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

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Title: Documentation%20and%20Informatics%20in%20Nursing


1
Documentation and Informatics in Nursing
  • Entry Into Professional Nursing
  • NRS 101

2
Why Document?
  • Accreditation (TJC)
  • Reimbursement (DRGs, Medicare)
  • Communication (Continuity, education)
  • Legal (Not documented, not done)

3
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

4
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

5
Purposes of Records
  • Communication
  • Legal Documentation
  • Financial Billing
  • Education
  • Research
  • Audits-Monitoring

6
Guidelines for Quality Documentation Reporting
  • Factual
  • Accurate
  • Complete
  • Current
  • Organized

7
Follow TJC Standards
  • Physical
  • Psychosocial
  • Environmental
  • Self-care
  • Client education
  • Discharge Planning
  • Evaluation of outcomes
  • Nursing Process oriented

8
Types of Documentation
  • Narrative
  • POMR
  • Source records
  • Charting by Exception
  • Critical Pathways
  • Record Keeping Forms
  • Acuity Recording Systems
  • Standardized Care Plans
  • Discharge Summary Forms

9
Types of Documentation
  • Discharge Summary Forms
  • Home Health
  • Long Term care
  • Computerized

10
Narrative
  • Traditional type of nursing charting
  • Story-like, repetitive
  • Time consuming

11
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

12
POMR Database
  • History and physical
  • Nursing admission assessment
  • On-going assessment
  • Labs
  • Radiology reports
  • Record of each hospital visit

13
POMR Problem List
  • Holistic needs based on data
  • Chronological list on front of chart
  • Dates when problem resolved or new problem occurs

14
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)

15
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

16
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

17
Critical Pathways
  • Multi-disciplinary care plans used in case
    management
  • Key interventions, expected outcomes, time frame
  • Variances charted and analyzed

18
Record Keeping Forms
  • Admission Assessment/Nursing history
  • Graphic Sheets (Vitals, weights, IO)
  • Nursing Kardex
  • Medication Administration Records

19
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

20
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

21
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)

22
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

23
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

24
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

25
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26
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27
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

28
SBAR Technique for Communication
  • S- Situation
  • B- Background
  • A- Assessment
  • R- Recommendation

29
End of Shift Report
  • Keep professional
  • Avoid judgemental language
  • Include assistive personnel

30
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

31
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

32
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

33
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

34
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

35
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

36
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