· 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

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Chapter 3 FON book Documentation