unit v documentation.pptx

for nursing students
unit 5

1. DOCUMENTATION AND REPORTING ANJANA THOMAS

2. Documentation Any written or electronically generated information Describe the care or service provided It is an accurate account of what occurred and when it occourred

3. Nursing documentation Assessment of patient health status, nursing interventions Care plan/ health plan Information reported to the physician Advocacy undertaken by the nurse on behalf of the patient

4. Record Clinical, scientific, administrative and permanent legal documentation of information related to patient health care

5. Purpose of recording Communication Quality of care Legal documentation Planning patient care Audit Research Reimbursement

6. Confidentiality Patient confidentiality – legal consideration The health insurance portability and accountability act (HIPAA)

7. HIPPA violations Gossiping / taking about the patient Mishandling the medical record Leaving medical record unsecured Illegally or unauthorized assessing of patient record Sharing information Texting or e-mailing on an unencrypted device Sharing information on social media

8. Types of patient record Patient clinical record Medical / nursing record Ward record Administrative record

9. Patient clinical record Knowledge of events involved in the patient’s illness, progress, care provided Patient’s identification and demographic data Present complaints Informed consent for treatment and procedure Admission nursing history Family history Physical examination findings Nursing diagnosis and problems Nursing care plan

10. Patient clinical record Medical history Tentative diagnosis Medical diagnosis Therapeutic orders Treatment given Progress notes Supportive care given Report of diagnostic studies Final diagnosis Patient education Summary of operative procedures discharge plan and summary Any specific instructions

11. Medical records Legal document providing information of a patient’s medical history and care by physicians, nurse practitioners and other health care members Identification Patient health history Medical examination findings Lab test result, medication prescribed referral orders Health instruction to the patient

12. Nursing records Progress notes Work sheets and kardexes Flow sheets Intake/ out put section Vital signs Patient care plan E- health record

13. Guidelines for nurse using electronic records Never reveal personal password and ID no Immediate inform your supervisor if there is suspicion Change password Choose password that are not easily deciphered Log off when not using Maintain confidentiality Locate printers in secured areas Retrieve printed information immediately Protect patient information Use system with security

14. Ward record Record of reduction or increase in bed Admission and discharge Linen record Indent book Rounds book Attendance book Record book Treatment book

15. Administrative record Treatment Admission Equipment losses and replacement Personal performance Organizational record

16. METHODS OF DOCUMENTATION 1. Narrative 2. problem oriented medical record 3. SOAPIER 4. PIE 5. Changing by exception

17. Narrative Traditional method Story like format Specific to patient condition and care Data is recorded with out an organization frame work

18. Problem oriented medical record Single list of patient problem Nursing process forms the basis for the POMR method Emphasis on patients problem

19. Advantage of POMR Give emphasis to patient’s perception of their problems Requires continues evaluation and revision of the care plan Greater continuity of care among health care team members Enhance effective communication Increase efficacy in gathering date Provide easy to read information in chronological order Reinforces use of the nursing process

20. Components of POMR Database Problem list Plan of care Progress notes SOAP Subjective data Objective data Assessment Planning

21. SOAPIER Structured way in which narrative progress notes are written by the health care team S- Subjective data – Information obtained from the patient O- Objective data - information measured or observed A- Assessment – interpretation/conclusion drawn about the sub/obj data P- Planning – Plan of care designed for resolve the stated problem I- Intervention -Refers to the specifics that have been performed by caregiver E- Evaluation – response to the nursing intervention R- Revision – care plan modification modifications suggested by the evaluation

22. Problem intervention evaluation (PIE) Problem, intervention and evaluation of nursing care Consist of a patient care assessment flow sheet and progress notes Flow sheet uses specific assessment criteria in a particular format Human needs or functional health pattern Notes are numbered or labeled according to the patients problem Resolved problems are dropped from the daily documentation

23. Focus charting Notes that include data, both subjective and objective Action or nursing intervention Response of the patient Notes are structured according to the patient’s concern Written in accordance with the nursing process Sign or symptoms Condition Nursing diagnosis Behavior Significant event Change in patient’s condition

24. Charting by exception Abnormal or significant findings or exceptions to norms are recorded Flow sheet : graphic record, fluid balance record, daily care record, patient teaching record Standards of nursing care : reference to the agencies printed standards of nursing practice Bedside assess to chart form, kept at the patient’s bedside to allow immediate recording

25. Computerized documentation

26. Computerized documentation Used in Clinical system Management information system Educational system

27. Advantages Legibility of information Increased time efficacy, consistency and accuracy Data base for research Link various sources Patient information, requests and result are sent and received quickly Standard terminology improve communication

28. Disadvantages No privacy if security measures are used System failure Expensive Need training whenever an updating system installed

29. Electronic health record Systematic collection of electronic health information about individual patients

30. Purpose Automation and streaming of the workflow in health care setting and increase safety through evidence- based decision support, quality management, and outcomes reporting

31. Advantage Instant access of all patient information Improved efficiencies and provide quality of care Help in decision making and ensure that the quality of services Maintain highest professional standards

32. Functions Health data and information Order management Result management Decision support Electronic connectivity and communication Patient support Administrative process Reporting

33. Barriers of EHR Technical problems Resource matter Financial concern - products are expensive and require a major investment. Training Concern with privacy

34. Common record keeping forms

35. Guidelines for documentation Date and time Timing Legibility Permanence Correct spelling Signature Accuracy Sequence Appropriateness Completeness Conciseness Accepted terminology Legal prudence Do not identify the chart by room number Accurate notation Avoid general words

36. DO’S DON’T’S Should be patient’s name on every sheet Check file before any care and charting Good skill in English language Use concise phrases in notes Make entries in serial order Use accepted abbreviations Should not be torn, back date or rewrite on the previously added document Not to use medical terms, if should not know exactly Not to chart for other staff Not to leave the space in between charting

37. REPORTING Reports are oral, written or audio taped exchange of information about the patient. It provides information on existing condition of patient. Common reports given by nurse include Shift report Transfer report Telephone report Incident report Reports can be compiled daily, weekly, monthly, quarterly and annually.

38. Guidelines for reporting Factual Accurate Complete Current issue Organization

39. Factual Report must consist of objective information Observe using the senses When reports do not have factual observed information, they cannot be accepted The exact quotation or words used by the patient must be reported.

40. Accurate Whenever reporting any quantity measures report exact amount Eg : patient drink adequate amount of water – patient drink 150ml of water Data should be concise, clear and easy to understand

41. Complete Must be complete containing all essential information Care plan information to be entered Patient health problem and nursing activities to recored

42. Current Information entered in a timely basis. 24 hour / 12 hour time cycle 13.00 or 1 pm

43. Organized Arranged in logical order Order of nursing process Assessment, diagnose, goal, plan, implementation, evaluation

44. Criteria of a Good Report It can be made promptly It should be clear, concise and complete All identified data should be included Easy to understand Important points should be emphasized

45. Purpose of writing report To show the kind and quantity of service rendered over to a specific period Show the progress in reaching goals To study health condition Interpret the services to the public and to other agencies

46. Types of reporting 1. change in shift report It is a report given by a nurse to another due to change in shift Provide continuity of care by providing quick summary of assigned patient Includes diagnosis of patient, present health condition, treatment and medication. Both the nurses while giving report should assess the patient together Types : oral and written report

47. 2. Telephone report Include communication about patient’s transfer to another ward and informing about patient’s health status Common – nurse to nurse, nurse to laboratory, nurse to physician Telephone report should be documented, include time of call, who made the call and to whom information is given.

48. 3. Transfer report Related to shifting the patient from one unit to another Transfer reports provide continuity of care by providing the information on telephone. It include : Patient name, age and diagnosis. Current health status of patient Any procedure or intervention that need to be performed after transfer of patient to other ward or unit.

49. 4. Incident reports or Accident reports Should be complete, clear and accurate as these are legal documents Filled in the office of nursing superintendent Studied for prevention of such accidents in future

50. 5. Intra division report Nurse incharge and bedside nurse Between nurse incharge and physician Head nurse and administrative supervisors

51. 6. Inter department report Reports shared with other department Report of patient discharged are send to admission, business office and information desk

52. Importance Employer – Employment, promotion, disposition Court of law for various purpose Used for a job and leave from work place Lawyers used for compensation and liability Damage against negligent act Execution of will Medico-legal reasons For use in consumer court

53. Guideline – minimize legal liabilities Patient identification data in all pages Write clearly and appropriately Facts should be based on the observation, conversation and action. Select only relevant facts Records should be neat, clean, complete and uniform Record all telephonic conversation and follow up Use standers terminologies and abbreviations Do not erase or change any entries No individual sheet should be separated Correct all mistake as soon as possible Record procedure after completion Never leave vacant space Do not write judgement comments Do not destroy the documents

54. Communication in health care team Face to face communication Written communication Consultation Referrals

55. Nursing informatics French word – informatique – computer science The use of computers technology to support nursing, including clinical practice, administration, education and research

56. Goal To improve health of population, communities, families and individuals by optimizing, information management and communication Use the technology in the direct provision of care, in establishing effective administrative system

57. Functions To enhance patient care and nursing practice Way of keeping patient information properly organized Nurses to make notes that every one can assess Help with dosing instructions, staff assignment and lab results Help and to create nursing care plan Coordinated information help in decision making

58. Framework Data Information Knowledge

59. Importance of nursing informatics Increase the accuracy and completeness of nursing documentation Improves the nurses workflow Eliminate redundant documentation Automates the collection and reuse of nursing data Facilitates analysis of clinical data Access to resources and reference Beneficial to nurses and interdisciplinary team Administrative – support for cost saving and productivity goals

60. Application Nursing clinical practice – point of care system and clinical information system Nursing administration Nursing education nursing research

61. Thank you….