docs

• ü The results of clients response to the diagnostic test and interventions.

  ü Written evidence of the interactions between and among health professionals, clients, their families and health care organizations.

  Documentation
• Purposes of documentation

  v professional responsibility

  v Accountability

  v Meeting legal and practical Standards

  v Communication

  v Education

  v Reimbursements

  v Research

  v communication
• l  is a method of communication that validates the care provided to the client. It should clearly communicate all Important information regarding the client,education

   

  Recording
• -Rely on clients medical records as a clinical data source to Determine if clients meet the research criteria for study.

  Research
• -Failure to document is a key factor because medical record is a legal document and in case of lawsuit the records serves as a description of exactly what happened to the client.

   

  Legal and Practice Standards
• WHAT SHOULD BE DOCUMENTED

  • Environmental factors(safety, equipment), self care, client education

  • Clients outcomes, clients response to treatments, or preventive care

  • Discharge assessment data

  • More comprehensive notations to clients who are seriously ill
• WHAT SHOULD BE DOCUMENTED

  • Collaboration / communication with other health care providers

  • Medication administration

  • Verbal orders

  • Telephone orders
• giving and receiving verbal orders is considered a high risk activity.

  miscommunication or lack of communication could lead to negative implications for the client.

  • nurses & physicians have shared

  • Verbal Orders
• HOW SHOULD INFORMATION BE DOCUMENTED

  ü CLEARLY,

  ü COMPREHENSIVELY,

  ü COMPLETELY

  ü HONESTLY

  ü ACCURATELY
• HOW SHOULD INFORMATION BE DOCUMENTED?

  ü Legibility and spelling Forms, flow sheets, Checklists and progress notes

  ü Blank space

  ü Changes or additions

  ü Abbreviations
• WHEN SHOULD INFORMATION BE DOCUMENTED

  ü TIMELY

  ü FREQUENTLY

  ü CHRONOLOGICALLY

  ü DOCUMENTATION SHOULD BE DONE AS SOON AS POSSIBLE AFTER AN EVENT HAS OCCURRED. Ex.

  Care provided, medication administered, client fall.
• particularly when precise assessment is required as a result of client conditions ex. Intensive care, fluctuating health status.

  FREQUENCY OF DOCUMENTATION SUPPORTS ACCURACY
• ü must be clearly identified (addendum to care) and should be individually dated, time and must be signed by the nurse involved.

  late entries
• IN THE EVENT OF A LOST ENTRY, NURSES NEED TO REFER TO AGENCY POLICY AND MAY RECONSTRUCT THE ENTRY BY CLEARL6Y INDICATING THE CARE/ EVENT AS A RELACEMENT FOR A LOST ENTRY.
• EFFECTS OF INCOMPLETE MEDICAL RECORDS:

   

  ü COST HOSPITALS REIMBURSEMENT PESOS WHEN THERE IS NO DOCUMENTATION OF THE SERVICES THAT WERE GIVEN

  ü HAMPER QUALITY ASSURANCE AND RISK MANAGEMENT EFFORTS.

  ü FORCE HOSPITALS TO SETTLE SUITS OUT OF COURT TO LOSE CASES BECAUSE LAWYERS CANNOT PREPARE A SOLID DEFENSE
• l OF MALPRACTICE CASES THAT COULD BE DISMISSED FOR LACK OF EVIDENCE END UP IN COURT BECAUSE THE PATIENT RECORD IS TOO POOR TO DEFEND THE HOSPITAL.

  85%
• Legal issues of documentation

  • Legible and neat writing
  • Proper use of spelling and grammar
  • Use of authorized abbreviation
  • Factual and time sequenced descriptive notation
  • General documentation guidelines
• Documenting client records


  1. Ensure you have the correct client record

  2. Document as soon as possible to ensure accurate recall of data

  3. Date and time each entry

  4. Sign each entry with your full legal name and with your signature

  5. Do not leave space between entries
• Quotation marks


  Indicate direct client responses
• Documenting in chronological order


  If not, state why
• Documentation


  • Write legibly
  • Use of permanent ink
  • Document in a complete and concise manner
• Do's in documentation

  Check that you have the:

  v correct chart

  v reflects nursing process

  v Write legibly

  v Chart the time you gave a medication, the administration

  v route, a patient's response

  v chart precautions or preventive measures used

  v record each phone call to a physician

  v Chart patients care at the time you provide it
• Don'ts in nursing documentation

  • Don't chart a symptom like chief complain of pain

  • Don't alter a patients record

  v Don't use short hand or abbreviations that aren't widely accepted

  v Don't write imprecise descriptions

  v Don't chart what someone else said, heard, felt or smelled unless information is critical

  v Don't chart ahead of time
• Charting


  • Consistent with your employers written policies
  • If you did it or saw it, you should chart it
  • If you didn't chart it, you didn't do it
  • Include any interactions with staff members or doctors, including failed attempts to reach them, concerning the care of a patient
  • Do not erase an error or remove pages, draw a line thru the error, note, it was an error and initial it
  • Records should be clear, legible, accurate and should use proper terminology
  • Chart chronologically at the time of occurrence or as soon as possible afterward
  • Charting should be in inked and signed appropriately
• • These are often called "graphic records" and are used as a quick way to reflect or show clients condition.

  • They are helpful records in documenting this such as vital signs, medications, intake and output, bowel movements, etc. the time parameters for a flow sheet can range from minutes to months.

  flowsheets
•  is an integral part of professional patient care rather than something that "takes away from patient care." Adequate documentation facilities, good communications can protect both the patient and the registered nurse

  charting
• ²  is a method of organizing health information in an individual’s record. It is a systematic approach to documentation and is intended to make the client and the client concerns the focus of care.

  focus charting
• ² has been designed by nurses for documentation of frequent or repetitive care and to encourage viewing the client from a positive rather than a negative (problem-only) perspective.

  The focus charting system
• ²  is focused on client and nursing concerns, with the focal point of client status and the associated nursing care.

  charting
• ²  is usually a client problem, concern, or nursing diagnosis, but is NOT a medical diagnosis or a nursing task or treatment (e.g. wound care, indwelling foley catheter insertion, tube feeding) (Doenges, Moorhouse, and Murr, 2010).

  focus
• l Identifies the content or purpose of the narrative entry

  l Separated from the body of the notes (D-A-R) in order to promote easy DATA RETRIEVAL and COMMUNICATION to other health care personnel

  l There may be more than one focus that requires charting at one time

  focus
• Nursing diagnosis


  • May be written as a nursing diagnosis
  • Can be a change in an acute condition
  • A potential problem
  • A change in patient behavior
  • A current individual concern or behavior, e.g. nausea, chest pain
  • A sign or symptom of importance to the nursing diagnosis, medical diagnosis, or treatment plan, e.g. fever, constipation
  • An acute change in an individual's condition, e.g. respiratory distress, seizure
  • A significant event in an individual's care, e.g. change in diet, catheterization, blood transfusion
  • A key word or phrase indicating compliance with standard care or policy, e.g. teaching plan
• l "Assessment phase of the nursing process"

  l It is where the following assessment cues are written:

          - vital signs

          - subjective and objective data (combined)

          - other observations/assessments noticed from the patient

  l SHOULD BE SPECIFIC AND CONCISE

  l Is the subjective and/or objective information supporting the stated focus or describing the observation at the time of a significant event

  l Must be aligned with the FOCUS

  l Should support the FOCUS

  l AVOID MISLEADING DATA.

  data
• ü Describes the nursing interventions

  ü Independent, dependent, collaborative

  ü Basic and perspective

  ü Past, present, or future

  ü Same with NCP proper, BUT it is more specific and concise

  ü Reflects the planning and implementation phase of the nursing process

  ü May include any changes to the plan of care

  action
• ü Reflects the evaluation phase of the nursing process

  ü Describes the patient outcome/response to the interventions or describes how the care plan goals have been attained

  ü TIP: response should answer the FOCUS.

  response
• Focus charting parts

  l Three columns are usually used in Focus Charting for documentation:

          -Date and Time

          -Focus Progress

          -Notes
• PROGRESS NOTES are organized into

  l D (data), A (action), and R (response), referred to as DAR (third column)