DOCUMENTATION

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DOCUMENTATION

• Lisa Brock, RN MSN
• NUR 102 Lab Module D
• Fall 2006

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Definition ofDocumentation

• Documentation is defined as anything written or
  printed that is relied on as a record or proof
  for authorized persons (Perry Potter, ed 6, pg
  45)

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Why do we document?

• Provide a written record of care given to the
  patient
• A record is a permanent legal written document
• IF IT IS NOT CHARTED, IT IS CONSIDERED NOT DONE

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Uses for Documentation

• Provide a record of care for financial
  reimbursement
• Clinical research
• Professional development

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What do you chart?

• Verbal orders
• Procedures
• PRN medications
• Intake and output

• Assessment
• Vital signs
• Any change in your patients condition

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Military Time

• Most facilities have gone to military time in
  documentation in which the clock is read as one
  24 hour cycle

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Documentation Guidelines

• Factual
• Accurate
• Complete
• Current
• Organized

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Forms and Formats

• Admission history form
• Flow sheets and graphic records
• Kardex
• Acuity
• Standardized care plans
• Discharge summary forms

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Methods of Recording

• Problem-Oriented Medical Records (POMR)data
  organized by problem or diagnosis
• Source records
• Charting by exception

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Standards of Care

• Case management and critical pathways
• (pg 54)

• Use of standardized language
• NANDA
• NIC
• NOC
• (pg 54)

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Home Care

• Specific guidelines for Medicare and Medicaid
  reimbursement
• Accurate assessment skills
• Multi-disciplinary approach
• JCAHO requirements

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Long-Term Care

• Called residents, not clients or patients
• Omnibus Budget Reconciliation Act of 1987
• Governed by Department of Health in each state
• Frequency of assessment

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Change of Shift Report

• Orally, taped, or walking rounds
• MAINTAIN CONFIDENTIALITY
• Do not delegate to assistive personnel

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Important Information

• Background
• Assessment
• Nursing diagnoses
• Interventions
• Outcomes

• Evaluations
• Family information
• Discharge plans
• Priorities
• Clarification

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Purpose of Records

• Communication
• Education
• Assessment
• Research

• Financial billing
• Auditing
• Legal documentation

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Documentation Formatspg 62, Box 3-4

• PIE
• Problem
• Intervention
• Evaluation

• SOAP
• Subjective
• Objective
• Assessment
• Plan

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Continued

• Narrative note
• Combine subjective and objective data

• Focus or DAR
• Data
• Action
• Response
• AdditionallyPlan

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Incident Reportspg 64, table 3-4

• Incidentany event not consistent with the
  routine
• Assist in identifying high-risk trends
• Not a part of the medical record

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Complete NCLEX Review Questions, pg 66