By: Cindy Quisenberry. Care Plan – a written, interdisciplinary document developed for each...
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Transcript of By: Cindy Quisenberry. Care Plan – a written, interdisciplinary document developed for each...
DocumentationBy: Cindy Quisenberry
Documentation• Care Plan – a written, interdisciplinary
document developed for each patient, listing the patient’s needs and goals as well as the actions and approaches that staff will take to help the patient meet their goals
Documentation• Documentation – written reports that the
facility maintains• Objective – information that can be observed;
factual; not subjective• Subjective – guess or hunch about what you
observe, or something a patient feels inside and tells you about (not objective)
Documentation• Assessment – an evaluation of a patient or
condition• Minimum Data Set (MDS) resident information
on the RAI, including levels of physical functioning and bowel and bladder continence
• Resident Assessment Instrument (RAI) – an assessment tool used in long term care facilities to document key information about residents including their care plans and outcomes
Documentation• Resident Assessment Protocols (RAPs) –
section of the RAI that includes a more detailed assessment of problem areas
• Quality Indicators – outcomes or a summary of the entire facility’s MDS information, which indicates the quality of care provided by a facility– Summary report can tell an agency (for example)
how many residents have pressure ulcers, etc.
Documentation• Think back to a special event you experienced
months ago, like a birthday or holiday. Try to remember the event in detail.
• What were people wearing? • What did they talk about?• What did they eat and how much?• What was their mood?• What time did each person come and go?
Documentation• You have probably forgotten many facts. It’s
only human to forget details like these.• Because of memory limits, we often have to
write things down. • If we do not write down details, the only known
“facts” might be what we happen to remember.• We do not know at the time how important
some details could be later on.• Therefore, the documentation you do on the job
is essential so that we do not loose information.
Documentation• Some written notes may be used months or
years later. • You and others in a facility can later state facts
with certainty because you wrote them down.
Documentation• Sources of Information– The patient is usually the main source of
information• Their needs• Their preferences• Verify with the charge nurse, etc.; some patient’s might
be confused.
– The Family– Other Staff
Documentation• Sources of Information– The Chart (Medical Record)• Main communication tool used by the interdisciplinary
team• Legal Record• Basic Tool for Planning, Recording, and Evaluating Plan
of Care• Confidential and Belongs to the Facility• Must be Complete and Accurate
– If it isn’t charted, it wasn’t done
• Contains the Patient’s Medical Hx, Current Records, Care Plans, Medication Records, etc.
Documentation• The Chart Contains– Patient’s identifying Information (Face Sheet or
Demographic Sheet)• Name • Medical Record Number• DOB, etc.
– Admission Papers (reason for admission)– Permission Forms • Consent to Treat• Instructions• DNR
Documentation• The Chart Contains– Sections of Documentation (from individual
disciplines)• Physician’s Orders• Nurse’s Notes• Graphics or Flow Sheets (VS’s, I & O, ADL’s, BM’s, etc.)• Progress Notes
– Physician– Physical Therapy– Respiratory Therapy– Dietary
• Lab, X-rays, etc.
Documentation• Other Communication Devices and Systems– Patient Wristbands– Colored Wristbands– Words or Symbols on the Patient’s Door, Bed or
Chart
Documentation• Facility Policies and Procedures– Rules for how to do things in the facility– Tell you how and why things are done• Completing the Personal Possession Record• Residents Leaving the Facility• HIPAA
If you are unsure of anything when talking with members of the team, the resident or family members, just ask. Don’t assume anything you are not sure of.
Documentation• Resident Assessment – CNA’s area key part of
gathering data, because they spend so much time with the residents– RAI-is first completed on a resident on admission,
and a new assessment is done at least yearly or whenever the resident’s condition changes (improvement or decline)• Five Parts
– The Minimum Data Set (MDS) – Done on Computer– Resident Assessment Protocols (RAPs)– Care Plan Development– Care Plan Implementation– Evaluation and Outcome
Documentation• RAI - different sections are completed by
different staff members– Nursing Section – Nurses complete this section,
however the nurse will ask the CNA for information• Examples
– Objective Data – “Mr. Brown puts on his own shirt, but he doesn’t button the buttons himself.”
– Subjective Data – “I think he could button his shirt if he had bigger buttons.”
Documentation• RAPs – done after the MDS is completed; a
detailed assessment of possible problem areas– Example• Mobility Problem
– Gives the staff additional information or “protocols” to determine if there is a problem
Documentation• Care Plan – an interdisciplinary document that
lists a resident’s needs and goals as well as the actions and approaches the team will use to help the resident to meet their goals.
• Use of the care plan ensures consistent care• List each patient’s medical, nursing and
psychological needs.• Good communication skills are needed in
care-plan meetings because many people are sharing a lot of information
Documentation• Care Plan– Problem - Poor appetite and weight loss since
beginning chemotherapy– Nursing Diagnosis – Imbalanced nutrition; less
than body requirements related to decreased appetite secondary to chemotherapy
– Goal – Patient will gain 2 pounds within three weeks
– Plan• Dietary and physician consult• Weigh every Friday morning
Documentation• Care Plan– Plan• High Calorie Diet• Monitor Intake and Output• High protein drink at 1000 and qhs• Offer ice cream if refuse to drink high protein drink
(resident likes ice cream)• Offer snack at bingo• Son will eat with resident at noon• Serve try in A wing lounge
Documentation• How to Report Information– Use a private place to give an oral report– Be careful when talking with family members and
visitors– Routine Reporting – reported at the end of a shift• What did you see, hear, smell, or touch when caring for
each patient?• Was anything new or changed?• Did I meet each resident’s needs?
Documentation• How to Report Information– Immediate Reporting• Frayed electrical cord• Any unusual incident, such as a resident’s fall• Any suspicion of resident abuse• Any resident’s complaint of ill health, such as a
complaint of pain or dizziness• Any unusual observations, such as a resident’s
temperature of 103 F or confusion and agitation in a normally alert resident
Documentation• How to Report Information– “By a Certain Time” Reporting• Example – the nurse may need a resident’s
temperature before the physician calls
Documentation• Incident Reports– Document an accident or an injury• Provide information about what happened• Protect residents, you, the facility, and others• Documents the incident and all related facts• May give information about what you:
– Heard– Saw– Smelled– Touched
• Do not document in the patient’s chart that you filled out an incident report
Documentation• Documentation:– Helps you to notice changes in the patient’s
condition (ie: comparing blood pressures) and the need for reporting
– Helps you watch trends as well as changes– Be sure you understand your facility’s policies and
procedures for your documentation– Some facilities use checklists or a combination of
different charting methods.
Documentation• Documentation may include:– General statements of care given– The resident’s appointments and activities– Any complaints from the resident– General statements about the resident’s
psychological well-being– Visitors, including physician’s visits
Documentation• Guidelines for Documentation (to prevent
misunderstandings)
– The patient’s name should be on every page.– Write all entries in permanent black ink, not pencil or
felt tip markers that may smear when wet.– Write each entry so that it is easy to read.– Charting is continuous. Do not leave spaces or skip
lines between entries.– Document only your own actions and observations.– Do not tamper with or change entries made into the
chart unless you make an error. If you make an error, correct it immediately and properly.
Documentation• Guidelines for Documentation (to prevent
misunderstandings)
– Use standard medical terminology and standard abbreviations.
– Write down the date and the time of each entry as required.
– Sign each entry and include your title after your name. In some cases you may initial the entry when your signature is somewhere else on the form.
Documentation• Correcting a Mistake– Draw a single line through the word.– ? Print the word “error” above or beside the word
(depends on the facilities policy).– Add your initials and date above it.– Then write the correct word before continuing– Do not try to cover an error with “x’s” or scribble all
over it, use white out, etc.– If you are correcting a large amount of writing, be
sure to write the reason you are making the correction. (discovered that you wrote information on the wrong patient’s chart)
Documentation• Correcting a Mistake– Do not try to erase a mistake. (NEVER erase a
mistake)– Ask someone for help if you cannot figure out how
to clearly correct a documentation mistake.
Documentation• The interdisciplinary care team uses the
minimum data set (MDS) to:a. Make roommate assignmentsb. Develop a resident’s care planc. Keep a record or monthly expensesd. Teach nurse assistants correct medical
terminology
Documentation• The interdisciplinary care team uses the
minimum data set (MDS) to:a. Make roommate assignmentsb. Develop a resident’s care planc. Keep a record or monthly expensesd. Teach nurse assistants correct medical
terminology
Documentation• Who is the primary source of information
about a resident?a. The residentb. The charge nurse c. The social workerd. The resident’s physician
Documentation• Who is the primary source of information
about a resident?a. The residentb. The charge nurse c. The social workerd. The resident’s physician
Documentation• A medical record is used to maintain:
a. The facility’s financial informationb. The facility’s equipment maintenance recordc. Lab results and reports by all care staffd. Correspondence between the resident and their
family
Documentation• A medical record is used to maintain:
a. The facility’s financial informationb. The facility’s equipment maintenance recordc. Lab results and reports by all care staffd. Correspondence between the resident and their
family
Documentation• Mr. Houston’s weight is checked each day.
Before the end of your shift, you would record this information on:a. A wall calendarb. A flow sheetc. The Quarterly Review formd. The Resident Assessment Protocols
Documentation• Mr. Houston’s weight is checked each day.
Before the end of your shift, you would record this information on:a. A wall calendarb. A flow sheetc. The Quarterly Review formd. The Resident Assessment Protocols
Documentation• You have just taken Mrs. Cotton’s
temperature. It is 98.4˚. This is a type of:a. A wall calendarb. A flow sheetc. The Quarterly Review formd. The Resident Assessment Protocols
Documentation• You have just taken Mrs. Cotton’s
temperature. It is 98.4˚. This is a type of:a. A wall calendarb. A flow sheetc. The Quarterly Review formd. The Resident Assessment Protocols
Documentation• The minimum data set (MDS) is one part of
the:a. Quality indicatorsb. Resident’s care planc. Resident Assessment Instrument (RAI)d. Resident Assessment Protocols (RAPs)
Documentation• The minimum data set (MDS) is one part of
the:a. Quality indicatorsb. Resident’s care planc. Resident Assessment Instrument (RAI)d. Resident Assessment Protocols (RAPs)
Documentation• A resident’s care plan is used as a tool to:
a. Determine whether the resident qualifies for Medicaid payments
b. Invite family members to facilities partiesc. Plan for new building improvementd. Coordinate all treatments and services for the
resident
Documentation• A resident’s care plan is used as a tool to:
a. Determine whether the resident qualifies for Medicaid payments
b. Invite family members to facilities partiesc. Plan for new building improvementd. Coordinate all treatments and services for the
resident
Documentation• Your role in the care plan meeting includes:
a. Sharing information about the residentb. Serving coffee and doughnuts to the
interdisciplinary teamc. Deciding which doctors and nurses should attendd. Diagnosing the resident’s medical condition
Documentation• Your role in the care plan meeting includes:
a. Sharing information about the residentb. Serving coffee and doughnuts to the
interdisciplinary teamc. Deciding which doctors and nurses should attendd. Diagnosing the resident’s medical condition
Documentation• Routine information about residents is usually
shared with the charge nurse:a. On your lunch breakb. At the end of your shiftc. During weekly personnel meetingsd. Immediately
Documentation• Routine information about residents is usually
shared with the charge nurse:a. On your lunch breakb. At the end of your shiftc. During weekly personnel meetingsd. Immediately
Documentation• When you write in a resident’s chart, you
should:a. Erase any mistakes and then write in the correct
informationb. Get the doctor’s permission before you write
anythingc. Write neatly and legiblyd. Correctly any mistakes you see that were made
by others
Documentation• When you write in a resident’s chart, you
should:a. Erase any mistakes and then write in the correct
informationb. Get the doctor’s permission before you write
anythingc. Write neatly and legiblyd. Correctly any mistakes you see that were made
by others