DOCUMENTATION - PowerPoint PPT Presentation

1 / 45
About This Presentation
Title:

DOCUMENTATION

Description:

DOCUMENTATION As a Loss Prevention Technique * This violates your patient s privacy and violates HIPAA. The only exception to this would be if you patient was a ... – PowerPoint PPT presentation

Number of Views:223
Avg rating:3.0/5.0
Slides: 46
Provided by: Christi1038
Category:

less

Transcript and Presenter's Notes

Title: DOCUMENTATION


1
DOCUMENTATION
  • As a Loss Prevention Technique

2
Todays Objective
  • Increase awareness of documentation risks,
    specifically targeting exposure to negligence and
    malpractice claims.
  • Enhance the quality of documentation by expanding
    awareness in order to provide quality patient
    care and avoid malpractice incidents.
  • To address the documentation steps in order to
    implement, and thus help protect your patient
    from harm and minimize your liability exposure.

3
Legal Perspective on Documentation
  • Not documented, not done.
  • Poorly documented, poorly done.
  • Incorrectly documented, fraudulent.

4
Quality Documentation is Quality Care
  • Structured writing typically inspires structured
    performance.
  • Document the Nursing Process
  • Assessment
  • Diagnosis
  • Planning
  • Implementation
  • Evaluation

5
You are what you document
  • A well-documented patient care record
  • Protects your patient
  • Demonstrates to the board of nursing that you are
    a competent nurse.
  • Minimizes the potential of being named as a
    defendant in a lawsuit.
  • Minimizes the potential of a court appearance if
    you ARE named in a suit.
  • Help you win if you go to court.

6
The Patient Care Record is a Legal Document.
  • Under state laws, the patient care record is the
    property of the health care provider.
  • Patient is entitled to a copy of the record under
    the laws of most states.
  • The record must reflect accurate and
    contemporaneous information.
  • The patient care record documents the care
    provided.

7
Basis for Reimbursement
  • Your documentation may influence how you and your
    employer are reimbursed for services rendered and
    minimize financial loss.

8
Considerations for Quality Documentation
  • Contemporaneous documentation
  • Accurate documentation
  • Fraudulent documentation
  • Inappropriate documentation

9
Documentation as a Loss Prevention Technique
  • Documentation Dos and Donts
  • 10 Risk Management Strategies

10
Risk Management Strategy 1
  • Do not erase.
  • Do not use white out.
  • Do not cross out an error with more than one line.

11
Risk Management Strategy 2
  • Record only the facts.
  • Document only observed behavior.
  • Document healthcare services rendered.

12
Risk Management Strategy 3
  • Do not write critical comments.
  • Do not document your opinions.

13
Risk Management Strategy 4
  • Begin each entry with the date and time and end
    each entry with signature and title.
  • Example
  • (03/31/09 - 750AM - Jane Doe, BCCNS)

14
Risk Management Strategy 5
  • Do not leave blank spaces.

15
Risk Management Strategy 6
  • Record all entries legibly and in ink.

16
Risk Management Strategy 7
  • Avoid generalized phrases such as "bed soaked" or
    "a large amount."

17
Risk Management Strategy 8
  • If an order is questioned, document that
    clarification was sought and discussed.

18
Risk Management Strategy 9
  • Document only your own observations and patient
    services rendered.

19
Risk Management Strategy 10
  • Do not permit any visiting relative or other
    third-party access to the patient care record.

20
Communication Challenges
  • Attributes
  • Factual
  • Accurate
  • Current
  • Confidential

21
Reporting Challenges
Nurses must communicate information about
patients to other nurses and other health care
workers.
  • Oral Report
  • Typically, conducted at change of shift.
  • Documentation/Written Report
  • Completed during shift.

22
Documentation Techniques Strengths and Weaknesses
23
Documentation Methods
  • Charting by Exception
  • FOCUS
  • Narrative
  • SOAP
  • Electronic

24
Documentation Methods
  • Charting by Exception

25
Documentation Methods
  • FOCUS

26
Documentation Methods
  • Narrative

27
Documentation Methods
  • SOAP

28
Documentation Methods
  • SOAP (SOOOAAP)

29
Documentation Methods
  • Electronic

30
Effective Risk Management Strategies
  • Comply with Nurse Practice Act
  • Practice Competent Nursing
  • Comply with Policies and Procedures
  • Follow Appropriate Incident Reporting

31
Incident Reporting
  • Losses can be reduced by a timely, prudent, and
    compassionate response to an incident!

32
Learn Your Organizations Guidelines
Examples of Reportable Incidents
  • Patient falls
  • Medication errors
  • Equipment failure
  • Complaint by patient, family, visitor
  • Treatment-related injuries
  • Missed/incorrect diagnosis
  • Employee exposures

33
BE ALERT! Report unusual occurrences
  • Document ONLY the facts
  • Report immediately, i.e., within 24 hours.
  • Do not speculate.
  • Do not draw conclusions.
  • Do not document impressions.

34
QUALITY MONITORING
  • Participate in investigations.
  • Maintain confidentiality of all information.

35
Open Charting
  • Encourages patients to review their own patient
    care record
  • Promotes meticulous documentation by healthcare
    providers
  • Fosters patient inclusion in the healthcare
    delivery process
  • Requires significant time
  • May raise patient queries regarding the
    healthcare delivered

36
Documentation Examples
37
(No Transcript)
38
(No Transcript)
39
(No Transcript)
40
(No Transcript)
41
(No Transcript)
42
(No Transcript)
43
(No Transcript)
44
Documentation Bloopers
  • Patient had waffles for breakfast and anorexia
    for lunch.
  • She is numb from her toes down.
  • While in ER, she was examined, x-rated, and sent
    home.
  • The skin was moist and dry.
  • Patient was alert and unresponsive.
  • Rectal examination revealed a normal size
    thyroid.
  • She stated that she had been constipated for
    most of her life, until she got a divorce.
  • Skin somewhat pale but present.
  • Patient has two teenage children, but no other
    abnormalities.
  • The patient refused an autopsy.
  • The patient has no previous history of
    suicides.
  • Patient has left white blood cells at another
    hospital.
  • On the second day, the knee was better, and on
    the third day it disappeared.
  • The patient has been depressed since she began
    seeing me in 1993.
  • Discharge status Alive but without permission.
  • Healthy appearing decrepit 69-year old male,
    mentally alert but forgetful.

45
THE END
Write a Comment
User Comments (0)
About PowerShow.com