Chapter 3 Documentation

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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:

Documented

communication

Permanent

record for accountability

Legal

record of care

Teaching

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

Traditional

Charting

Narrative

Care given is descriptive

Written in abbreviated story form

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

Database: History and physical, diagnostic

tests, identify and prioritize the health problems on the medical -…

SOAPIER

S – Subjective

O – Objective

A – Assessment

P – Plan

I – Intervention

E – Evaluation

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

Data

Action

Response

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

Assessment

Problem

Intervention

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

Used for any event not consistent with routine

care of a patient

Give only objective information

Do not admit liability or give unnecessary

details

Do not mention the incident report in the

nurse’s notes

24-hr fpatient care reports and acuity forms

Accurate assessment information and

documentation of activities of daily living

Use flow sheets and checklists

Acuity charting

Rates each patient’s severity of illness

Determines efficient staffing patterns

Discharge summary

Pertains to patient’s continued health care

after discharge

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

Property of institution of health care provider

The patient usually does not have immediate

access to full records

To gain access, need to follow established

policy of facility

Lawyers can gain access to chart with the

patient’s written consent

Confidentiality

Patient’s Bill of rights and the law guarantee

the patient’s medical record information-…

Electronic documentation

Institutions have mainframe computers for data

processing tasks

Progressive hospitals’ computers handle provider

orders, pharmacy, laboratory, diagnostic imaging orders, central supply

requests, care planning, documentation and billing

Most efficient computer systems have bedside or

handheld terminals for data entry

Do not share your password used to log into the

computer

Do not leave the computer without logging it off

Follow correct protocol for correcting errors

Be sure stored records have backup files

Do not leave information about patient displayed

on the monitor.

Use of fax machines

Transmit information between offices, hospitals

and other facilities

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

Assessment

NURSING Diagnosis

Plan

identify outcomes

Implementation

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

Pieces of data

Subjective

Verbal statements provided by the patient

Objective

Observable and measureable signs

Can be recorded

Sources of Data

Primary sources

Patient

Most accurate

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

Interview

Biographic data

Reason patient is seeking health care

History of present illness

Past health history

Environmental history

Psychosocial history

Physical exams

Head-to-toe format

Data Clustering

Related cues are grouped together

Attention is then focused on health concerns

that need support and assistance

This assists the identification of nursing

diagnoses

Diagnosis

Identify the type and cause of a health

condition

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”

The LPN/RN may both observe and collect data

RN is responsible for analyzing and interpreting

Once the initial assessment has been completed,

the data requires analysis

Nursing

Diagnosis

Is a type of health problem that can be

identified

Provides the basis for selection of nursing

interventions to achieve outcomes for which the nurse has accountability

North American Nursing Diagnosis Association

(NANDA) in 1990

North Americal Nursing Diagnosis Association

International (NANDA-l) in 1992

Approves the official definition for a nursing

diagnosis

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

Problems that is identified based on a pattern

of related cues, this analysis is given a title or label

Called nursing diagnosis

Provides a concise name for the identified

health problem

Lists of nursing diagnoses are often presented

in alphabetical order

Adjectives add meaning to the nursing diagnosis

Imbalanced, impaired, perceived, etc…

Contributing, etiologic or related factors

Conditions that might be involved in the

development of a problem and are found in the nursing diagnosis handbooks

May become the focus for nursing interventions

Written as “related to” in the actual nursing

diagnosis

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

The nursing diagnosis label from NANDA-l

The contributing/etiologic/related factor

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

The nursing diagnosis label from NANDA-l

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

Ex: 1: posttrauma syndrome

Health Promotion

Nursing Diagnosis

Wellness nursing diagnosis

A clinical judgement about an individual, group

or community in transition from a specific level of wellness to a higher level

of wellness

Written in a 1-part statement

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

Certain physiologic complications that nurse

monitor to detect onset or changes in status

Nurses manage problems using

physician-prescribed and nurse-prescribed interventions to minimize the

complications of the event

Medical Diagnosis

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

Nursing diagnoses address human response to

health problems and life processes

The nurse addresses the patient’s concerns about

the medical problem

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:

Guide the selection of nursing interventions,

selected to promote the achievement of the desired outcome

Outcome statement establishes the measuring

standard that is used to evaluate the effectiveness of the nursing intervention

Alternate

names are:

Patient goal

Patient-centered goal

Objective

Behavioral Objective

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

Nursing

diagnoses are ranked in order of importance for the patient’s life and health

Physiologic

needs come before safety and security (maslow)

Safety

and security needs come before love and belonging needs

Life-

and health-threatening problems are ranked before other types of problems

Actual

problems may be ranked before risk problems

Priorities

change as the patient progresses in the hospitalization; as some problems are

resolved, new ones can be addressed

Selecting nursing interventions

Nursing

interventions

Activities

that promote the achievement of the desired patient outcome

Classified

as physician-prescribed or nurse-prescribed

Physical-prescribed

interventions are ordered by a physician for a nurse or other health care

professional to perform

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

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

Date

Signature of the nurse responsible for the plan

of care

Subject (who will carry out the activity)

Action verb

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

Common components in the educational setting

NANDA-l diagnostic labels

Patient-centered goals and desired patient

outcomes

Nursing interventions

Orders

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

This phase includes ongoing activities of data

collection, prioritization, performance of nursing interventions and

documentation

Both nurse- and physician-prescribed therapy are

included

Documentation is a vital component of the

implementation phase

“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

Review the patient-centered goals/desired

patient outcomes that were established in the planning phase

Reassess the patient to gather data indicating

the patient’s actual response to the nursing intervention

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

The outcome was achieved

The outcome was not achieved

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

Nursing Intervention Classification (NIC) is a

research group working at the university of Iowa to standardize the language

used to organize and describe interventions

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

Assessment

Observe and report significant cues to the

charge nurse or health care provider

Diagnosis

Assist with the determination of accurate

nursing diagnoses

Gather data to confirm or eliminate problems

Planning

Assist with setting priorities

Suggest interventions

Assist with the development of realistic

patient-centered goals/desired patient outcomes

Implementation

Assist with the establishment of priorities

Carry out physician and nursing orders

Evaluate the effectiveness of nursing activities

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

A health care system whose aim is to enhance specific

clinical and financial outcomes withing a specific time frame

Case management

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

Assists the patient and family to receive

required services, coordinates these services and evaluates the adequacy of

these services

Clinical pathways

Miltidisciplinary plan that schedules clinical

intervention over an anticipated time frame for high-risk, high volume, high

cost types of cases

Includes such elements as diagnostic tests,

treatment, activities, medications, consultations, education, daily outcomes

and discharge planning

Variance

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

It addresses the patient’s right to refuse or

accept medical treatment and privacy of all information received from the

patient

Chapter 3 Documentation

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