Documentation 101 - BMH/Tele

Documentation Documentation 101101

Natalie Bermudez, RN, BSN, MSNatalie Bermudez, RN, BSN, MS

Clinical Educator for TelemetryClinical Educator for Telemetry

For Novice and For Novice and Experienced Nurses New Experienced Nurses New

to Bethesda Memorial to Bethesda Memorial HospitalHospital

Nursing DocumentationNursing Documentation

“Documenting your patient’s care has

always been important. But with health care growing increasingly

complex, expert documentation skills

have become indispensable.”(Seeber-Combs, 2006, p. 1)


Cost constraints, sicker patients, and nurses’ growing roles further emphasize the need

for a properly documented medical

record.

(Seeber-Combs, 2006, p. 1)


“When you document effectively, your patient’s medical

record reflects your professionalism.”


Reasons for DocumentationReasons for Documentation

Continuity-of-Care Tool

Patient Protection Device

Quality Management Aid

Legal Safety Net


Documentation SystemsDocumentation Systems

Source-Oriented

Problem-Oriented

Narrative Notes

Focus Charting (DAR)

PIE Documentation

Charting By Exception

(Seeber-Combs, 2006)

Charting By ExceptionCharting By Exception

When you use CBE, you document only

abnormal or significant findings or deviations from established norms.


Charting By ExceptionCharting By Exception

This system eliminates lengthy, repetitive notes and

makes trends or changes in the

patient’s condition more obvious.


Documentation Made EasyDocumentation Made Easy

1. Document what the patient tells you

2. Document what you assess

3. Document what you do

4. Document outcomes of what you do

5. Document what you teach

BMH Tools for DocumentationBMH Tools for Documentation

PCAR (Patient Care Activity Record)PCAR (Patient Care Activity Record)

Patient LogisticsMedical Diagnosis/Diagnoses

Medication ListRecent Vital Signs & Lab ResultsPending Procedures/Labs/Tests

Diet/Activity/Code StatusNursing Interventions

IVFs & Cardiac Rhtyhm

Tools for DocumentationTools for Documentation

Problem ListProblem List• Nursing Diagnoses

• Specific Goals and Interventions

Nurses NotesNurses Notes• CBE documentation

• Narrative-style documentation


Shift AssessmentShift Assessment• Documentation of initial multi-system

assessment

• Charting By Exception

Cardiac Monitoring StripsCardiac Monitoring Strips• Provides important assessment data

• Remains part of permanent health record


Flow Sheets and ChecklistsFlow Sheets and Checklists

IV Site

Neuro-checks

PCA Pumps

Post-Cardiac Catheterization

Incident ReportsIncident Reports

Medication errors or harm to clients, staff, or visitors

Risk management tool

Use to track trends and patterns

For Quality Assurance

Not for punitive measures

Kept separately of health record

Legal AspectsLegal Aspects

A patient chart is a legal document

Any documentation on the patient’s chart is permanent

Assure that only pertinent information is entered

Telephone OrdersTelephone OrdersOnly registered nurses may obtain a

telephone order

A telephone order may only be taken via the telephone

All telephone orders must have the date and time the order is received

Must also include name of RN and physician

EXAMPLESEXAMPLES

Nurses’ Notes:Nurses’ Notes:

• Pertinent Information

• Precise and concise

• Descriptive words

• Quotation marks when necessary

• Avoid words like “appears to be” or “seems to be”

EXAMPLESEXAMPLES

Nurses’ Notes:Nurses’ Notes: 826/10 – 08:00

Patient received in bed awake. Alert and oriented x 3. Patient c/o nausea. Medicated with Phenergan 25 mg IM – left deltoid. Will continue to monitor for medication effectiveness and/or adverse reactions. No other complaints or concerns verbalized at this time.

EXAMPLESEXAMPLES

Nurses’ Notes:Nurses’ Notes: 8/26/10 – 17:30Patient stated “I have pain in my chest. It feels like

an elephant is sitting on me”. Patient is pale, diaphoretic, and has SOB. Vital signs: B/P 130/70, HR 120, O2 Sat 92% on RA. Nitro-stat SL x 2 tabs administered with complete relief of chest pain. Stat call placed to physician. Stat EKG done and faxed to physician’s office as requested. Patient started on a Nitro drip @ 20 mcg/min per physician orders and will be transferred to ICU when bed available.

EXAMPLESEXAMPLES

Shift Assessment:Shift Assessment: 8/26/10 – 08:00

Neuro: WNL

Resp: WNL

If WITHIN NORMAL LIMITS is documented there is no need to write in “Comments” that “Patient is

AAO x 3” or “Lungs are clear”.

EXAMPLESEXAMPLES

Shift Assessment:Shift Assessment: 8/26/10 – 08:00

If you documented the shift assessment @ 0800, then it is not necessary to document

a narrative assessment in the Nurse’s Notes for the same time.

EXAMPLESEXAMPLES

Shift Assessment is done:Shift Assessment is done: 8/26/10 – 08:00

AAO x 3. No neuro deficits. Lungs are clear/diminished at bases bilaterally. O2 sat with 2L NC is 100%. Oral mucosa and nailbeds are

pink with adequate CR. Heart sounds are regular; no murmurs. Rhythm is sinus 70’s.

Abdomen soft, non-tender. Bowel sounds are positive x 4; last BM 9/29/07. Foley catheter in

place draining clear, yellow urine. MAE. Ambulates to bathroom independently; steady gait. 0/9% NaCL @ 50 ml/hr infusing to LFA IV

site; no redness or swelling at insertion site.

EXAMPLESEXAMPLES

Admission AssessmentAdmission Assessment

&&

Nursing Admission HistoryNursing Admission History

EXAMPLESEXAMPLES

Nursing Admission Nursing Admission History/AssessmentHistory/Assessment

• Needs to be completed ASAP

• Includes Home Meds

• Immunization & TB History

• Past Medical/Surgical History

• Social History

• Assessment Needs to be Thorough

EXAMPLESEXAMPLES

Problem List:Problem List:

Documentation needs to be completed for each problem on the list once per shift

If problem goals have been met, problem may be removed from the list (Resolved)

Problem list may be updated to include new problems

EXAMPLESEXAMPLES

PCAR:PCAR:

Needs to be initiated on admission and updated by nursing on an as needed basis

Communication tool for nurses!!!!!!!!!!!!

EXAMPLESEXAMPLES

PCAR:PCAR:

Routine Activities…

Conditioning Parameters…

Call Physician If…

EXAMPLESEXAMPLESTelephone Orders:Telephone Orders:

All telephone orders should be verified by repeating the orders to the physician

Label verbal orders with RBTORBTO = Read Back Telephone Order

All telephone orders need to be signed by physician with date and time within 48 hours!!!

EXAMPLESEXAMPLES

Verbal Orders:Verbal Orders:8/26/10 19:008/26/10 19:001) Start IV Nitro drip @ 20 mcg/min and

titrate for chest pain relief.2) Stat EKG3) Cardiac enzymes every 6 hours x 3, first

set stat4) O2 2L NC, titrate to keep O2 sat > 92%RBTO: Dr. Von Sohsten/N. Bermudez, RN

Incident ReportsIncident Reports

What is an incident report?

What info do I include in an incident report?

Do I document the event/occurrence in the nurses’ notes?

How should I document the occurrence … what should I say?

Documentation in a NutshellDocumentation in a Nutshell

Documentation should tell a story without making it sound like a novel!!!

Parts of documentation are like pieces of a puzzle

Document facts

• Avoid judgments or suggestive comments


Be sure to TIME and DATE all entries

Change TIME and DATE to the actual time of occurrences

Incident Reports should not be documented as such

• Document details of incident only


Remember that the patient chart is a LEGALLEGAL document

ReferenceReference

Seeber-Combs, C. (2006). Mosby’s surefire documentation: How, what, and when nurses need to document, (2nd ed. ). St. Louis, MO: Mosby Elsevier.

Documentation 101 - BMH/Tele

Education

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