Documentation and Reporting

Assistant Professor um College of Nursing, AIIMS Patna, Bihar, India
5. Feb 2015

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Documentation and Reporting

  2. Documentation as Communication  Reporting and recording are the major communication techniques used by health care providers.
  3.  DOCUMENTATION serves as a permanent record of client information and care.  REPORTING takes place when two or more people share information about client care, either face to face or by telephone
  4. Documentation as Communication  Documentation is defined as written evidence of: • The interactions between and among health professionals, clients, their families, and health care organizations. • The administration of tests, procedures, treatments, and client education. • The results or client’s response to these diagnostic tests and interventions.
  5. PURPOSES OF CLIENT’S RECORD CHART 1.1. Communication.Communication. Provides efficient and effectiveProvides efficient and effective method of sharing information.method of sharing information. 2.2. Legal Documentation.Legal Documentation. It is admissible as evidenceIt is admissible as evidence in a court of a court of law. 3.3. Research.Research. Provides valuable health-related data forProvides valuable health-related data for research.research. 4.4. Statistics.Statistics. Provides statistical information that canProvides statistical information that can be utilized for planning people’s future utilized for planning people’s future needs. 5.5. Education.Education. Serves as an educational tool forServes as an educational tool for students in health discipline.students in health discipline.
  6. 6.6. Audit & Quality Assurance.Audit & Quality Assurance. Monitors the qualityMonitors the quality of care received by the client and the competenceof care received by the client and the competence of health care givers.of health care givers. 7.7. Planning Client Care.Planning Client Care. Provides data which theProvides data which the entire health team uses to plan care for the client.entire health team uses to plan care for the client. 8.8. Reimbursement.Reimbursement. Provides the basis for decisionsProvides the basis for decisions regarding care to be provided and subsequentregarding care to be provided and subsequent reimbursement to the agency, to cover health-reimbursement to the agency, to cover health- related expenses.related expenses.
  7. Types of Medical Records Components of medical record:-  Patient identification & demographic data  Present complains  Informed consent for treatment & procedure  Admission nursing history  Family history  Physical examination finding  Medical history  Tentative history  Medical diagnosis  Therapeutic order  Treatment given  Medical progress notes  Supportive care given  Reports of diagnosis studies  Final diagnosis  Patient education  Summary of operative procedures  Discharge plan and summary  Any specific instructions
  8. Types of Nursing Records  Admission nursing assessment  Nursing care plan  Kardexes  Pertinent information about patient  Medication with date of order & time of administration  Daily treatment & procedures  Flow chart  Graphic record (TPRBP)  Fluid balance record  Medication  Skin assessment record  Progress notes
  9. Legal and Practice Standards  Informed consent means that the client understands the reasons and risks of the proposed intervention.  Witnessing confirms that the person who signs the consent is competent.
  10. Elements of Effective Documentation  Use of Common Vocabulary  Legibility  Abbreviations and Symbols  Organization  Accuracy  Documenting a Medication Error  Confidentiality  Factual  Complete  Current  Organized
  11. Elements of Effective Documentation  Use of Common Vocabulary • Improves communication and lessens the chance of misunderstanding between members of the health team.
  12. Elements of Effective Documentation  Legibility • Print if necessary. • Do not erase or obliterate writing. • State the reason for the error. • Sign and date the correction.
  13. Concepts of Nursing-NUR 123 Elements of Effective Documentation Correcting a documentation error
  14. Elements of Effective Documentation  Abbreviations and Symbols • Always refer to the facility’s approved listing. • Avoid abbreviations that can be misunderstood.
  15. Elements of Effective Documentation  Organization • Start every entry with the date and time. • Chart in chronological order. • Chart medications immediately after administration. • Sign your name after each entry.
  16. Elements of Effective Documentation  Accuracy • Use descriptive terms to chart exactly what was observed or done. • Use correct spelling and grammar. • Write complete sentences.
  17. Elements of Effective Documentation  Documenting a Medication Error • Document in the nurses’ progress notes: - Name and dosage of the medication - Name of the practitioner who was notified of the error - Time of the notification - Nursing interventions or medical treatment - Client’s response to treatment
  18. Elements of Effective Documentation  Confidentiality • The nurse is responsible for protecting the privacy and confidentiality of client interactions, assessments, and care.c
  19.  Factual:- • A factual record contains descriptive, objective information about what a nurse sees, hears, feels & smells. • An objective description is the result of direct observation & measurement. Elements of Effective Documentation
  20. Elements of Effective Documentation  Complete:- • The information within a recorded entry or a record must be complete, containing appropriate and essential information.
  21.  Current:- • Timely entries are essential in a patient’s ongoing care. Delays in documentation leads to unsafe patient care. • Health organizations use military time to avoid misinterpretation of AM & PM. Elements of Effective Documentation
  22. Current • Following activities should enter timely :- Vital signs, Pain assessment, Administration of medication & treatment, Preparation for diagnostic test or surgery, Change in patient’s status & who notified, Admission, transfer, discharge or death of the patient, Patient’s response to treatment
  23.  Organized:- • Communicate information in a logical order. • It is effective when notes are concise, clear, & to the point Elements of Effective Documentation
  24. TYPES OF Recording
  25. Types of records  Patient clinical records  Individual staff records  Ward records  Administrative records with educational value
  26. Common ward records  Patient clinical records  Staff attendance record  Staff leave record  Staff patient assignment record  Student attendance and patient assignment record  Ward indent record  Ward inventory record  Equipment maintenance record  Ward incidence record  Infection surveillance record  Ward quality indicator record  Ward diet supply record  Emergency drug and crash card record  Patient admission/discharge/shift record
  27. Methods of Documentation  Narrative Charting  Source-Oriented Charting  Problem-Oriented Charting  PIE Charting  Focus Charting  Charting by Exception (CBE)  Computerized Documentation  Case Management with Critical Paths
  28. Methods of Documentation  Narrative Charting (TRADITIONAL CLIENT RECORD) • Describes the client’s status, interventions and treatments; response to treatments is in story format. • Narrative charting is now being replaced by other formats. • Five Basic components of a Traditional Client Record  Admission sheet  Physician’s order sheet  Medical history  Nurse’s notes  Special records and reports (referrals, X-ray, reports, laboratory findings, report of surgery, anesthesia record, flow sheets, vital signs, I&O,
  29. Methods of Documentation  Source-Oriented Charting • Each person or department makes notations in a separate section/s of the client’s chart. • Narrative recording by each member (source) of the health care team on separate records. • Most Traditional • Different disciplines chart on separate forms • Each reader must consult various parts of the record to get a complete picture • Records become bulky • For example the admission department has an admission sheet, nurses use the nurses’ notes, physicians have a physician notes, etc….
  30. Methods of Documentation  Problem-Oriented Medical Record( POMR) /Nurse’s or narrative notes (SOAPIE format) • Uses a structured, logical format called S.O.A.P.  S- SUBJECTIVE. WHAT PT TELLS YOU.  0 – OBJECTIVE. WHAT YOU OBSERVE, SEE.  A – ASSESSMENT. WHAT YOU THINK IS GOING ON BASED ON YOUR DATA.  P – PLAN. WHAT YOU ARE GOING TO DO. CAN ADD TO BETTER REFLECT NURSING PROCESS  I – INTERVENTION (SPECIFIC INTERVENTIONS IMPLEMENTED)  E – EVALUATION. PT RESPONSE TO INTERVENTIONS.  R – REVISION. CHANGES IN TREATMENT.  Uses flow sheets to record routine care.  SOAP entries are usually made at least every 24 hours on any unresolved problem.
  31. Methods of Documentation  PIE Charting • P: Problem statement • I: Intervention • E: Evaluation Example: • P: Patient reports pain at surgical incision as 7/10 on 0 to 10 scale • I : Given morphine 1mg IV at 23:35. • E : Patient reports pain as 1/10 at 23:55.
  32. Methods of Documentation  Focus Charting (DAR) • A method of identifying and organizing the narrative documentation of all client concerns. • Uses a columnar format within the progress notes to distinguish the entry from other recordings in the narrative notes (Date & Time, Focus, Progress note)  DATA – SUBJECTIVE OR OBJECTIVE THAT SUPPORTS THE FOCUS (CONCERN)  ACTION – NURSING INTERVENTION  RESPONSE – PT. RESPONSE TO INTERVENTION Ex:  D – COMPLAINING OF PAIN AT INCISION SITE , PS: 7/10  A – REPOSITIONED FOR COMFORT. DEMEROL 50MG IM GIVEN.  R – STATES A DECREASE IN PAIN, “FEELS MUCH BETTER.”
  33. Example of focus charting Date & Time Focus: Progress notes: 09.Sep.2013 Acute pain related to surgical incision D: Patient reports pain as 7/10 on 0 to 10 scale. A: Given morphine 1mg IV at 2335. R: Patient reports pain as 1/10 at 2355.
  34. Methods of Documentation  Charting by Exception (CBE) • The nurse documents only deviations from pre-established norms (document only abnormal or significant findings). • Avoids lengthy, repetitive notes.
  35. Methods of Documentation  Computerized Documentation • Increases the quality of documentation and save time. • Increases legibility and accuracy. • Facilitates statistical analysis of data.
  36. Methods of Documentation  Case Management Process • A methodology for organizing client care through an illness, using a critical pathway. • A critical pathway is a multidisciplinary plan or tool that specifies assessments, interventions, treatments and outcomes of health related problems a cross a time line.
  37. Forms for Recording Data  Kardex  Flow Sheets  Nurses’ Progress Notes  Discharge Summary
  38. Forms for Recording Data  The Kardex is used as a reference throughout the shift and during change-of-shift reports. • Client data (e.g name, age, admission date, allergy) • Medical diagnoses and nursing diagnoses • Medical orders, list of medications • Activities, diagnostic tests, or specific data on the pt.
  39. Provides a concise method of organizing andProvides a concise method of organizing and recording data about a client, making informationrecording data about a client, making information readily accessible to all members of the health team.readily accessible to all members of the health team. It is a series of flip cards usually kept in portable fileIt is a series of flip cards usually kept in portable file It is a way to ensure continuity of care from one shiftIt is a way to ensure continuity of care from one shift to another and from one day to the another and from one day to the next. It is a tool for change – of – shift report. ButIt is a tool for change – of – shift report. But endorsement is not simply reciting content of kardex.endorsement is not simply reciting content of kardex. Health care needs of the client is still primary basis forHealth care needs of the client is still primary basis for endorsement.endorsement.
  40.  Usually include the following data:Usually include the following data: • Personal dataPersonal data • Basic needsBasic needs • AllergiesAllergies • Diagnostic testsDiagnostic tests • Daily nursing proceduresDaily nursing procedures • Medications and intravenous (IV) therapy, bloodMedications and intravenous (IV) therapy, blood transfusionstransfusions • Treatments like oxygen therapy, steam inhalation,Treatments like oxygen therapy, steam inhalation, suctioning, change of dressings, mechanical ventilation.suctioning, change of dressings, mechanical ventilation.  Entries usually written in pencil. This implies the kardex isEntries usually written in pencil. This implies the kardex is for planning and communication purpose only.for planning and communication purpose only.
  41. Forms for Recording Data Flow Sheets  The information on flow sheets can be formatted to meet the specific needs of the client. (e.g.: graphic sheets for vital signs, intake & output record, skin assessment record). Nurses’ Progress Notes  Used to document the client’s condition, problems and complaints, interventions, responses, achievement of outcomes.
  42. Forms for Recording Data  Discharge Summary • Client’s status at admission and discharge. • Brief summary of client’s care. • Interventions and education outcomes. • Resolved problems and continuing need. • Referrals. • Client instructions.
  43. Reporting
  44. Reporting  Verbal communication of data regarding the client’s health status, needs, treatments, outcomes, and responses  Reporting is based on the nursing process.
  45. Reporting :- Types  Summary / Hand-Off Reports  Walking Rounds Reports  Incident or Occurrence Reports  Telephone Reports and Orders
  46. Reporting Summary / Hand-Off Reports  Commonly occur at change of shift (or when client care is transfers to another health care provider). Walking Rounds Reports  Occur in the client’s room  Include Nursing, physician, interdisciplinary team. Incident or Occurrence Reports  Used to document any unusual occurrence or accident in the delivery of client care.
  47. Reporting Telephone Reports and Orders • Provide clear accurate and concise information • The nurse documents telephone report by including the following information: - when the call was made - who made the call/report - who was called - to whom information was given - what information was given - what information was received
  48.  Only RN’s may receive telephone orders The order need to be verified by reporting it clearly and precisely. The order should be countersigned by the physician who made the order within the prescribed period of time (within 24 hours)
  49. 16-49 Documenting a Telephone Order
  50. GENERAL DOCUMENTATION GUIDELINES * Ensure that you have the correct client record or chart. * Document as soon as the client encounter is concluded to ensure accurate recall of data. * Date and time of each entry. * Sign each entry with your full legal name and with your professional credentials. * Do not leave space in between entries. * If an error is made while documenting, use a single line to cross out the error, then date, time and sign the correction * Never change another person’s entry even if it is incorrect * Use quotation marks to indicate direct client responses. * Document in chronological order * Use permanent ink * Document all telephone calls that you received that are related to client’s case.
  51. Minimizing legal liability through effective record keeping  Date & time  Timing  Legibility  Permanence  Correct spelling  Signature  Accuracy  Sequence  Appropriateness  Completeness  Conciseness  Accepted terminology 24 Hour Time
  52. CORRECTING ERRORS  IF YOU SPILL SOMETHING ON THE CHART, DO NOT DISCARD NOTES. RECOPY, PUT ORIGINAL AND COPIED SHEETS IN CHART. WRITE “COPIED” ON COPY.  DO NOT SCRIBBLE OUT CHARTING.  AVOID USING “ERROR” OR “WRONG PATIENT” WHEN MAKING CORRECTION.  FOLLOW YOUR FACILITIES POLICY.  DO NOT ALTER CHARTING, IT IS A LEGAL DOCUMENT. *Correct errors by drawing a single horizontal line *through the error *Write the word error above the line, then sign *your signature *No ink eradication, erasures or use of occlusive materials.
  53. Thank you forThank you for your attentionyour attention
  54. Questions 1. Document is a………. evidence. 2. Use of Common Vocabulary Improves communication and lessens the chance of ………… between members of the health team. 3. Chart should be done in ……….. order. 4. TRADITIONAL CLIENT RECORD also called………………………. 5. Start every entry with………. 6. What is SOAPIE elaborate. 7. Health organizations use…….. time to avoid misinterpretation. 8. What is DAR 9. What is CBE 10. Kardex is a series of ………… usually kept in portable fileseries of ………… usually kept in portable file
  55. ANSWERS 1. Written 2. Misunderstanding 3. Chronological 4. Narrative Charting 5. Date and time 6. S- subjective, 0 – OBJECTIVE, A – ASSESSMENT, P – PLAN, I – INTERVENTION, E – EVALUATION, R – REVISION. 7. Military 8. Data , action , response 9. Charting by Exception 10.10. Flip cardsFlip cards