Download - Fund (3)7 Document 2010
-
8/6/2019 Fund (3)7 Document 2010
1/33
Elsevier items and derived items 2009 by Saunders, an imprint of Elsevier Inc.
Documentation of Nursing Care
1
-
8/6/2019 Fund (3)7 Document 2010
2/33
Th eory` Identify t h ree purposes of documentation` Correlate nursing process wit h th e process of c h arting` Discuss maintaining confidentiality of medical records` Compare and contrast 5 main met h ods of written
documentation` Compare and contrast t h e five main met h ods of written
documentation` List legal guidelines for recording on medical records` Relate t h e approved way to correct entries in medical records
th at were made in error
2
-
8/6/2019 Fund (3)7 Document 2010
3/33
Clinical Practice` Correctly make entries on a daily care flow s h eet` Use a systematic way of c h arting to ensure t h at all
pertinent informationh
as been included` Document t h e c h aracterization of a sign or symptoms in
a sample c h arting situation` Apply t h e general c h arting guidelines in t h e clinical
setting
3
-
8/6/2019 Fund (3)7 Document 2010
4/33
` Provides a written record of t h e h istory, treatment,care, and response of t h e patient w h ile under t h e
care of a h ealt h care provider ` Is a guide for reimbursement of costs of care` May serve as evidence of care in a court of law` S h ows t h e use of t h e nursing process`
Provides data for quality assurance studies
4
-
8/6/2019 Fund (3)7 Document 2010
5/33
` Is a legal record t h at can be used as evidenceof events t h at occurred or treatments given
` Contains observations by t h e nurses about t h epatients condition, care, and treatmentdelivered
` S h ows progress toward expected outcomes
5
-
8/6/2019 Fund (3)7 Document 2010
6/33
` W ritten nursing care plan or interdisciplinarycare plan is framework for documentation
` Ch arting organized by nursing diagnosis or problem` Implementation of eac h intervention
documented on flow s h eet or in nursing notes` Evaluation statements placed in nurses
notes and indicate progress toward t h e statedexpected outcomes and goals
6
-
8/6/2019 Fund (3)7 Document 2010
7/33
` Contains data about patients stay in a facility` Only h ealt h care professionals directly caring for
th e patient, or t h ose involved in researc h or teac h ing, s h ould h ave access to t h e c h art` Patient information s h ould not be discussed wit h
anyone not directly involved in t h e patients care
7
-
8/6/2019 Fund (3)7 Document 2010
8/33
` Source-oriented (narrative) c h arting` Problem-oriented medical record (POMR)
ch arting` Focus c h arting` Ch arting by exception` Computer-assisted c h arting` Case management system c h arting
8
-
8/6/2019 Fund (3)7 Document 2010
9/33
` Organized according to source of information` Separate forms for nurses, p h ysicians, dietitians,
and ot h er h ealt h care professionals to documentassessment findings and plan t h e patient's care` Narrative c h arting requires documentation of
patient care in c h ronologic order
9
-
8/6/2019 Fund (3)7 Document 2010
10/33
` AdvantagesInformation in c h ronologic order Documents patients baseline condition for eac h s h iftIndicates aspects of all steps of t h e nursing process
` DisadvantagesDocuments all findings: makes it difficult to separatepertinent from irrelevant informationRequires extensive c h arting time by t h e staff Discourages p h ysicians and ot h er h ealt h teammembers from reading all parts of t h e c h art
10
-
8/6/2019 Fund (3)7 Document 2010
11/33
11
-
8/6/2019 Fund (3)7 Document 2010
12/33
` Focuses on patient status rat h er t h an onmedical or nursing care
` Five basic parts: database, problem list, plan,progress notes, and disc h arge summary
12
-
8/6/2019 Fund (3)7 Document 2010
13/33
` AdvantagesDocuments care by focusing on patients problemsPromotes problem-solving approac h to careImproves continuity of care and communication bykeeping relevant data all in one place
Allows easy auditing of patient records in evaluatingstaff performance or quality of patient careRequires constant evaluation and revision of careplanReinforces application of t h e nursing process
13
-
8/6/2019 Fund (3)7 Document 2010
14/33
` DisadvantagesResults in loss of c h ronologic c h arting
More difficult to track trends in patient statusFragments data because more flow s h eets required
14
-
8/6/2019 Fund (3)7 Document 2010
15/33
` Pproblem identification` Iinterventions` Eevaluation
` Follows t h e nursing process and uses nursingdiagnoses w h ile placing t h e plan of care wit h inth e nurses progress notes
` TH IS IS TH E TY PE OF C H AR T ING W ET EAC H Y OU T O DO BASED ON ICPs mixedin wit h focus c h arting.
15
-
8/6/2019 Fund (3)7 Document 2010
16/33
16
-
8/6/2019 Fund (3)7 Document 2010
17/33
` Directed at nursing diagnosis, patient problem,concern, sign, symptom, or event
` Th ree components:D: data, A : action, R : response (DAR)x O R D: data, A : action, E : evaluation (DAE)
17
-
8/6/2019 Fund (3)7 Document 2010
18/33
` AdvantagesCompatible wit h th e use of t h e nursing processS h ortens c h arting time: many flow s h eets,ch ecklistsNot limited to patient problems or nursingdiagnoses
` DisadvantagesIf database insufficient, patient problems missedDoesnt ad h ere to c h arting wit h th e focus onnursing diagnoses and expected outcomes
18
-
8/6/2019 Fund (3)7 Document 2010
19/33
19
-
8/6/2019 Fund (3)7 Document 2010
20/33
` Based on t h e assumption t h at all standards of practice are carried out and met wit h a normal
or expected response unless otherwisedocumented
` A long h and note is written only w h en t h estandardized statement on t h e form is not met
20
-
8/6/2019 Fund (3)7 Document 2010
21/33
` AdvantagesH igh ligh ts abnormal data and patient trends
Decreases narrative c h arting timeEliminates duplication of c h arting` Disadvantages
Requires detailed protocols and standardsRequires staff to use unfamiliar met h ods of recordkeeping and recordingNurses so used to not c h arting t h at important datasometimes omitted
21
-
8/6/2019 Fund (3)7 Document 2010
22/33
` Electronic h ealt h record (E H R)Computerized record of patient's h istory and careacross all facilities and admissions
` Computerized provider order entry (CPOE)Provides efficient work flow
Automatically routs orders to appropriate clinicalareas
22
-
8/6/2019 Fund (3)7 Document 2010
23/33
` Documentation done as interventions areperformed using bedside computers
` Variations depending on t h e system` Some produce flow s h eets wit h nursing
interventions and expected outcomes` Ot h ers use a POMR format to produce a
prioritized problem list
23
-
8/6/2019 Fund (3)7 Document 2010
24/33
` AdvantagesDate and time of t h e notation automatically recordedNotes always legible and easy to readQuick communication among departments about patient needsMany providers h ave access to patients information at onetimeCan reduce documentation timeElectronic records can be retrieved very quicklyReimbursement for services rendered is faster and completeCan provide a complete record of t h e patient's medical h istoryCan reduce errors
24
-
8/6/2019 Fund (3)7 Document 2010
25/33
` DisadvantagesSop h isticated security system needed to prevent
unaut h orized personnel from accessing recordsInitial costs are considerableImplementation can take a long timeSignificant cost and time to train staff to use t h e
systemComputer downtime can create problems of input,access, transfer of information
25
-
8/6/2019 Fund (3)7 Document 2010
26/33
` A met h od of organizing patient care t h roug h anepisode of illness so clinical outcomes are
ac h ieved wit h in an expected time frame and ata predictable cost
` A clinical pat h way or interdisciplinary care plantakes t h e place of t h e nursing care plan
26
-
8/6/2019 Fund (3)7 Document 2010
27/33
` Be specific and definite in using words or ph rases t h at convey t h e meaning you wis h
expressed` W ords t h at h ave ambiguous meanings and
slang s h ould not be used in c h arting
27
-
8/6/2019 Fund (3)7 Document 2010
28/33
` Sentences not necessary Articles (a, an, t h e) may be omittedTh
e word patient omitted wh
en subject of sentence` Abbreviations, acronyms, symbols acceptable to
th e agency used to save time and space` Ch oose w h ich be h aviors and observations are
notewort h y
28
-
8/6/2019 Fund (3)7 Document 2010
29/33
` If writing not legible, misperceptions can occur ` Completeness is more important t h an brevity
(see Boxes 7-1 t h roug h 7-3 for c h artingguidelines)` Record information about t h e patients needs
and problems and specify nursing care given for th ose needs or problems
29
-
8/6/2019 Fund (3)7 Document 2010
30/33
` Not a part of t h e permanent medical record` A quick reference for current information about
th e patient and ordered treatments` Usually consists of a folded card for eac h patient
in a h older t h at can be quickly flipped from onepatient to anot h er
30
-
8/6/2019 Fund (3)7 Document 2010
31/33
` Room number, patient name, age, sex, admittingdiagnosis, p h ysicians name
` Date of surgery` T ype of diet ordered` Sc h eduled tests or procedures` Level of activity permitted` Notations on tubes, mac h ines, ot h er equipment in use` Nursing orders for assistive or comfort measures` List of medications prescribed by name` IV fluids ordered
31
-
8/6/2019 Fund (3)7 Document 2010
32/33
` h ttp://www.twlk.com/ h ealt h care/422-0002.pdf
32
-
8/6/2019 Fund (3)7 Document 2010
33/33
` Scenerio: 1 day post-op knee surgery` Pain r/t surgical manipulation of rt knee AEB subj
ye h it h urts even w h en I bend it. obj c/o pain 5/10 atrest and 8/10 wit h ROM.
` (eac h clinical group come up wit h one intervention)
` I1(FMC-assess)` I2(MMC AMprovide)` I3(MMC PM teac h )
33