Chapter 17Documenting, Reporting, and

Conferring

Characteristics of Effective DocumentationCharacteristics of Effective Documentation

• Consistent with professional and agency standards

• Complete

• Accurate

• Concise

• Factual

• Organized and timely

• Legally prudent

• Confidential

What is Confidential?What is Confidential?

• All information about patients written on paper, spoken aloud, saved on computer

– Name, address, phone, fax, social security

– Reason the person is sick

– Treatments patient receives

– Information about past health conditions

Patient RightsPatient Rights

• See and copy their health record

• Update their health record

• Get a list of disclosures

• Request a restriction on certain uses or disclosures

• Choose how to receive health information

Policy for Receiving Verbal Orders in an EmergencyPolicy for Receiving Verbal Orders in an Emergency

• Record the orders in patient’s medical record.

• Read back the order to verify accuracy.

• Date and note the time orders were issued in emergency.

• Record V.O., the name of the physician followed by nurse’s name and initials.

Policy for Physician Review of Verbal Orders Policy for Physician Review of Verbal Orders

• Review orders for accuracy.

• Sign orders with name, title, and pager number.

• Date and note time orders signed.

Duties of RN Receiving a Telephone OrderDuties of RN Receiving a Telephone Order

• Record the orders in patient’s medical record.

• Read order back to practitioner to verify accuracy.

• Date and note the time orders were issued.

• Record T.O., full name and title of physician or nurse practitioner who issued orders.

• Sign the orders with name and title.

Purposes of Patient RecordsPurposes of Patient Records

• Communication with other healthcare professionals

• Record of diagnostic and therapeutic orders

• Care planning

• Quality of care reviewing

• Research

• Decision analysis

• Education

• Legal and historical documentation

• Reimbursement

Purposes of Recording DataPurposes of Recording Data

• Facilitate patient care

• Serve as a financial and legal record

• Help in clinical research

• Support decision analysis

Methods of DocumentationMethods of Documentation

• Source-oriented records

• Problem-oriented medical records

• PIE charting

• Focus charting

• Charting by exception

• Case management model

• Computerized records

Case Management ModelsCase Management Models

• Collaborative pathways

• Variance charting

Major Components of POMRMajor Components of POMR

• Defined database

• Problem list

• Care plans

• Progress notes

Formats for Nursing DocumentationFormats for Nursing Documentation

• Initial nursing assessment

• Kardex and patient care summary

• Plan of nursing care

• Critical collaborative pathways

• Progress notes

• Flow sheets

• Discharge and transfer summary

• Home healthcare documentation

• Long term care documentation

Types of Flow SheetsTypes of Flow Sheets

• Graphic record

• 24-hour fluid balance record

• Medication record

• 24-hour patient care records and acuity charting forms

Medicare Requirements for Home HealthcareMedicare Requirements for Home Healthcare

• Patient is homebound and still needs skilled nursing care.

• Rehabilitation potential is good (or patient is dying).

• The patient’s status is not stabilized.

• The patient is making progress in expected outcomes of care.

Four Basic Components of RAI (Resident Assessment Tool)Four Basic Components of RAI (Resident Assessment Tool)

• Minimum data set

• Triggers

• Resident assessment protocols

• Utilization guidelines

Benefits of RAIBenefits of RAI

• Residents respond to individualized care

• Staff communication becomes more effective

• Resident and family involvement increases

• Documentation becomes clearer

Change of Shift ReportChange of Shift Report

• Basic identifying information about each patient

• Current appraisal of each patient’s health status

– Changes in medical conditions and patient response to therapy

– Where patient stands in relation to identified diagnoses and goals

• Current orders (nurse and physician)

• Summary of each newly admitted patient

• Report on patient transferred or discharged

Methods of ReportingMethods of Reporting

• Face-to-face meetings

• Telephone conversations

• Messengers

• Written messages

• Audio-taped messages

• Computer messages

Conferring About CareConferring About Care

• Consultations and referrals

• Nursing and interdisciplinary team care conferences

• Nursing care rounds