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Documentation and Informatics in Nursing

Documentation and Informatics in Nursing. Entry Into Professional Nursing NRS 101. Why Document?. Accreditation (TJC) Reimbursement (DRG’s, Medicare) Communication (Continuity, education) Legal (Not documented, not done). Multi-Disciplinary Communication. Reports-Oral: End of shift

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Documentation and Informatics in Nursing

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

  2. Why Document? • Accreditation (TJC) • Reimbursement (DRG’s, 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, I&O) • 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 • DRG’s 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, MAR’s physician orders • Maintain confidentiality with pass codes, looking at other records • Nursing Information Systems • Clinical Information Systems • Electronic Medical Record

  25. 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

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

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

  28. 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

  29. 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

  30. 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

  31. 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

  32. 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

  33. 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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