nursing documentation (NCI) – Flashcards

provides written record of history treatment care response of patient while under care of healthcare provider. Permanent record of accountability purposes

Serve as evidence in court of law (legal record of care- may protect or hurt you)

Teaching purpose (how to document appropriately) research and data collection( research project assurance)

Used in licensing and accreditation Justifies reimbursment Demonstrates compliance with Nurse Practice Act

Written care plan provides the framework Charting is organized by nursing diagnosis or problem; Initial assessment (data collection) is completed and charted each shift; Standard areas of assessment (data collection) are noted on flow sheets; Written notes are completed for abnormalities; Nursing diagnoses (problems) are entered on plan of care which is created soon after admission; Plan reviewed and updated at least every 24 hours; implementation of interventions documented on flow sheet or written note- Specifics of what was done, how it was done, patient response are entered on chart; Evaluation statement placed in notes to indicate progress toward goals-If goal met, diagnoses (problem) is marked "resolved" and removed from plan, if not being, goal is altered (revised)

Brief Concise Accurate No open lines Facts only Legible Complete Timely Correct patient name, date, time Sign each entry

Chart after care is given, not before Chart as soon as and as often as possible Chart only your own care, not someone else's Use direct quotes when appropriate describe each item as seen Objective only, no opinions Facts only-nonjudgemental A nurse cannot effectively and efficiently use health record until some understanding and knowledge of common abbreviations and medical terms have been developed Most facilities have a published list of generally accepted medical abbreviation and terms approved for use in charting Joint Commission for Accreditation of Hospitals Organization (JCAHO), or The Joint Commission as it is now known, has published a list of "Do Not Use" abbreviations because these have been know to cause confusion

Problem, Implementation, Evaluation

Data, Action, Response and evaluation, Education and patient teaching (DARE)

Subjective, Objective, Assessment, Plan, Intervention/Implementation, Evaluation, Revision

problem is numbered and charting is according to numbered problem

only chart what is out of ordinary

on electronic system

"story" of what happened-written note of what occurred through all systems

Chart is divided into specific sections or blocks. Emphasis is placed on specific sheets of information; typical sections are admission sheet, physician's orders, progress notes, history and physical examination data, nurse's admission information, care plan and nurse's notes, graphics, and laboratory and x-ray reports;

Nursing care Plan-Preprinted guidelines used to care for patients with similar health problem. Developted to meet the nursing needs of patient/ Based on nursing assessment and nursing diagnosis;

Clinical-Critical-Pathways-Managed care isa systematic approach that provides a framework to target the coordination of medical and nursing interventions. Allows staff from all disciplines to develop integrated care plans for a projected length of stay for a specific case type;

The nurse and other team members use the pathways to monitor a patient's progress and as a documentation tool Kardex/Rand-Card system used to consolidate patient orders and care needs in a centralized, concise way Kept at the nursing station for quick references-24hour Patience Care Records and Acuity Charting Forms: Consolidation of the nursing records into a system that accommodates a 24-hour period is often done-aids in the elimination of unnecessary record-keeping forms; Accurate assessment information and documentation of activities of daily living are more easily obtained with 24-hour notations

Using the facility format Facility forms Carting format-Narrative, PIE, FOCUS, SOAP/SOAPIER, Problem-Oriented, Charting by Exception, Computer-Assisted (Electronic), Traditional(narrative/block), Approved method to correct entries in record

Dont's: Include staffing problems, conflicts, conversations Mention incident reports Use words associated with errors Name a second patient Use unapproved abbreviation Document information obtained in shift report Chart opinions or assumptions Chart what someone else did Scribble or write over errors Use correction fluid Double document Use colored ink-Black only

Charting by Exception using Flow Charting, Narrative Note, Order of Documentation, words to avoid, Basic Rules

Opening note Date&Time, report received, Initial Head to Toe; Done within first 60-90 minutes At least every 2 hours documentation; Always note pain and safety; Never leave blank lines; Don't indent on nurses notes; Closing note, Repot given(to whom); Signature (credentials)

Vital Signs; LOC; ABC's, "the star" Head to Toe (visually place star on patients' forehead)-Note everyting not mentioned on flow sheet; Pacemaker, Surfical scars, wound, Tubes (foley, GT, NG tube, etc)

Normal; good/bad/big; tolerated well; sleeping; comfortable; appears; seems; and; the; his; her; that; is (at times); Pt.(repeatedly) Always document: pain, safety

if not consistent with routine of health care unit; used when patient care was not consistent with facility of national standards of expected care

objective, observed information; do not admit liability or give unnecessary details

Neer record in a patient's chart that an incident report was completed (in other words, do not mention the incident report in the nurse's notes)

fear on unknown, loss of identity, disorientation, separation anxiety, loneliness

meet with admission clerk/secretary-obtains infor, places ID band on pt and allergy band, provide consent for treatment and Pt bill of right and responsibilities to patient or legal guardian, address Patient Self-Deterination Act and HIPPA(telephone versus ER admission)

admission to clean, organized room, address pt by surname, explain hospital routine, assess immediate needs, have pt give valuables to family to take home, have pt change into pj's or hospital gown, assess further needs, provide pt teaching and orientation to surroundings, obtain health history and prioritize needs, make comfortable, notify physician of admission, obtain orders in none have been received before this time.

write a paragraph when, why, patient is being transferred and were they are being transferred

moving pt from one unit to another or one health care facility to another

ensures continuity of care (Continuing of established pt care from one setting to another) and legal protection for transferring facility and staff

Physician's order begins the transfer process

the systematic process of planning for pts care after discharge from the hospital/facility

when the pt is admitten

teach the pt and family about pt illness and effect of illness on pt lifestyle, provide instructions for home care, communicate dietary or activity instructions, explain purpose/adverse effects/scheduling of medication treatments, arranging for transportation, arranging follow-up care if required, coordination outpatient or home health care services

pt, family, all healthcare workers-nurse, physician, therapy, social services, dietary; uses the strengths of the patient in planning; provides resources to meet pt limitations; is focussed on improving pt long-term outcomes

the ultimate desired outcome is to limit the number of return visits of the pt to the healthcare system if possible

safe and effective use of meds/medical equipment;nutrition and modified diets; rehabilitation techniques to support adaptation to or functional independence in environment; access to community resources as needed; when/how to obtain further treatment; patient/family responsibilities in ongoing health care needs and knowledge/skills to carry out responsibilities; maintenance of standards of good grooming and hygiene

age group(especially order adults; multi system disease processes; major surgical procedures; chronic/terminal illnesses

physicians' order obtained; contact business office to make sure there is no billing arrangements to keep pt in facility- make arrangements for pt/or fam to visit office for bill arrangements; if not physicians' order, obtain against medical advice paperwork and notify appropriate ind.. about pt's decision to leave w/o drs approval; notify fam or appropriate person to transprot pt to home or location; gather equip, supplies, pt belongings in prep for discharge; review discharge office release; check that personal belongings in preparation for discharge; review discharge inst. w/pt/fam/significant other/guardian; check for business office release; check that personal belongings list corresponds with belongings releases @ time of discharge; have pt dam/significant other sign discharge inst's and belongings list; trans pt and belongings, equip &supplies to transport vehicle; assist pt to vehicle; which pt and fam/representative well as they leave facility; return to unit; document discharge process

alternative form to discharge narrative not- information is provided that pertains to the pt continued health after discharge; discharge summary forms make the summary concise and interactive.

examples of doc's that would meet requirements and thus result in denied reimbursements. Medicare has specific guidelines for establishing eligibility for home health care reimbursement.

50% of nurse time is spent in documentation

quality control, justification for reimbursement form medicare, medicaid, or private insurance. Have unique problems from different health providers to access the medical records.

*Omnibus Budget Reconciliation Act (OBRA) of 1987(reg long-term care facilities regarding standards for pt care) * Frequent written nursing records *Documentation Minimum Data Set (MDS)

facility, not the patient

Record Ownership and Access, patients written permission

Patient Bill of Rights

sharring passwords to owns computer with pt records,do not leave pt info display on monitor, follow agency's confidentiality procedures