminating the negative connotation attached to “problem.” Focus charting is directed at a nursing diagnosis (e.g., pain), a patient problem (pressure injury), a concern (decreased food intake), a sign (fever), a symptom (anxiety), or an event (return from surgery). The note has three components: Data, Action, and Response (DAR) or Data, Action, and Evaluation (DAE) (Fig. 7.5). The data component contains subjective and objective information that describes or supports the focus of the note. The action component includes interventions performed or to be 90 UNIT III Communication in Nursing Date 7/18/18 Time 1420 Problem Pain r/t ROM exercises of rt knee by CPM machine P. I. E. Nurse’s Notes Reinstruct in use of PCA and measures for distraction. Instructions for use of PCA given; encouraged to watch TV movie for distraction. Knee position on CPM machine OK; machine functioning at ordered settings. Repositioned upper body for comfort. Using PCA as needed; pain decreased. States is tolerable at 3 on a scale of 1-10. Watching movie.--------C. Harris, LPN FIGURE 7.4 Example of PIE charting. Date 7/01/18 Time 1300 Problem Skin breakdown right ankle D. A. R. Patient Progress Slight serous drainage on dressing; wound 1x2 cm c left red border; no odor; states hurts slightly.---------------------------Cleansed c sterile saline. DuoDerm thin applied. Wound clean; minimal drainage present.-----T. Harper, RN FIGURE 7.5 Example of focus charting. implemented. The response component describes the outcomes of the interventions and whether the goal has been met. The advantages of focus charting: • It is compatible with the use of the nursing process. • It shortens documentation time by using many low sheets and checklists. • The focus is not limited to patient problems or nursing diagnoses. The disadvantages of focus charting: • If the database is not complete, patient problems may be missed. • It does not adhere to charting with the focus on nursing diagnoses and expected outcomes. CHARTING BY EXCEPTION Charting by exception was developed in the early 1980s by a group of nurses in Wisconsin. The goal was to decrease the lengthy narrative entries of traditional documentation systems and reduce repetition of data. Charting by exception is based on the assumption that all standards of practice are carried out and met with a normal or expected response unless otherwise documented. Agency-wide and unit-speciic protocols (standard procedures) and standards of nursing care are the heart of the system. The standards and protocols are integrated into low sheets and forms, and the nurse needs only to document abnormal indings or responses correlated with the nursing diagnoses listed on the nursing care plan (Fig. 7.6). Charting by exception is the direct opposite of the adage, “If it wasn’t documented, it wasn’t done.” Charting by exception assumes that, unless documented to the contrary, all standards and protocols were followed and all assessment values were within accepted limits. This type of documentation may present some problems with legalities when a medical record is called into court because only abnormalities are documented in written words. The advantages of charting by exception: • It highlights abnormal data and patient trends. • It decreases narrative documentation time. • It eliminates duplication of charting. • It lends itself to computerized documentation systems. Disadvantages of charting by exception: • It requires development of detailed protocols and standards. • It requires retraining staff to use unfamiliar methods of record keeping and documenting. • Nurses become so used to not charting that important data are sometimes omitted. COMPUTER-ASSISTED CHARTING An electronic health record (EHR) is a computerized comprehensive record of a patient’s history and care across all facilities and admissions. This type of record has been set up as a goal of the Stimulus Law that President Obama signed in 2009. QSEN Considerations: Informatics Nursing Informatics Nursing informatics is the “science and practice (that) integrates nursing, its information and knowledge, with management of information and communication technologies to promote the health of people, families, and communities worldwide” (American Medical Informatics Association, 2015). The electronic health record is a component of informatics. Documentation of Nursing Care CHAPTER 7 GUIDELINES FOR USE OF THE NURSING/PHYSICIAN ORDER FLOW SHEET 1. Indicate the Nursing Diagnosis that relates to the nursing order in the far left-hand column of the category boxes. If the order is a physician order, indicate “D.O.” (“Doctor Order”) instead of the nursing diagnosis number. 2. Indicate the nursing or physician order. If the nursing order includes an assessment to be completed, use the following protocol: a. NEUROLOGIC ASSESSMENT - will include orientation, pupil movement, sensation, quality of speech/swallowing, and memory. b. CARDIOVASCULAR ASSESSMENT - will include apical pulse, neck veins, CRT, peripheral pulses, edema, and calf tenderness. c. RESPIRATORY ASSESSMENT - will include respiratory characteristics, breath sounds, cough, sputum, color of nailbeds/mucous membranes, and CRT. d. GASTROINTESTINAL ASSESSMENT - will include abdominal appearance, bowel sounds, palpation, diet tolerance, and stools. e. URINARY ASSESSMENT - will include voiding patterns, bladder distention, and urine characteristics. f. INTEGUMENTARY ASSESSMENT - will include skin color, skin temperature, skin integrity, and condition of mucous membranes. g. MUSCULOSKELETAL ASSESSMENT - will include joint swelling, tenderness, limitations in ROM, muscle strength, and condition of surrounding tissue. h. NEUROVASCULAR ASSESSMENT - will include color, temperature, movement, CRT, peripheral pulses, edema, and patient description of sensation to affected extremity. i. SURGICAL DRESSING/INCISIONAL ASSESSMENT - will include condition of surgical dressing and/or color, temperature, tenderness of surrounding tissue, condition of sutures/staples/steri-strips, appearance of wound including color, any exudate present, granulation tissue; approximation of wound edges, and presence of any drainage. j. PAIN ASSESSMENT - will include patient description, location, duration, intensity on a scale of 1 to 10, radiation, precipitating factors. k. POST-MYELOGRAM COMPLICATION ASSESSMENT - will include headache, nausea, and vomiting. l. MYELOGRAM SITE ASSESSMENT - will include presence of ecchymosis and drainage. OR Specify exactly which parts of assessment should be completed. 3. Top of sheet should be dated. Time should be indicated in the small box in upper right-hand corner of each category box. 4. Upon carrying out an order that has no significant findings, a “ ” in the appropriate category box is sufficient to indicate it was done. If the order includes an assessment, the following parameters will be considered a negative assessment and constitute the use of a “ .” a. NEUROLOGIC ASSESSMENT - Alert and oriented to person, place, and time. Behavior appropriate to situation. Pupils equal, round and reactive to light. Active ROM of all extremities with symmetry of strength. No paresthesia. Verbalization clear and understandable. Swallowing without coughing or choking on liquids and solids. Memory intact. b. CARDIOVASCULAR ASSESSMENT - Regular apical pulse, S1 and S2 audible. Neck veins flat at 45 degrees. CRT <3 sec. Peripheral pulses palpable. No edema. No calf tenderness. c. RESPIRATORY ASSESSMENT - Respirations 10-20/min at rest. Respirations quiet and regular. Breath sounds vesicular throughout both lung fields, bronchial over major airways, with no adventitious sounds. Sputum clear. Nailbeds and mucous membranes pink. CRT <3 sec. d. GASTROINTESTINAL ASSESSMENT - Abdomen soft. Bowel sounds active (5-34/min.) No pain with palpation. Tolerates prescribed diet without nausea and vomiting. Having BMs within own normal pattern and consistency. e. URINARY ASSESSMENT - Able to empty bladder without dysuria. Bladder not distended after voiding. Urine clear and yellow to amber. f. INTEGUMENTARY ASSESSMENT - Skin color within patient’s norm. Skin warm and intact. Mucous membranes moist. g. MUSCULOSKELETAL ASSESSMENT - Absence of joint swelling and tenderness. Normal ROM of all joints. NO muscle weakness. Surrounding tissues show no evidence of inflammation, nodules, nail changes, ulcerations, or rashes. h. NEUROVASCULAR ASSESSMENT - Affected extremity is pink, warm and movable within patient’s average ROM. CRT <3 sec. Peripheral pulses palpable. No edema. Sensation intact without numbness or paresthesia. i. SURGICAL DRESSING/INCISIONAL ASSESSMENT - Dressing dry and intact. No evidence of redness, increased temperature, or tenderness in surrounding tissue. Sutures/staples/steri-strips intact. Wound edges well-approximated. No drainage present. j. PAIN ASSESSMENT - If medication alone relieves pain and expected outcome is met, documentation on the Medication Profile is sufficient. No specific problem needs to be identified in the Nurses’ Notes or Flow Sheet. k. POST-MYELOGRAM COMPLICATION ASSESSMENT - Absence of headache, nausea, and vomiting. l. MYELOGRAM SITE ASSESSMENT - Steri-strip dry and intact. No drainage present. 5. Upon carrying out an order that has significant findings, an asterisk is entered in the appropriate box. An asterisk (*) in the category box indicates to “See Significant Findings Section.” 6. If status remains unchanged from previous asterisk entry, current entry may be indicated with an “ .” 7. If an order no longer needs to be carried out, the next unused category box in that row indicates “order D/Ced,” and a line should be drawn through the remaining boxes. Any unused rows can be left blank. 8. Each flow sheet is used for 24 hours. FIGURE 7.6 Guidelines for the use of the nursing or physician order low sheet. These guidelines appear on the reverse side of the irst page of the low sheet. (From Burke, L. J., & Murphy, J. [1995]. Charting by exception applications: making it work in clinical settings. Albany, NY: Delmar.) 91 92 UNIT III Communication in Nursing QSEN Considerations: Informatics KSAs for Prelicensure Licensed Practical Nurse/Licensed Vocational Nurse Students KNOWLEDGE SKILLS ATTITUDES • Knowledge of why information and technology skills are essential for safe patient care. • Identify essential information needed in a database to support patient care. • Describe examples of how computerized information is related to patient care quality and safety. • Recognize the time, effort, and skill needed for technology to become an effective and reliable tool for patient care. • Learn how data are managed in the care setting before performing patient care. • Apply technology to support patient care. • Document patient care in an electronic health record. • Navigate the electronic health record. • Respond appropriately to clinical decision-making alerts, in collaboration with the RN. • Appreciate the need to seek continuous learning of information technology skills. • Value technology that supports clinical decision making. • Protect patient privacy and conidentiality in electronic health records. • Value nurses’ involvement in design of information technology systems for patient care. KSA: knowledge, skills, attitudes; RN: registered nurse. Adapted from http://qsen.org/competencies/pre-licensure-ksas/#informatics In addition to knowing how to use information and communication technologies, such as EHRs to assist in providing care, it is also important to assure the information is secure and conidential. Within a hospital system, computer records are protected by passwords and a irewall. With the addition of wireless technology, the security issues have increased. Each user who has access to a patient record must have a secure password, which must be changed regularly to maintain security. Encryption and authentication software is used when reports are transmitted outside of the health care facility campus. See Box 7.1 for tips on computer documentation. Legal and Ethical Considerations Box 7.1 Tips for Computer Documentation • Attend a computer documentation orientation held by the facility. Obtain a “quick reference guide.” • Determine the “superuser” on your unit to be used as a resource. • Refresh the computer screen often to keep track of the most current medical orders and other health care providers’ entries. • Document in a timely manner. • Do not “copy and paste” anyone else’s documentation. • Do not share passwords or computer codes. Your code is your legal electronic signature. • Review your notes for accuracy before you select “confirm” or “save.” • Never walk away from your terminal without logging off. Confidentiality and Security With Computer Documentation You have a legal obligation to guard your password and not give it to anyone at any time for any reason. Be sure to shred any printed documents, such as report sheets or ISBAR-R communication sheets that may have any identiiable information before leaving the unit. In addition, keep them concealed while working. HIPAA requirements (see Chapter 3) mandate that all patient information be kept conidential. Although your password gives you access to the records of patients on your unit, you will not be able to access patient records on other units. Only administrative personnel can view the record of any patient in the hospital. ISBAR-R: introduction, situation, background, assessment, recommendation, readback; HIPAA: Health Insurance Portability and Accountability Act. Computerized provider order entry (CPOE) provides for eficient worklow because, when orders are entered into the computer, they are automatically routed to the appropriate clinical areas for action. For example, an order for a new medication is entered on the computer and then automatically posted to the electronic medication administration record (eMAR) for that patient and to the pharmacy for the order to be illed. The order is always legible, and transcribing errors are eliminated. In computerized documentation systems, it is important to have standard terminology appropriate for the entire interdisciplinary team. The Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT) is a reference vocabulary developed for this purpose (International Health Terminology Standards Development Organisation, 2015). This is important in evidence-based practice for researchers to understand the relationships in the data to predict trends and consequences of care. Health care agencies are mandated to use electronic documentation of patient care (Centers for Medicare and Medicaid Services, 2015). Documentation can be done as interventions are performed with the use of a workstation on wheels (Fig. 7.7) or a hand-held terminal carried from room to room. Computer-assisted documentation can save nursing time. Entries can be made at the point of care, at the time a change in condition is observed or a treatment is given. The information is fresh, and no time has to be spent recalling details or organizing events in sequence. If the system uses a drop-down table or menu to select from, you can quickly choose the appropriate description or intervention and do not have to key in free text. Test and diagnostic results can be electronically added to the medical record as they are received, allowing for more rapid information low between health care providers. Documentation of Nursing Care FIGURE 7.7 Nurse using a workstation on wheels at the bedside to do point-of-service documentation. Computerized systems for documenting patient care vary. Any documentation system can be supported using electronic documentation. Some organizations use a combination of manual and electronic documentation. For example, some documentation systems produce a low sheet with the expected patient outcomes and nursing interventions listed. The nurse initials those interventions that were implemented, writes a narrative note for other necessary information, and adds the printout page to the medical record. This adds some limited electronic functions to a manual system. Other systems use the POMR format and produce a prioritized problem list. A care plan is constructed by selecting the diagnoses, expected outcomes, and nursing interventions from speciic screens on the computer and keying in required information. A touch screen may be part of the system for choosing items. A third type of system consists of selecting data from display screens to build the low sheets and progress notes. The display screens are structured to allow documentation of current data and provide space for the addition of new indings. Much of the everyday care can be documented rapidly and completely in just seconds using such screens. Often the progress notes from all disciplines involved in the patient’s care are integrated. A medical record of vital sign trends or laboratory value trends can be printed quickly. Figure 7.8 shows an example of a patient’s electronic medical record. In fully implemented EHRs, clinical information from all sources low into the record. This results in a longitudinal medical record that contains documentation of all of a patient’s health care through time. The record is divided into episodes of care. An episode of care can occur in the outpatient or inpatient setting, any time the patient received medical assessment and/or medical intervention. As mentioned earlier, laboratory results, diagnostic imaging results, pathology reports, medication administration, and other information from CHAPTER 7 93 all care delivery settings are available via the EHR. This provides virtually instant access to a complete medical history. At this time, fully integrated EHRs are not common. There are multiple vendors for EHR systems. Integration of these systems with an agency’s current needs requires computer programming and interfaces, which can be expensive and time-consuming. Organizations must invest signiicant time and money to develop a true longitudinal EHR. Most organizations using EHRs have a computer system that collects health care information while the patient is receiving either inpatient or outpatient services. The inpatient and outpatient systems may be integrated, allowing physicians to access all patient information in the computer system from their ofices. However, the clinic medical record and the hospital system’s medical record may still remain separate and require access to both computer systems to review. A major consideration when using an electronic documentation system is conidentiality. Every individual who accesses the medical record has a password that is necessary for access to the assigned patient’s medical record. Based on their position or job code, the person will be given a level of security that will allow access to only the speciic information required for the job. When working on documentation at the computer, never leave the terminal while part of a patient’s medical record is on the screen. Situate terminals so that passersby cannot view the information displayed. Organizations have speciic policies outlining access, security, and use of the EHR. Organizations often require health care providers to sign nondisclosure agreements (see Chapter 3) regarding conidential patient information. Electronic records provide vital information to health care personnel instantly so they can immediately review previous problems, treatments, and responses. Cultural Considerations Helpful Specific Cultural Information Including the following patient information can enable the health care team with care coordination: • Primary language spoken and communication needs (The Joint Commission requirement). • Head of family or spokesperson. • Dietary differences and foods not permitted in the diet. • Ability to read and write in English. • Beliefs about cause of illness. • Special concerns related to religious/spiritual beliefs. • Individual needs for uninterrupted time for meditation or prayer. Advantages of computer-assisted documentation: • The date and time of the notation are automatically recorded. • Notes are always legible and easy to read. • There is quick communication between departments about patient needs. 94 UNIT III Communication in Nursing FIGURE 7.8 Example of portion of a patient’s electronic medical record. • Multiple health care providers can access the same patient’s information at one time. • It can reduce documentation time. • Electronic records can be retrieved quickly. • Reimbursement for services rendered can be faster and more complete because of complete and accurate documentation. • A true electronic medical record can provide a complete longitudinal record of the patient’s medical history at one point of access. • Well-designed systems can reduce errors, having a positive effect on patient safety. Disadvantages of computer-assisted documentation: • A sophisticated security system is necessary to prevent unauthorized personnel from accessing patient records. • Initial costs are considerable because many more terminals and an appropriate networking system must be purchased and interfaced for the system to work eficiently. • Implementation of a full EHR system can take considerable time. This results in the need to use two systems, paper and electronic, during that transition. • Signiicant cost and time are involved in training staff to use the system. • Computer downtime can create problems of input, access, and transfer of information. Well-established backup plans (downtime procedures) must be developed. CASE MANAGEMENT SYSTEM CHARTING Case management is a method of organizing patient care through an episode of illness so that clinical outcomes are achieved within an expected time frame and at a predictable cost (see Chapters 1 and 2). A clinical pathway or interdisciplinary care plan takes the place of the nursing care plan. Documentation of variances is placed on the back of the pathway sheets. For example, a patient is admitted for abdominal surgery. The wound is healing well, but the patient develops pneumonia. The variance would be documented as in Figure 7.9. Think Critically Which method of documentation seems easiest to you? Can you explain why? Documentation of Nursing Care Variation Airway Clearance Cause Pneumonia 7/23 7/23 7/24 7/24 7/26 7/26 CHAPTER 7 95 Action Taken ↑ fluids to 2000 mL/day Proventil inhaler for wheezing Incentive spirometer use encouraged every 1° while awake Instructed in home O2 use Unit Air contacted for oxygen delivery FIGURE 7.9 Example of variance charting. THE DOCUMENTATION PROCESS When documenting patient care, present the patient’s needs, problems, and activities in terms of behaviors. The notes focus on the immediate past and the present, never the future. In other words, only record what you have done for the patient, not what you plan to do. For example, after assisting a patient to ambulate, you might record, “Ambulated 20 feet down the hall and back.” Documentation should be accurate, brief, and complete. When documentation follows these guidelines, it presents a photographic view of the patient to anyone who reads the nursing notes. ACCURACY IN DOCUMENTATION Be speciic and deinite in using words or phrases that convey the meaning you wish expressed. Avoid using the words appears to or seems in phrases such as appears to be resting. Document the behavior; the patient either is or is not resting. Words that have ambiguous meanings and slang should not be used in documentation. For example, how much is “a little,” “a small amount,” or a “large amount”? What do phrases such as ate well, taking luids poorly, and tolerated well mean? Although such words give a general idea of what is meant, they are not speciic: they are subjective phrases. Someone else reading the notes will not know if the patient who “ate well” had a half a piece of toast, juice, and a cup of coffee or ate a bowl of cereal, scrambled eggs, two slices of bacon, 4 oz of orange juice, and two cups of coffee. Instead of documenting a conclusion such as “taking luids poorly,” record the behavior and the speciic amounts of liquid taken in a particular amount of time, such as “given luids at frequent intervals, but takes only a few swallows; intake from 0700 to 1000: 30 mL of coffee, 60 mL of orange juice, and 50 mL of water.” Speciic data about size, amounts, and other measurements provide a means for the reader to determine whether the condition is getting better, getting worse, or staying the same. Rather than use the term tolerated well, describe what happened, even if it is a statement such as “walked in hall without problems.” BREVITY IN DOCUMENTATION When charting, sentences are not necessary. Articles (a, an, and the) may be omitted. Because the medical record is about a particular patient, the word patient is left out whenever it is the subject of the sentence. Each statement should begin with a capital letter and end with a period. Rather than stating, “Patient left for surgery via stretcher at 10:15,” simply state, “To surgery via stretcher at 10:15.” Abbreviations, acronyms, and symbols acceptable to the agency are used in documentation to save time and space. Each agency has its own list of acceptable abbreviations and symbols. This list is usually found in the policy and procedures manual. You must choose which behaviors and observations are noteworthy, or your nurse’s notes will be lengthy and irrelevant. In most agencies, if data (such as patient voiding) are recorded on a low sheet, they need not be documented again in the nurse’s notes. No other notation is made in the nurse’s notes unless there is a problem or some signiicant related data. A good way to learn what should and should not be documented is to read over the notes of experienced nurses who are known to document accurately and well. A rule of thumb is that if the behavior or inding is abnormal or is a change from previous behavior or data, document it. LEGIBILITY AND COMPLETENESS IN DOCUMENTATION Legibility is important in any handwritten documentation. The medical record may be called into court, and what you wrote may be scrutinized and evaluated. If the writing is not easily legible, misperceptions of what was written can occur. Completeness is more important than brevity. You should record information about the patient’s needs and problems and specify the nursing care given for those needs or problems. In other words, any time you document anything abnormal, also document what you did about it, or at minimum who you notiied. If you document, “Skin at IV site reddened and slightly swollen,” you must include a note about what you did about the problem. The full note should read, “Skin at right forearm IV site reddened and slightly swollen in 4-cm area. IV DC’d and warm moist pack applied for 20 minutes. Redness and swelling receding. IV restarted in left hand with 20 ga catheter.” What constitutes complete documentation may vary among hospitals, extended-care facilities, and other health care agencies. Home care documentation must particularly note safety factors in place and the need for continued care (Fig. 7.10). Long-term care facilities may require only a monthly summary for 96 UNIT III Communication in Nursing Routine Home Health Assessment Patient: Clifford-Oscar, Randall Nurse: Williams, Cerys Visit Date: 3/19/2017; 4:26PM Data/Safety/Dx - Patient Data Source of information: Residence Lives with Financial concerns Assistance with care Main caregiver Caregiver availability Assistance type Patient Patient’s owned or rented residence Lives alone None Relatives Son One to two times a week Environmental support—home maintenance IADL assistance Facilitates patient participation in appropriate medical care Financial agent Health care agent Medical power of attorney Psychosocial support Shopping None of the above Bowel/bladder (incontinence) Endurance Ambulation Dependent ADLs Up as tolerated Health risks Functional limitations (485) Activity oders (485) Data/Safety/Dx - Safety Pt with Hx of falls Yes History/Vitals/Pain - Primary Pain Location Descript Present pain Acceptable pain (Phys) 0 3 History/Vitals/Pain - Vital Signs Temperature Radial pulse Apical pulse Pulse rhythm/quality Respirations 99.0 60 60 Regular 20 Comment: O2 sat 97% on RA 130/70 Bilaterally equal and weak B/P sitting Pedal pulses Psychosocial/Skin/Ulcers Skin S/S Dry Friable/fragile Intact None present Wound/pressure injury/ stasis ulcer HENT/Res/CV/Neu - Cardiovascular Cardiovascular signs/sypmtoms Consistently cold extremities Dysp after amb <20 ft: dress/use commode Endurance limitations S1 S2 Heart (cardiac) sounds HENT/Res/CV/Neu - Head/Ears/Eyes/Nose/Throat HEENT S/S Status of vision Hearing/understanding Expression ability Speech patterns Glasses Impaired vision Partially impaired cannot see medication labels or newsprint No observable impairment can hear and understand complex instructions and abstract conversation Expresses complex ideas, feelings, and needs clearly without visible impairment Spontaneous Patient: Clifford-Oscar, Randall Team: Home Care Record #: 12345 FIGURE 7.10 Printout from home care agency electronic documentation. (Courtesy Mission Hospice and Home Care, San Mateo, California.) Documentation of Nursing Care CHAPTER 7 Routine Home Health Assessment Patient: Clifford-Oscar, Randall Nurse: Williams, Cerys Visit Date: 3/19/2017; 4:26PM HENT/Res/CV/Neu - Neurological Neuro S/S Mental status (485) Confusion occurrence Anxiety occurrence Depression identification Behavior issues Behavior occurrence No significant findings [Go to Mental Status] Alert Oriented Never None of the time None of the above observed or reported None of the above behaviors observed Never HENT/Res/CV/Neu - Respiratory Respiratory sign/symptoms Lung fields right Lung fields left Dyspnea Diminished endurance/fatigue Dyspnea on exertion Endurance limitations Orthopnea Pursed-lip breathing Clear all lobes Clear both lobes With moderate exertion such as while dressing, using commode, walking distances less than 20 feet Musc/ADLs/IADLs - Musculoskeletal Musculoskeletal S/S Holds on to furniture GI/GU/Endc/Plan Immune system Medication change since last visit No signs of infection Potential for infection No GI/GU/Endc/Plan - Gastrointestinal Last BM Present bowel pattern Bowel incontinence occurrence Today Regular Very rarely or never has bowel incontinence GI/GU/Endc/Plan - Genitourinary Genitourinary S/S Urinary incontinence WNL for patient [Go to M1600] Patient requires a urinary catheter (i.e., external - indwelling - intermittent suprapubic) (GO TO GASTRO INTESTINAL) GI/GU/Endc/Plan - Medical Safety Med safety measures Stress body mechanics Universal/Standard precautions Label/Storage of medication GI/GU/Endc/Plan - Nutrition Nutritional S/S Nutritional requirements Meal patterns Skin turgor No significant findings No added salt Eats alone most of the time Eats 3 meals a day Rebounds instantly GI/GU/Endc/Plan - Planning Plan for next visit Education/assist Medications assessed for Instructed/copy to Plan of care discussed with Patient has not had any S/S of UTI since last visit. Changed 18 french 10ml catheter, patient tolerated procedure well. Able to fully insert catheter without feeling resistance or bladder limitation this visit. Patient reports catheter comfortable, pale yellow urine draining well. Assistance need Diet/exercise Disease process Medication management Safety measures Effectiveness Patient Patient Patient: Clifford-Oscar, Randall Team: Home Care Record #: 12345 FIGURE 7.10, cont’d 97 98 UNIT III Communication in Nursing patients in stable condition or a note when their condition changes (Fig. 7.11), whereas hospitals caring for acutely ill patients require continual documentation of the patient’s condition, with entries made every few hours. For completeness in documentation about the patient’s signs or symptoms, note something about each of the seven factors listed in Box 7.2. WHAT TO DOCUMENT In addition to assessment data related to signs and symptoms, information on the topics in Box 7.3 is to Date/Time 4/15/18 7-3 shift be documented either on low sheets or in the nurse’s notes. The documentation examples included with the procedures throughout this book show how to describe different types of information. General Documentation Guidelines In addition to those mentioned above, there are several other general rules to consider when charting (Box 7.4). Figure 7.12 shows the use of regular versus military time for medical record entries. Licensed Nurses Progress Notes Pt asked both nurses at med carts for IM injection Cortisone and “could I have meds right now?” Instructed to take seat at breakfast table. Pt’s roommate called nurse. Pt supine on floor no changes to LOC. Walker at side A/O. Answered all questions appropriately, no ∆ in speech and mentation.---------------------------------------------------------------------------------------------------VS taken by this RN: T 98.6, P 76, R 16, BP 120/80.------------------------------------------------Denies HA, no s/s CVA/TIA- clear conversation, no paralysis. C/O right knee discomfort when asked what heppened- why she fell. Assisted to chair. Denies pain. Neuro VS unremarkable: PERL hand grips strong- no s/s hypoglycemia, no sweating or lethargy, alert, gave complete date, answered questions appropriately. Reported to supervisor: Vivian Violet, RN DON. ------------------------------------------------------------------------------------------------------------M. Markham, RN FIGURE 7.11 Example of long-term care facility documentation. Box 7.2 Guidelines for Documenting a Sign or a Symptom Location in the body: Describe the exact location. Quality: Describe in patient’s terms; for example, a person having a myocardial infarction (heart attack) might describe the chest pain as feeling as if the chest is being “squeezed in a vise.” Quantity: Document the intensity of the symptoms (i.e., mild, moderate, or severe). Use a scale of 0 to 10 for pain, with 10 being the highest. Indicate the degree of impairment and the frequency, volume, and size or extent of the sign or symptom. Note the number of times the patient has vomited, the amount each time, and whether nausea is constant or intermittent. Chronology: Note the sequence of development: 1. Time of onset of the sign or symptom 2. Duration (minutes, hours, or days) 3. Pattern of variation and frequency and the course of the signs or symptoms (e.g., Do they stay the same, get better, or get worse over time?) Setting: Where is the patient (e.g., at home, in bed, or in the car)? What is the patient doing (e.g., running, sleeping, or eating). Who is the patient with (e.g., mother, spouse, or boss) when the symptoms occur? Aggravating or alleviating factors: What makes the signs or symptoms worse and what makes them better? Does a hot shower make a skin rash worse? Does eating cause more or less pain? Associated manifestations: Signs and symptoms rarely occur singly. For instance, does the patient have nausea before vomiting? Has there been a weight change since the onset of vomiting? Box 7.3 • • • • • • • • • • • • • • • • • • • • • • • • Types of Information to Be Documented Admission note Assessment data for all body systems Body care Death Degree of activity Diagnostic tests Diet and luids Discharge from the facility Dressings and wound care Intake and output Intravenous infusions Medications Mental state and mood Mood, concerns, or discomfort Oxygen in use Primary care provider’s visits and calls to provider Postoperative care Procedures performed Sleep Specimens obtained and their disposition Patient education Travel from the unit Tubes and equipment in use Visitors Documentation of Nursing Care Box 7.4 2400 General Guidelines for Documenting • Verify you are on the correct patient’s computer screen before beginning to document in the medical record. Record the initial assessment at the beginning of the shift. • Use a 24-hour clock (military time; see Fig. 7.12). • Documentation is done only by the person who made the observation or performed the intervention and who is legally responsible for the accuracy and quality of care. • Record objective data after completing each task. Never document before a task is actually done. • Follow hospital policy for amending the record. • Clearly identify care given by another health care team member. • When a patient refuses a medication, record an explanation for the refusal in the medical record. Document the exact words the patient used when refusing to comply with the treatment regimen. Document any instructions given to the patient and any patient behaviors that are against the instructions. • Spell medical record entries correctly. Use a dictionary or “spell check” to check words you are unsure ho