Documentation
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| Documenting and Reporting is | The Process of preparing and recording all pertinent observations, interventions and responses relating to the complete record of a client's care; vital tool for communication among health care team members facilitates care
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| The Purposes of Client Records | Communication, Care planning, Legal documentation, Education, Research, Quality review Reimbursement
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| Documentation of Care - | Documentation of Care, Nursing Interventions, Patient Responses
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| Guidelines for Documentation | Agency policies govern method and frequency of charting used and who can write on the record Content should be accurate, concise, complete, relevant, sequential, orderly and factual, Format uses correct spelling, grammar, terminology
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| Guidelines for Documentation | Timely, with date and time of observations and follow-up noted, Accountable with each entry signed, Confidential; protected and secured for privacy at all times
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| Methods of Documentation | Source Oriented Records, Problem Oriented Medical Records, SOAP, (SOAPIE, SOAPIER)PIE, Focus Charting (DAR)Charting by Exception, Case Management Model
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| Source Oriented Charting: Narrative | Notations entered chronologically, Not organized by client's problems, Relevant information located in different areas of the chart, Each healthcare group keeps data on separate forms, Information fragmented
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| Problem Oriented Medical Records (POMR) | Organized around client's problems rather than sources of information, All heatlh care team members write information on the same forms, Progress notes focus on client's problems, Major parts of POMR - database, problem list, care plan, progress notes
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| SOAP, SOAPIE, SOAPIER | Subjective Data, Objective, Data, Assessment, Plan, Implementation, Evaluation, Response/Revise
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| Select Problem e.g. Wound Infection | S: patient states "my leg hurts", O: red open area observed on leg with purulent drainage, A: wound infection continues, P: clean wound and cover wtih a dressing, I: wound cleaned with NS and dry dressing applied, E: pt. states leg feels better, R: will m
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| PIE: Problem, Intervention, Evaluation | P - Client unable to walk to BR due to vertigo, I - Assisted pt to BR, BP assessed before, during and after ambulation, E - Patient able to walk to BR with assistance. BP 134/86 in ed, 100/70 dangling, 130/82 after ambulting, Orthostatic hypotension conti
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| Focus Charting (DAR) | Data, Action, Response, D - Pt. holding head and complaining of headache as 8 on 0 to 10 scale, A - Adminstered Tylenol 650 mg p.o. 1000, R - 10:30 am. pt. states pain decreased to 4 on 0 to 10 scale and is smiling
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| Charting by Exception (CBE) | Assumption: all predetermined standards are met w/normal resopnse unless documented; Eliminates lengthy and repetitive narrative notes; Emphasizes only significant data & makes it easy to retrieve; Improved tracking of important patient responses
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| Case Management Model | Case manager is responsible for planning, coordinating care and consulting with other health care team members to ensure that patienTs are discharged in a timely manner; Focuses on care during an entire episode of illness across every setting where patien
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| Computerized Records | Client information is placed directly into computer and care plan developed on computer; Increase accuracy (standardized format); reduced time in documentation; Computers right at or near bedside or hand held systems; Facilitates storing and retrieval of
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| Nursing Documentation Formats | Initial nursing assessment; Health history & physical examination; Baseline database; Kardex/Patient care summary; Basic & Summarized patient information; Easily accessible by all team members
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| Nursing Documentation Formats | Nursing Care Plan; Nursing diagnoses, goals/outcomes, actions; Standardized but individualized for each patient; Critical Pathways; Charting is focused on expected outcomes for each day of care
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| Nursing Documentation Formats | Progress Notes; informs care givers of the progress patient is making toward achieved expected outcomes; Discharge or transfer summary; Reason for treatent, patient condition, level of goal achievement, instructions for continued care; Home health or Long
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| Flowsheets | Usually check off or fill in blank; Graphic/Clinical record, Vital signs, weight, BM's, I&O; 24-hour fluid balance record, intake and otuput per shift and total 24 hours; Medication adminstration Record, Records all medications given to patient, includes
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| Legal Issues | Follow guidelines for documentation; Must also be legible; Chronological order, no blanks; Blank ink, no erasure or white out; Documentation is best legal defense
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| Rule of Documentation | Not Documented; Not DONE!!
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