Chapter 3 Documentation

· Documenting involves recording the intervention carried out to meet the patients needs · Document interventions, time care was given, and the signature and title of the person providing the care is essential · Documentation is an integral part of the implementation phase of the nursing process and is necessary for the evaluation of patient care and for reimbursement 5 purposes of patient records: 1. Documented communication 2. Permanent record for accountability 3. Legal record of care 4. Teaching 5. Research and data collection · A medical record should furnish all health care providers with a concise, accurate, written picture of a patient’s medical and nursing problems, care planned and given, and the patient’s response to treatment. · Auditors · Peer review o Individual nurse conduct · Quality assurance, assessment, and improvement o d · Diagnosis-related groups (DRGs) o D § System classifying patient by age, diagnosis, and surgical procedure, producing 300 different categories used in predicting the use of hospital resources, including length of stay § Basis for reimbursement rates for Medicare and Medicaid § Many private insurance companies use a · Nurses notes o Where nurses record observations, care given and patient’s responses o Institutions are reimbursed by insurance companies or government programs only for documented care Electronic Health Record (EHR) · Use of record · Ease of use and documentation · Point-of-care · Computers on wheels (cows) · PHR (personal health record) · Security SBAR (R) · Situation, background, assessment, and recommendations, read back · Communicates between provider and nurse, nurse and nurse · Joint Commission states “it meets the National Patient Safety Goals” Guidelines for Documentation · Quality and accuracy of the nurse’s notes are extremely important · Correct spelling, grammar, and punctuation, as well as good penmanship and other writing skills are important in documentation · Information recorded in the chart should be clear, concise, complete and accurate · Military time is typically used · The registered nurse (RN) is responsible for the initial admission nursing history, physical assessment, and development of care plan. Charting rules · All sheets should have correct patient name, identification number, date of birth, date and time if appropriate · Use only approved abbreviations and medical terms · Be timely, specific, accurate and complete · Write legibly · Follow rules for grammar and punctuation · Leave no empty lines, chart consecutively (draw a line through the empty space and sign. Signifies “I’m done”) · Chart after care is given · Chart as soon and as often as possible · Chart only your own care; never chart for anyone else · Use direct quotes as appropriate · Be objective in charting · Describe each item as you see it. · Avoid judgmental terms and placing blame. · Sign each entry · Chart all ordered care as given · Note patient responses to treatments and/or medications · When patient leaves the unit, chart the time and method of transportation on departure and return. · Use only hard-pointed, permanent, black ink pens; no erasers or correcting fluids are allowed on charts · If a charting error is made, identify the error according to the facilities policy and make the correct entry. (draw a line through an error and initial) · When making a late entry, note it as a late entry, and proceed with the entry · Follow each institution’s policies and procedures for charting. · Avoid general, empty phrases such as “status unchanged” or “had a good day” “will continue to monitor” · If you question an order, record that clarification was sought. Common medical abbreviations and terminology · Standard medical abbreviations and terminology · Most facilities have a published list of generally accepted medical abbreviations and terms approved · Appendix A page 1251-1252 Recording Methods: Traditional Chart · D · D · d Traditional Charting · Narrative · Care given is descriptive · Written in abbreviated story form o Includes: § Patient need or problem data § Whether someone was contacted § Care treatments provided § Response to treatment § Organized in a head-to-toe manner Problem-oriented medical record (POMR) · Scientific problem-solving system or method · Principal sections: database, problem list, care plan and progress notes o Database: History and physical, diagnostic tests, identify and prioritize the health problems on the medical -… · SOAPIER o S – Subjective o O – Objective o A – Assessment o P – Plan o I – Intervention o E – Evaluation o R – Revision Focus Charting · Modified list of nursing diagnoses · Nursing process used with focus on patient needs · A focus is not a medical diagnosis · DARE o Data o Action o Response o Education/patient teaching Charting by Exception · Complete physical assessment, observations, vital signs, IV site and rate, and other 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. · More detailed flow sheets, which reduce the time needed to chart, are used with this method · APIE o Assessment o Problem o Intervention o Evaluation Record-Keeping Forms and Examples · Makes medical documentation easy and quick · Eliminate duplication of data · Unnecessary to document each time medication is given · Kardex · Nursing Care Plan · Incident report o Used for any event not consistent with routine care of a patient o Give only objective information o Do not admit liability or give unnecessary details o Do not mention the incident report in the nurse’s notes · 24-hr fpatient care reports and acuity forms o Accurate assessment information and documentation of activities of daily living o Use flow sheets and checklists · Acuity charting o Rates each patient’s severity of illness o Determines efficient staffing patterns · Discharge summary o Pertains to patient’s continued health care after discharge o Concise and instructive form Documentation and Clinical Pathways · Managed care is a systematic approach that provides a framework to target the coordination of medical and nursing interventions · Allows staff from all disciplines to develop integrated care plans for a projected length of stay for a specific case type · The nurse and other team members -… Home Health Care Documentation · Documentation provides quality control and reimbursement from Medicare, Medicaid and private insurance companies · Must note patient education a demonstration of learning · Coordination of services and compliance of regulation reflected by all members of the health care team Long-Term Health Care Documentation · Omnibus Budget Reconciliation Act (OBRA) of 1987 regulates standards for resident assessment, individualized care plans, and qualifications for health care providers · Department of Health (DOH) for each state governs frequency of written nursing records of residents · Supports multidisciplinary approach in assessment and planning processes of patient care Special Issues in Documentation · Record Ownership and Access o Property of institution of health care provider o The patient usually does not have immediate access to full records o To gain access, need to follow established policy of facility o Lawyers can gain access to chart with the patient’s written consent · Confidentiality o Patient’s Bill of rights and the law guarantee the patient’s medical record information-… · Electronic documentation o Institutions have mainframe computers for data processing tasks o Progressive hospitals’ computers handle provider orders, pharmacy, laboratory, diagnostic imaging orders, central supply requests, care planning, documentation and billing o Most efficient computer systems have bedside or handheld terminals for data entry o Do not share your password used to log into the computer o Do not leave the computer without logging it off o Follow correct protocol for correcting errors o Be sure stored records have backup files o Do not leave information about patient displayed on the monitor. · Use of fax machines o Transmit information between offices, hospitals and other facilities o Vital for rapid information transmission and are as important as computers for documentation and data handling Nursing process and critical thinking Nursing Defined Nursing Process · Organizational framework for the practice of nursing · Problem solving · Six phases o Assessment o NURSING Diagnosis o Plan o identify outcomes o Implementation o Evaluation · ANA Nursing Scope and Standards of Practice Assessment Data · ANA Definition, “Systematic, dynamic process by which the registered nurse, through interaction with the patient, family, groups, communities, populations and health care providers, collects and analyzes data” · Information is gathered to identify the condition of the patient’s health · Review and physical examination of ALL body systems · Cognitive, psychosocial, emotional, cultural, and spiritual components · Focused assessment is advisable if patient is critically ill, disoriented or unable to respond · The LPN assists the registered Nurse (RN) Types of Data · Cue o Pieces of data · Subjective o Verbal statements provided by the patient · Objective o Observable and measureable signs o Can be recorded Sources of Data o Primary sources § Patient · Most accurate o Secondary § Family members, significant other, medical records, diagnostic procedures and nursing literature § When the patient is unable to supply information, secondary sources are used · Methods of Data Collection o Interview § Biographic data § Reason patient is seeking health care § History of present illness § Past health history § Environmental history § Psychosocial history o Physical exams § Head-to-toe format · Data Clustering o Related cues are grouped together o Attention is then focused on health concerns that need support and assistance o This assists the identification of nursing diagnoses · Diagnosis o Identify the type and cause of a health condition o ANA defines as “A clinical judgement about the patient’s response to actual or potential health conditions or needs. Diagnoses provide the basis for determination of a plan of care to achieve expected outcomes” o The LPN/RN may both observe and collect data § RN is responsible for analyzing and interpreting o Once the initial assessment has been completed, the data requires analysis · Nursing Diagnosis o Is a type of health problem that can be identified o Provides the basis for selection of nursing interventions to achieve outcomes for which the nurse has accountability o North American Nursing Diagnosis Association (NANDA) in 1990 o North Americal Nursing Diagnosis Association International (NANDA-l) in 1992 § Approves the official definition for a nursing diagnosis o Components of a nursing diagnosis § Definition · Presents a clear, precise description of the problem · Helps to identify the difference between similar nursing diagnoses § Defining Characteristics · Cues that tell how the diagnosis is manifested · Clinical cues, signs and symtoms that furnish evidence that a problem exists · Written as “manifested by” in the nursing diagnosis statement § 4 components addressed · Nursing diagnosis title or label · Definition of the title or label o Problems that is identified based on a pattern of related cues, this analysis is given a title or label o Called nursing diagnosis o Provides a concise name for the identified health problem o Lists of nursing diagnoses are often presented in alphabetical order o Adjectives add meaning to the nursing diagnosis § Imbalanced, impaired, perceived, etc… · Contributing, etiologic or related factors o Conditions that might be involved in the development of a problem and are found in the nursing diagnosis handbooks o May become the focus for nursing interventions o Written as “related to” in the actual nursing diagnosis o Risk factors are those that increase susceptibility of a patient to a problem Actual Nursing diagnosis · Represents a condition that is currently present · Cuse from nursing assessment indicate problem exists · Usually represent by 3-part statement o The nursing diagnosis label from NANDA-l o The contributing/etiologic/related factor o The specific cues, signs and symptoms from the patient’s assessment § EX: 1:stress 2: related to sleep deprivation 3: manifested by student states “I only had 4 hrs of sleep last night because I was up studying.” Risk nursing diagnosis · A clinical judgement that an individual, family or community is more vulnerable to develop the problem than others in the same or similar situation · The assessment indicates that risk factors are present that are known to contribute to development of the problem · Written in a two-part statement o The nursing diagnosis label from NANDA-l o The risk factor § EX: 1: Risk for impaired skin integrity 2: related to immobilization Syndrome Nursing Diagnosis · Used when a cluster of actual or risk nursing diagnoses are predicted to be present in certain circumstances · Current syndrome diagnoses: Posttrauma syndrome, Rape-trauma syndrome, Risk for disuse syndrome, Impaired environmental interpretation syndrome, and relocation stress syndrome o Ex: 1: posttrauma syndrome Health Promotion Nursing Diagnosis · Wellness nursing diagnosis o A clinical judgement about an individual, group or community in transition from a specific level of wellness to a higher level of wellness o Written in a 1-part statement o The words “readiness for enhanced” are used in a wellness nursing diagnosis § Ex: 1:readiness for enhanced learning Other Types of Health Problems · Collaborative problems o Certain physiologic complications that nurse monitor to detect onset or changes in status o Nurses manage problems using physician-prescribed and nurse-prescribed interventions to minimize the complications of the event · Medical Diagnosis o The identification of a disease or condition through a scientific evaluation of physical signs, symptoms, history, laboratory tests and procedures · Different medical and nursing diagnoses o Nursing diagnoses address human response to health problems and life processes o The nurse addresses the patient’s concerns about the medical problem o Nursing diagnosis may change or resolve as care is provided or the condition changes Outcomes Identification · Outcomes statement indicates the degree of wellness desired, expected or possible for the patient to achieve · Serves 2 functions: o Guide the selection of nursing interventions, selected to promote the achievement of the desired outcome o Outcome statement establishes the measuring standard that is used to evaluate the effectiveness of the nursing intervention · Alternate names are: o Patient goal o Patient-centered goal o Objective o Behavioral Objective o Patient outcomes · Provides a description of the specific measurable behavior the patient will exhibit in a given time frame · “Patient will statement” Planning · The nurse establishes priorities of care and nursing interventions are chosen that will best address the nursing diagnosis · Information is communicated through care plan so that all health care personnel will be directly involved in the care of the patient · The nurse decides what interventions will be effective after working with the patient and significant others · Priority setting o Nursing diagnoses are ranked in order of importance for the patient’s life and health o Physiologic needs come before safety and security (maslow) o Safety and security needs come before love and belonging needs o Life- and health-threatening problems are ranked before other types of problems o Actual problems may be ranked before risk problems o Priorities change as the patient progresses in the hospitalization; as some problems are resolved, new ones can be addressed · Selecting nursing interventions o Nursing interventions § Activities that promote the achievement of the desired patient outcome § Classified as physician-prescribed or nurse-prescribed o Physical-prescribed interventions are ordered by a physician for a nurse or other health care professional to perform o Physician-prescribed interventions § Actions ordered by a physician for a nurse or other health care provider to perform § Medications, wound care, diagnostic tests § Nursing judgement still used § Assessing, teaching and validating the safety of physician orders expected of nursing professionals o Nurse-prescribed interventions § Actions the nurse can legally order to begin independently § Providing a back massage, turning patient every 2 hrs, monitoring for complications § When determining interventions, the nurse should consider the contributing/ etiologic/ related factors, risk factors, patient-centered goal/desired outcomes, and the nursing diagnosis label Writing nurse interventions · Because nursing interventions in manuals and textbooks are often broad, general statements, it is often necessary to convert these into more specific, instructional statements · Nursing interventions must be written to reduce the likelihood of misinterpretation · Should include the subject, action verb, and qualifying details · Usually a “Nurse will” statement Writing Nursing Orders · Necessary to provide instruction to all caregivers · Nursing orders should include o Date o Signature of the nurse responsible for the plan of care o Subject (who will carry out the activity) o Action verb o Qualifying details Communicating the Nursing Care Plan · Written nursing care plan is the product of the nursing process · It’s important to have written guidelines to promote the continuity of patient care · Formats for the written nursing care plan vary among institutions · Nursing care plans may be prepared for each patient, be standardized for a group of patients or be computerized · Linear care plans versus concept maps o Common components in the educational setting § NANDA-l diagnostic labels § Patient-centered goals and desired patient outcomes § Nursing interventions § Orders o One of two types of care plans are noted in the educational setting · Care plan in a 4- or 5-column format · Concept map Implementation · Fifth phase of the nursing process (action) · The nurse and other members of the team put the established plan into action to promote outcome achievement · Using evidence-based interventions, the plan is implemented in a timely and safe manner · Phase of the nursing process in which the established plan is put into action to promote achievement of the outcome o This phase includes ongoing activities of data collection, prioritization, performance of nursing interventions and documentation o Both nurse- and physician-prescribed therapy are included o Documentation is a vital component of the implementation phase o “if it was not charted, it wasn’t done” is a constant principle of nursing Evidence-based practice · Nursing research is the basis for evidence-based practice Evaluation · A determination is made about the extent to which the established outcomes have been achieved o Review the patient-centered goals/desired patient outcomes that were established in the planning phase o Reassess the patient to gather data indicating the patient’s actual response to the nursing intervention o Compare the actual outcome with the desired outcome and make a critical judgement about whether the patient-centered goals/desired patient outcome was achieved · The nurse should make one of three judgements or decisions o The outcome was achieved o The outcome was not achieved o The outcome was partially achieved · The plan of care is changed during this phase of the nursing process · Modifications can be made if the outcome has been achieved, partially achieved or not achieved Standardized languages: NANDA-l, NIC, NOC · The NANDA-l has formed a relationship with two other groups o Nursing Intervention Classification (NIC) is a research group working at the university of Iowa to standardize the language used to organize and describe interventions o Nursing sensitive outcomes classification (NOC) is a research group working at the university of Iowa that has developed a standardized system to name and measure the results of patient outcomes Role of the LPN/LVN · The nursing process may vary from state to state; review the states nurse practice act · Provide direct bedside nursing care · This direct care position allows the LPN/LVN to closely observe, prioritize, intervene and evaluate the care provided to and for the patient · Role of the LPN/LVN in the nursing process o Assessment § Observe and report significant cues to the charge nurse or health care provider o Diagnosis § Assist with the determination of accurate nursing diagnoses § Gather data to confirm or eliminate problems o Planning § Assist with setting priorities § Suggest interventions § Assist with the development of realistic patient-centered goals/desired patient outcomes o Implementation § Assist with the establishment of priorities § Carry out physician and nursing orders § Evaluate the effectiveness of nursing activities o Evaluation § Assist with reevaluation of the patients health state after nursing interventions § Suggest alternative nursing interventions when necessary Nursing Diagnosis and Clinical Pathways · Managed care o A health care system whose aim is to enhance specific clinical and financial outcomes withing a specific time frame · Case management o A certified specialty; refers to the assignment of a health care provider to a patient so the care of that patient is overseen by one individual o Assists the patient and family to receive required services, coordinates these services and evaluates the adequacy of these services · Clinical pathways o Miltidisciplinary plan that schedules clinical intervention over an anticipated time frame for high-risk, high volume, high cost types of cases o Includes such elements as diagnostic tests, treatment, activities, medications, consultations, education, daily outcomes and discharge planning · Variance o Patient does not achieve the projected outcome Critical Thinking · Critical thinkers think with a purpose · They question information, conclusions and points of view · They are logical and fair in their thinking · Critical thinking is a complex process and no single simply definition explains all of the aspects of critical thinking · The nurse must be able to not only perform skills, but also think about what he/she is doing · Nurses use a knowledge base to make decisions, generate new ideas and solve problems Characteristics · Reflect or think about what is being learned · Look for relationships among concepts or ideas · Analyze or critique behaviors · Make self-correction · Realize they don’t know everything · Involve creative thinking Admission, Transfer, and Discharge Admission to a facility · Upon admission to the health care facility, patient will sign a concent form that gives permission for treatment to be given · The patient self-determination act of 1991 and the Health Insurance Portability and Accountability Act are also presented upon admission to a health care facility o It addresses the patient’s right to refuse or accept medical treatment and privacy of all information received from the patient