By James Avoka Asamani RGN, Dip., BSc (Hons), MPhil (Candidate) Email: avokaj@yahoo.com
Objectives By the end of this session, we will be able to Explain the purposes of documentation in health care. Discuss the principles of effective documentation. Describe various methods of documentation. Write standard nurses notes
A CHINESE SAYING If I hear, I forget If I see, I remember and If I do, I know!! What is documentation? What is Nursing Documentation? Documentation is any written or electronically generated information about a client that describes the care or service provided to that client. Documentation is an accurate account of what occurred and when it occurred. 6 What is documentation?- contd Documentation is defined as written evidence of: The interactions between and among health professionals, clients, their families, and health care organizations The administration of tests, procedures, treatments, and client education The results or clients response to these diagnostic tests and interventions
Why documentation today? Why documentation today? A recent study in Eastern Region findings are worrying; 54.2% of patient care records captured all the nursing care rendered However, 45.8% of patient care records did not capture some of the nursing care 63% of patient care records did not have nurses progress notes written after the first day of admission.
Common Documentation Errors 0.00% 10.00% 20.00% 30.00% 40.00% 50.00% 60.00% 4.10% 14.30% 10.20% 51.00% 26.50% 12.20% 46.90% 53.10% 57.10% 12.20% Percent of Patients' Folders Found Purposes of documentation 11 Purposes of documentation Professional Responsibility and Accountability Communication Education Research Legal and Practice Standards 12 Professional Responsibility and Accountability Recording provides written evidence of what was done for the client, the clients response, and any revisions made in the care plan. 13 Professional Responsibility and Accountability contd Recording documents compliance with professional practice standards and accreditation criteria. Written records are a resource for review, audit, reimbursement, and research. Documentation provides a written legal record to protect the client, institution and practitioner.
14 Education Health care students use the medical record as a tool to learn about disease processes, diagnoses, complications, and interventions. Clinical rounds and case conferences rely heavily on information contained in the medical record. 15 Research Researchers rely heavily on medical records as a source of clinical data. Documentation can validate the need for research. 16 Legal and Practice Standards In 80% - 85% of malpractice lawsuits involving client care, the medical record is the determining factor in providing proof of significant events. Nursing care and the documentation of that care will be measured according to the standard of a reasonable and prudent nurse with similar education and experience in a similar situation.
17 Legal and Practice Standards Informed Consent Advance Directives 18 Legal and Practice Standards Informed consent means that the client understands the reasons and risks of the proposed intervention. Witnessing confirms that the person who signs the consent is competent. 19 Legal and Practice Standards An advance directive allows the client to participate in end-of-life decisions. Patient Self-Determination laws requires health care facilities to document whether the client has such a directive. 20 Reimbursement NHIS evaluates medical records to determine if patient bills are justified Medical record documentation is the mechanism for the peer review.
Types of Documentation Front index sheet Temperature chart (vital signs) Fluid intake and output Nurses notes Special monitoring charts Ward report Annual report Incident report Medication chart (treatment chart) Admission and discharge book Ward statistics etc.
Principles of Effective Documentation A focus on Nurses progress notes Nurses Notes/Point of Care Documentation Nurses note is a report of the interventions carried out on the patient and its outcome. This type of documentation is predominantly used by nurses and mostly referred to during court proceedings.
24 Principles of Effective Documentation Nursing notes must be - logical - focused - relevant to care - and must represent each phase of the nursing process General Principles of Documentation Ensure that you have the correct client record or chart Document as soon as the client encounter is concluded to ensure accurate recall of data Date and time each entry. Sign each entry with your full legal name and with your professional credentials Principles of Documentation contd Do not leave space between entries. Never change another persons entry, even if it is incorrect. Use quotation marks to indicate direct client responses (e.g., I feel lousy). Document in chronological order (if chronological order is not used, state why).
Principles of Documentation contd Use a permanent-ink pen (black is usually preferable because of its ability to photocopy well). Document in a complete but concise manner. Document all telephone calls that you make or receive that are related to a clients case.
Elements of Effective Documentation 29 Elements of Effective Documentation Use of Common Vocabulary Legibility Abbreviations and Symbols Organization Accuracy Documenting a Medication Error Confidentiality 30 Elements of Effective Documentation Use of Common Vocabulary Enhances the quality of documentation. Supports the efforts of research. Improves communication and lessens the chance of misunderstanding between members of the health team. Never use words that others dont understand 31 Elements of Effective Documentation Legibility Make your handwriting readable Print if necessary. Do not erase or obliterate writing even if there an error.
Correcting a documentation error To correct an error in a paper-based nurses note, follow the SLIDE rule. Cross through the word(s) with a Single Line, Initials, Date and time of correction and Explanation.
(Baker, 2000)
33 Elements of Effective Documentation Correcting a documentation error 34 Elements of Effective Documentation Abbreviations and Symbols Always refer to the facilitys approved listing. Avoid abbreviations that can be misunderstood. 35 Elements of Effective Documentation Organizing your notes Start every entry with the date and time. Chart in chronological order. Chart in a timely fashion to avoid omissions. Chart medications immediately after administration. Sign your name and rank after each entry. 36 Elements of Effective Documentation Charting a late entry 37 Elements of Effective Documentation Accuracy Use factual, descriptive terms to chart exactly what was observed or done. Use correct spelling and grammar. Write complete sentences. Maintain continuity of care by recording with respect to notes made on previous shifts. 38 Elements of Effective Documentation Documenting a Medication Error Chart the medication on the MAR. Document in the nurses progress notes: - Name and dosage of the medication - Name of the practitioner who was notified of the error - Time of the notification - Nursing interventions or medical treatment - Clients response to treatment 39 Elements of Effective Documentation Confidentiality The nurse is responsible for protecting the privacy and confidentiality of client interactions, assessments, and care. The clients significant others, insurance companies, or other parties not directly involved in care provided by the health team may not have access to clients records. Guidelines for documenting assessment findings Record all data that contribute directly to the assessment (e.g., positive assessment findings and pertinent negatives) Document any parts of the assessment that are omitted or refused by the client Avoid using judgmental language such as good, poor, bad, normal, abnormal, decreased, appears to be, and seems.
Guidelines for documenting assessment findings Avoid evaluative statements (e.g., client is uncooperative, client is lazy); cite instead specific statements or actions that you observe (e.g., client said I hate this place and kicked dustbin) State time intervals precisely (e.g., every 4 hours, bid, instead of seldom, occasionally)
Guidelines for documenting assessment findings Do not make relative statements about findings (e.g., mass is the size of an egg); use specific measurements (e.g., mass 3 cm 5 cm) Draw pictures when appropriate (e.g., location of scar, masses, skin lesion, decubitus, etc.) Refer to findings using anatomical landmarks (e.g., left upper quadrant [of abdomen], left lower lobe [of lung], midclavicular line, etc.) Guidelines for documenting assessment findings Use the face of the clock to describe findings that are in a circular pattern (e.g., breast, tympanic membrane, rectum, vagina) Document any change in the clients condition during a visit or from previous visits. Describe what you observed, not what you did.
Methods of documentation Methods of Documentation Most methods of documentation fall into one of two categories: Documentation by inclusion and Documentation by exception (Coleman, 1997). Methods of Documentation 1. Narrative documentation (Story Writing) 2. Problem-Oriented Medical Record (POMR) or SOAP/SOAPIER and 3. Focus Charting or DAR (Data, Action, Response)
Any of these methods may be used to document on an inclusion or exception basis.
47 Narrative Charting
Describes the clients status, interventions and treatments; response to treatments is in story format. Narrative charting is now being replaced by other formats. 48 Problem-Oriented Medical Records (POMR) A single list of patient problems is made every day Uses a structured, logical format called S.O.A.P. - S: subjective data - O: objective data - A: assessment (conclusion stated in form of nursing diagnoses or client problems) - P: plan 49 Problem-Oriented Charting (POMR) Uses flow sheets to record routine care. A discharge summary addresses each problem. SOAP entries are usually made at least every 24 hours on any unresolved problem. SOAP was developed on a medical model. 50 Problem-Oriented Charting (POMR) SOAPIE and SOAPIER refer to formats that add: I: Intervention E: Evaluation R: Revision 51 Problem-Oriented Charting (POMR) Focus Charting (Also called DAR) With this method, the nurse identifies a focus based on client concerns or behaviours determined during the assessment. For example, a focus could reflect: a. A current client concern or behaviour, such as decreased urinary output. b. A change in a clients condition or behavior, such as disorientation to time, place and person. c. A significant event in the clients treatment, such as return from surgery.
Focus Charting - DAR Data: Subjective and/or objective information that supports the stated focus or describes the client status at the time of a significant event or intervention. Action: Completed or planned nursing interventions based on the nurses assessment of the clients status. Response: Description of the impact of the interventions on client outcomes.
Example of DAR 55 Methods of Documentation Computerized Documentation Increases the quality of documentation and save time. Increases legibility and accuracy. Enhances implementation of the nursing process. Enhances the systematic approach to client care. Provides clear, decisive, and concise key words (standardized nursing terminology). 56 Reporting Verbal communication of data regarding the clients health status, needs, treatments, outcomes, and responses Summary of current critical information to facilitate clinical decision making and continuity of client care 57 Reporting Reporting is based on the nursing process, standards of care, and legal and ethical principles. Reports require participation from everyone present. 58 Reporting Summary Reports Walking Rounds Telephone Reports and Orders Incident Reports 59 Summary Reports Commonly occur at change of shift (or when client is transferred). Assessment data Primary medical and nursing diagnoses Recent changes in condition, adjustments in plan of care, and progress toward expected outcomes Client or family complaints
60 Documenting a Telephone Order 61 Incident Reports Used to document any unusual occurrence or accident in the delivery of client care. The incident report is not part of the medical record, but it may be used later in litigation. SUMMARY In summary, regardless of the method used, nurses are responsible and accountable for documenting client care including assessments, interventions carried out, and results of the interventions on client outcomes. Clients who are very ill, considered high risk or have complex health-care needs require more comprehensive, in depth and frequent documentation by the nurse providing care
And finally, If you have been, Thanks for listening Avokas Research Interest Nursing management and leadership Adult Medical-Surgical nursing Health systems and policies Workload analysis Contact: +233 (0)246811379 / +233(0)209409458 Email: avokaj@yahoo.com