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					Documentation and
Informatics in Nursing


Entry Into Professional Nursing
NRS 101
Why Document?

 Accreditation (TJC)


 Reimbursement (DRG’s, Medicare)


 Communication (Continuity, education)


 Legal (Not documented, not done)
Multi-Disciplinary Communication

 Reports-Oral: End of shift
          Written
 Record-Chart: Permanent, legal,
  healthcare management on-going
  account
 Healthteam: All disciplines, nursing,
  social workers, discharge planning PT,
  OT, RT
Documentation

 Anything written or printed that is relied
  on as a record of proof for authorized
  persons

 Reflects quality of care


 Provides evidence of healthcare team
  members care rendered
Purposes of Records

 Communication
 Legal Documentation
 Financial Billing
 Education
 Research
 Audits-Monitoring
Guidelines for Quality
Documentation & Reporting
 Factual


 Accurate


 Complete


 Current


 Organized
Follow TJC Standards

 Physical
 Psychosocial
 Environmental
 Self-care
 Client education
 Discharge Planning
 Evaluation of outcomes
 Nursing Process oriented
Types of Documentation

 Narrative
 POMR
 Source records
 Charting by Exception
 Critical Pathways
 Record Keeping Forms
 Acuity Recording Systems
 Standardized Care Plans
 Discharge Summary Forms
Types of Documentation

 Discharge Summary Forms
 Home Health
 Long Term care
 Computerized
Narrative

 Traditional type of nursing charting
 Story-like, repetitive
 Time consuming
Problem-Oriented Medical
Records
 Data organized by problem or diagnosis
 Ideally all healthcare team members can
  contribute to list
 Coordinated plan of care
 POMR Components: Database, problem
  list, NCP, progress notes
POMR Database

 History and physical
 Nursing admission assessment
 On-going assessment
 Labs
 Radiology reports
 Record of each hospital visit
POMR Problem List

 Holistic needs based on data


 Chronological list on front of chart


 Dates when problem resolved or new
  problem occurs
POMR Progress Notes

 SOAP/SOAPIE Notes: Subjective data,
  objective data, assessment, plan,
  intervention, evaluation
 PIE Charting: Problem-Intervention-
  Evaluation
 Focus Charting/DAR-Data (subjective
  and objective) Action (intervention)
  Response of Client (evaluation)
Source Records

 Chart is so organized that each
  discipline has own section to record data
 Sections can be easily located
 Disadvantage: Not organized by client
  problems
 Narrative style notes
Charting by Exception

 Streamlines documentation
 Reduces repetition, saves time
 Short version to document normals, routine
    care items
   Based on established standards
   Progress note when standard not met
   Assumes all standards are met unless
    otherwise charted
   Exceptions must be noted
Critical Pathways

 Multi-disciplinary care plans used in case
  management
 Key interventions, expected outcomes,
  time frame
 Variances charted and analyzed
Record Keeping Forms

 Admission Assessment/Nursing history


 Graphic Sheets (Vitals, weights, I&O)


 Nursing Kardex


 Medication Administration Records
Acuity Reporting Systems

 Staffing patterns based on acuity of
  patients
 Numeric rating for interventions
 Varies per unit and standard
 Update every 24 hours and justify
Standardized Care Plans

 Pre-printed established guidelines
 Based on health problems
 Need to modify based on individual
  assessment, update and use judgement
 Standards of care are known, promotes
  continuity, staff knowledge
Discharge Summary Forms

 DRG’s encourage early discharge, but
  must ensure good patient outcomes
 Necessary resources, Client and family
  involved in process
 Begins at admission
 Client education integral to process
  (food-drug interactions, rehab referrals,
  medications, disease process)
Home Health

 Medicare/Medicaid Guidelines
 50% of nursing time is documentation
 Care witnessed by client and family
 Good assessment skills
 Health care team focused
 Direct care in home
 Use of laptops for documentation
Long Term Care

 Residents not clients
 Governmental agencies: Many
  standards and policies regarding
  assessments, individualized plan of care
 Dept. of Health in each state determines
  frequency of charting
 Skilled Nursing Units
Nursing Informatics

 Computer based patient care record
 Assessments, care plans, MAR’s
  physician orders
 Maintain confidentiality with pass codes,
  looking at other records
 Nursing Information Systems
 Clinical Information Systems
 Electronic Medical Record
Reporting

 Oral or written
 Change of shift
 Nurse to nurse
 Promotes continuity
 Report on client health status, care
  required for next shift, significant facts,
  head to toe assessment, pertinent labs,
  priority needs, treatments, family issues
SBAR Technique for
Communication
 S- Situation
 B- Background
 A- Assessment
 R- Recommendation
End of Shift Report

 Keep professional
 Avoid judgemental language
 Include assistive personnel
Telephone Reports

 Inform physician of changes
 Client transfers to different units
 Result reports from lab or radiology
 Client transfers to different institutions
 Info needed: When call made, to whom,
  info given
 Keep clear, accurate, repeat info if
  necessary
Telephone Orders

 Physician to RN
 Physician must co-sign within 24 hours
 Nightime, emergency orders
 Guidelines and procedure per institution
 Be careful, precise and accurate with
  order
 Write order as said by physician, repeat
  it back
Transfer Reports

 Unit to unit report
 Phone or in person
 All pertinent data about patient
 Send all belongings with client
 Review clothing/belonging list prior to
  transfer
 Transfer Sheet Documentation
Incident Reports

 Any event not considered routine (falls,
    needlesticks, med errors, accidental omissions,
    visitor injury)
   Risk Management will analyze trends
   Changes in policy/procedure, educational
    programs may be related to findings
   Notify supervisor, physician of incident
   Nurse who witnesses makes out report
   Do not assign blame, be objective, facts only
Tips for Documentation

 Accurate, timely, thorough, factual, neat
 Use only approved abbreviations & terms
 Blue or black ink
 Always get and give report
 Focus on a team approach
 Date, time each entry, do not block chart
 Document in a timely fashion
 Follow the nursing process
 Use appropriate forms
Documentation Tips

 Correct errors promptly, using proper
  technique
 Write on every line, leave no spaces
 Sign each entry with full signature and
  correct title
 Follow institution policy and procedure
  for charting
 Military vs standard time

				
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