NURSE-3101 Lecture Notes - Lecture 9: Trailing Zero, Medical Record, Pain Scale

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Published on 29 Sep 2016
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Chapter 16 Documentation
Documentation
Written or electronic legal record of all pertinent interactions with the patient.
FIRST, A NOTE ON PRIVACY
oAll information about patients is considered private or confidential, whether
written on paper, saved on a computer, or spoken aloud.
oThis includes the patient’s medical record (written or electronic), telephone calls,
voice mails, fax transmissions, e-mails, and conversations with clinical staff.
Documentation Guidelines
AIM
oComplete, accurate, concise, factual, organized, timely.
Facilitates care coordination.
Legal document.
CONTENT
oRecord objective data and observations of behavior (not interpretations).
oDon’t generalize
“Seems comfortable.” (Use a pain scale instead).
oNote problems as they occur, in an orderly, sequential manner.
Record your nursing intervention and the patient’s response.
oDocument in a legally prudent manner.
oDocument date/time doctor notified.
Document doctor’s name and what you told them.
Document the response (“orders received” or “no orders received”).
Document if nurse manager notified.
TIMING
oDocument in a timely manner.
Follow agency policy regarding frequency of documentation.
Modify this if changes in patient’s status warrant more frequent
documentation.
oIndicate date and time entry was written.
Indicate time of observations and interventions if these are different from
time entry is written.
oDocument nursing interventions as closely as possible to the time they are
performed.
The more seriously ill the patient, the greater the need to keep
documentation current.
The following situations require complete documentation:
oPatient is admitted, transferred, or discharged.
oWhen a procedure is performed.
oReceiving patient post-operatively or post-procedure.
oCalling doctor about changes in condition or abnormal lab values.
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oAny change in patient status.
FORMAT
oCheck to make sure you have the right chart before writing!
Print or write legibly in dark ink.
oUse correct grammar and spelling.
Use standard terminology, only commonly accepted terms and
abbreviations. (Follow policy).
oIn a written document, never skip lines.
Draw a single line through blank spaces.
ACCOUNTABILITY
oSign first initial, last name, and title to each entry.
oDraw a single line through an incorrect entry, and write the words “mistaken
entry or “error in charting” above or beside the entry and sign. (Follow policy).
oAfter indicating the error, re-write the entry correctly.
oThe same procedure is followed on a computer.
The computer saves the erroneous entry with a single line drawn through it
and the re-written entry next to it.
oThe patient record is permanent.
CONFIDENTIALITY
oStudents allows access to patient records for educational reasons.
Student bound professionally and ethically to keep all information in
confidence.
Never use a patient’s name on your care plan.
Error Prone/ “Do not use” Abbreviations
Error prone abbreviations (some examples).
oOD, OS, OU (right eye, left eye, both eyes).
oo.d. (Once daily); q.o.d. (every other day).
oSC, SQ, sub q (subcutaneous).
o < or > (write out “less than” or “greater than”).
“Do not use” (some examples).
oU. or u instead of “units”
oTrailing zeros if greater than 1 and lack of leading zeros if less than 1.
Common Agency Policies
How often you must document.
Acceptable abbreviations.
How errors must be corrected.
How patients may access their medical record.
oRecord often incomplete until after discharge.
oMay review record if doctor or RN there to interpret.
oCharge for copying record.
oRemember: the hospital owns the record and is the custodian of the record
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It is the record of the hospital’s activities.
But, patient owns the information contained within and is entitled to
access to it and chance to correct it.
Purposes of Patient Records
Communication between disciplines.
Diagnostic and therapeutic orders.
oVerbal orders only in medical emergencies.
oRead back”: recipient reads back the order as he/she heard it; person giving the
order confirms correctness.
oPerson receiving verbal order enters it in record.
Then enter, “ v.o. Dr. Smith/A. Jones, RN”.
oPerson giving the order must sign it.
oCare planning.
oQuality process and performance improvement.
oResearch.
oAnalysis of hospital services (prolonged stays, etc.).
oEducation.
oCredentialing, regulation, legislation.
oLegal documentation. Patient records are legal documents.
oReimbursement.
Charts reviewed for evidence assigned DRG correct.
oHistorical documentation.
Methods of Documentation
Computerized documentation and electronic health records (EHRs).
oAll features of written record.
oWork list of patient’s treatments, procedures, medications for the shift.
oDocument immediately at bedside computer terminal.
oReady access to all computerized information (office visits, x-rays, etc.)
oProblem: not all computer systems talk to each other.
oProblem: computer security issues, passwords, hacking.
Source-oriented record (old fashioned hand-written chart).
oPaper format in which each health care group keeps data on its own separate
form.
oSeparate sections for nurse, physician, lab, radiology.
oMost recent entry closest to the front.
oEasy for each discipline to chart its activities but fragmented.
oProgress notes: notes written to inform caregivers of patient progress (doctor, PT,
social worker).
oNarrative notes: progress notes written by nurses; address routine care, normal
findings, patient problems, nursing interventions, patient responses.
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