Documentation%20and%20Informatics%20in%20Nursing

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Documentation and Informatics in Nursing

• Entry Into Professional Nursing
• NRS 101

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Why Document?

• Accreditation (TJC)
• Reimbursement (DRGs, Medicare)
• Communication (Continuity, education)
• Legal (Not documented, not done)

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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

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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

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Purposes of Records

• Communication
• Legal Documentation
• Financial Billing
• Education
• Research
• Audits-Monitoring

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Guidelines for Quality Documentation Reporting

• Factual
• Accurate
• Complete
• Current
• Organized

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Follow TJC Standards

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

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Types of Documentation

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

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Types of Documentation

• Discharge Summary Forms
• Home Health
• Long Term care
• Computerized

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Narrative

• Traditional type of nursing charting
• Story-like, repetitive
• Time consuming

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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

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POMR Database

• History and physical
• Nursing admission assessment
• On-going assessment
• Labs
• Radiology reports
• Record of each hospital visit

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POMR Problem List

• Holistic needs based on data
• Chronological list on front of chart
• Dates when problem resolved or new problem occurs

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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)

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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

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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

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Critical Pathways

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

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Record Keeping Forms

• Admission Assessment/Nursing history
• Graphic Sheets (Vitals, weights, IO)
• Nursing Kardex
• Medication Administration Records

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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

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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

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Discharge Summary Forms

• DRGs 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)

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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

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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

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Nursing Informatics

• Computer based patient care record
• Assessments, care plans, MARs physician orders
• Maintain confidentiality with pass codes, looking
  at other records
• Nursing Information Systems
• Clinical Information Systems
• Electronic Medical Record

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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

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SBAR Technique for Communication

• S- Situation
• B- Background
• A- Assessment
• R- Recommendation

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End of Shift Report

• Keep professional
• Avoid judgemental language
• Include assistive personnel

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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

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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

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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

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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

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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

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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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