FUNDAMENTALS

• Purposes of nursing documentation

  • Reimbursement
  • Education
  • Accreditation
• Reimbursement


  Patient records are used to demonstrate to payers that patients received the care for which reimbursement is being sought
• Education


  Health care students use medical record as tool to learn about disease processes, nursing diagnoses, complications and interventions
• Principles of Effective Documentation

  • Nursing documentation should be patient centered
  • Nursing documentation must contain the actual work of nurses including education and psychosocial support
  • Nursing documentation is written to reflect the objective clinical judgement of the nurse
  • Nursing documentation must be presented in a logical and sequential manner
  • Nursing documentation should be written contemporaneously, or as events occur
  • Nursing documentation should record variances in care within and beyond the health care record
  • Nursing documentation should fulfill legal requirements
• Source-Oriented Charting


  Narrative charting used, each healthcare group keeps data on its own separate form, data are fragmented, making it difficult to track problems chronologically with input from different groups of professionals
• Narrative Charting


  Traditional method of nursing documentation, chronologic account in paragraphs describing client status, interventions and treatments, and client's response
• Problem-Oriented Medical Records


  Data arranged according to client problem, less efficient because assessments and interventions must be repeated for more than one problem, four basic components: Data Base, Problem List, Plan of Care, Progress Notes – Uses SOAP, SOAPIE, SOAPIER
• Progress Notes


  Chart entry made by all health professionals involved in a client's care, includes: S - subjective data, O - objective data, A - assessment data, P - plan, I - implementation, E - evaluation, R - revision
• Pie Charting


  Plan of care is incorporated into the progress notes in which problems are identified by number, P - problem statement, I - intervention, E - evaluation
• Focus Charting


  Goal is to bring the focus of care back to the patient & the patient's concerns & strengths, D - Data-assessment phase, A - Action-planning and implementing phase, R - Response-evaluation phase
• Chart by Exception


  Only abnormal or significant findings or exceptions to norms are recorded in a narrative form, presumes that unless documented otherwise, all standardized protocols have been met and no further documentation is needed, examples include flow sheets
• Computerized Documentation


  Use of computers to store the client's database, new data, create and revise care plans and document client's progress
• Case Management


  A multidisciplinary approach to planning and documenting client care, using critical pathways which identify the outcomes that certain groups of clients are expected to achieve on each day of care, along with the interventions necessary for each day
• Critical Pathway


  Comprehensive pre-printed standard plan reflecting ideal course of treatment for diagnosis or procedure, especially with relatively predictable outcomes, a goal that is not met is called a variance
• Nurse's Progress Notes


  Document client's condition, problems, complaints, interventions, and client's response to interventions
• Discharge Summary


  Starts during admission, summarizes the reason for treatment, significant findings, the procedures performed & treatment rendered
• KARDEX and Patient Care Summary


  Kardex is used to communicate conveniently and concisely the plan of nursing care for each patient
• Guideline for Reporting Client Data

  Should be concise, including pertinent information but no extraneous detail
• Change-of-SHIFT Report / Endorsement Report

  Report given by a primary nurse to the nurse replacing him or her or by the charge nurse to the nurse who assumes responsibility for continuing care of the patient, uses SBAR format (Situation, Background, Assessment, Recommendation)
• Walking (Nursing) Rounds


  Two or more nurses visit selected clients at bedside to obtain information that will help plan nursing care
• Telephone Orders


  Must be repeated back to the physician, transcribed on an order sheet, and countersigned by the primary care provider within a time described by agency policy
• Incident Report


  A tool used to document the occurrence of anything out of the ordinary that results in or has the potential to result in harm to a patient, employee, or visitor
• Body Alignment


  Refers to the relationship of body parts to one another
• Balance


  Directly related to alignment and achieved when center of gravity is low, stable (wide) base of support, and vertical line from center of gravity through base of support
• Line of Gravity


  Imaginary vertical line which goes through center of body
• Center of Gravity


  Point at which all of the mass of an object is centered; in the adult, who is in a standing position it is in the pelvis
• Base of Support


  Foundation of an object, to stabilize: lower your center of gravity and broaden your base of support
• Body mechanics


  The coordinated efforts of the musculoskeletal & nervous system to maintain balance, posture & body alignment during lifting, bending, moving & performing ADL's, correct body alignment reduces strain on musculoskeletal structures, maintains muscle tone, & contributes to balance
• Principles of Body Mechanics

  • Use wide base of support
  • Keep center of gravity low
  • Keep line of gravity passing through base of support
  • Face direction of movement when possible
  • Roll, pull, push objects rather than lift
  • Use largest & strongest muscles
  • Keep object close to center of gravity
  • Reduce area of contact
• Loss


  Occurs when a valued person, object, or situation is changed or made inaccessible
• Types of Loss


  • Actual Loss
  • Perceived loss
  • Anticipated loss
  • Physical Loss
  • Psychological loss
  • Maturational Loss
  • Situational Loss
• Grief


  Grief occurs with loss caused by separation as well as with loss caused by death, bereavement is the state of grieving during which a person goes through grief reaction, mourning is the period of acceptance of loss and grief during which the person learns to deal with the loss
• Kubler-Ross Grief and Death Reactions

  • Denial
  • Anger
  • Bargaining
  • Depression
  • Acceptance
• Five Principles of Palliative Care

  • Respects the goals, likes and choices of the dying patient
  • Looks after medical, emotional, social, and spiritual needs of the dying person
  • Supports the needs of the family members
  • Helps patient gain access to needed healthcare providers and appropriate settings
  • Builds ways to provide excellent end of life care
• Advanced Directives


  Living wills provide specific instructions about the kinds of health care that should be provided or foregone in a particular situation, durable power of attorney appoints an agent the person trusts to make decisions in the event of the appointing person's subsequent incapacity
• Factors that influence Grief and Dying

  • Developmental
  • Family
  • Socioeconomic
  • Cultural influences
  • Religion
  • Cause of Death
• Living wills


  Provide specific instructions about the kinds of health care that should be provided or foregone in a particular situation
• Durable power of attorney


  Appoints an agent the person trusts to make decisions in the event of the appointing person's subsequent incapacity
• Factors that influence Grief and Dying

  • Developmental
  • Family
  • Socioeconomic
  • Cultural influences
  • Religion
  • Cause of Death
• Developmental


  Death of a parent can retard a child's development. Children may not understand death but their sense of loss is great.