7 Documentation Written evidence of: The interactions between and among health care professionals, clients, their families, and health care organizations.The administration of tests, procedures, treatments, and client education.The results of, or client’s response to, diagnostic tests and interventions
8 Purposes of Documentation ResearchSatisfaction of Legal and Practice standardsReimbursemen tProfessional responsibilityAccountabilityCommunicationEducation
9 Documentation as Communication Documentation is a communication method that confirms the care provided to the client.It clearly outlines all important information regarding the client.
10 Documentation as Education The medical record can be used by health care students as a teaching tool.It is a main source of data for clinical research.
11 Documentation & Research The medical record is a main source of data for clinical research.
12 Legal & Practice Standards Nurses are responsible for assessing and documenting that the client has an understanding of treatment prior to intervention.Two indicators of the above are Informed Consent and Advance Directives.
13 Informed ConsentA competent client’s ability to make health care decisions based on full disclosure of the benefits, risks, and potential consequences of a recommended treatment plan.The client’s agreement to the treatment as indicated by the client’s signing a consent form.
14 Advanced DirectivesWritten instructions about a client’s health care preferences regarding life-sustaining measures. (e.g. living will and durable power of attorney for health care).Allows clients, while competent, to participate in end-of-life decisions.
15 Documentation & Reimbursement Accreditation and reimbursement agencies require accurate and thorough documentation of the nursing care rendered and the client’s response to interventions.
16 Principles of Effective Documentation Elements of nursing process needed tobe made evident in documentation include:Assessment.Nursing Diagnosis.Planning and outcome identification.Implementation.Evaluation.Revisions of planned care.
17 Elements of Effective Documentation To ensure effective documentation, nurses should:Use a common vocabulary.Write legibly and neatly.Use only authorized abbreviations and symbols.Employ factual and time- sequenced organization.Document accurately and completely, including any errors.
18 Methods of Documentation Narrative ChartingSource-oriented chartingProblem-oriented chartingPIE chartingFocus chartingCharting by exceptionComputerized documentationCritical pathways
19 Narrative ChartingThis traditional method of nursing documentation takes the form of a story written in paragraphs.Before the advent of flow sheets, this was the only method for documenting care.
20 Source-Oriented Charting A narrative recording by each member (source) of the health care team on separate records.
21 Problem-Oriented Charting Focuses on the client’s problem and employs a structured, logical format called SOAP charting:S: Subjective data (what the client states)O: Objective data (what is observed/inspected)A: AssessmentP: Plan
23 Focus ChartingA documentation method that uses a column format to chart data, action, and response (DAR).
24 Charting by ExceptionA documentation method that requires the nurse to document only deviations from pre- established norms.
25 Charting by ExceptionA documentation method that requires the nurse to document only deviations from pre- established norms.
26 Computerized Documentation: Advantages Decreased documentation time.Increased legibility and accuracy.Clear, decisive, and concise words.Statistical analysis of data.Enhanced implementation of the nursing process.Enhanced decision making.Multidisciplinary networking.
27 Critical PathwaysA comprehensive, standard plan of care for specific case situations.The pathway is monitored to ensure that interventions are performed on time and client outcomes are achieved on time.
28 Forms for Recording Data KardexFlow SheetsNurse’s Progress NotesDischarge Summary
29 KardexA summary worksheet reference of basic information that traditionally is not part of the record. Usually contains:Client data (name, age, marital status, religious preference, physician, family contact).Medical diagnoses: listed by priority.Allergies.Medical orders (diet, IV therapy, etc.).Activities permitted.
30 Flow SheetsVertical or horizontal columns for recording dates and times and related assessment and intervention information. Also included are notes on:Client teaching.Use of special equipment.IV Therapy.
31 Nurse’s Progress Notes Used to document:Client’s condition, problems, and complaints.Interventions.Client’s response to interventions.Achievement of outcomes.
32 Discharge SummaryHighlights client’s illness and course of care. Includes:Client’s status at admission and discharge.Brief summary of client’s care.Intervention and education outcomes.Resolved problems and continuing care needs.Client instructions regarding medications, diet, food-drug interactions, activity, treatments, follow-up and other special needs.
33 Trends in Documentation Nursing Minimum Data Set.Nursing Diagnoses.Nursing Intervention Classification.Nursing Outcomes Classification.
34 Nursing Minimum Data Set The elements that should be contained in clinical records and abstracted for studies on the effectiveness and costs of nursing care. Focuses on:Demographics.Service.Nursing care.
35 Nursing DiagnosesA clinical judgment about individual, family, or community responses to actual or potential health problems or life processes.
36 Nursing Intervention Classification A comprehensive standardized language for nursing interventions organized in a three-level taxonomy.
37 Nursing Outcomes Classification A classification system that comprises 190 outcome labels and corresponding definitions, measures, indicators, and references.
38 Summary ReportsThe outlining of information pertinent to the client’s needs as identified by the nursing process.Commonly given at end-of-shift.
39 Walking RoundsA reporting method used when the members of the care team walk to each client’s room and discuss care and progress with each other and with the client.
40 Telephone Reports and Orders Telephone communications are another way nurses:Report transfers.Communicate referrals.Obtain client data.Solve problems.Inform a client’s family members regarding a change in client’s condition.
41 Incident ReportsThe documentation of any unusual occurrence or accident in the delivery of client care, such as falls or medication errors.
42 Focus ChartingThe Focus Charting System is the accepted documentation system at Windsor Regional Hospital.
43 Advantages of Focus Charting Flexible enough to adapt to any clinical practice setting and promotes interdisciplinary documentationCenters on the nursing process, including assessment, planning, implementation and evaluationInformation is easy to find because data is organized by the focus.It promotes communication between all care team members.
44 Advantages of Focus Charting Encourages regular documentation of patient responses to careHelps organize document so that it is concise and preciseCan be easily adapted to computer based documentation systems
45 Focus Charting Combines The Focus: It describes the focus of actionsDAR format: Is the structure used to document patient assessment, care interventions or actions and patient responses to the actions or care
46 The Focus System Uses: Progress Notes Focus Lists Flow Sheets Care PlansFlow Sheets
47 Developing the FocusRefers ToExampleA patient behaviourInability to ambulateAn acute change in the patient’s conditionLoss of consciousness or increase in blood pressureA significant event in the patient’s therapySurgeryA special patient needDischarge planning needHypotension, or chest painA sign or symptomA focus may also be written in the format of a nursing diagnosis
48 Entering the Focus on the Focus List: A FOCUS LIST sheet is used as an index or quick reference for what you will find in the progress notes. All disciplines should record on the focus listEntering the Focus on the Focus List:The focus is numbered in order that they are listedDocument the focusThe date the focus is identified is indicated in the active column12Inability to ambulateChest painNursingNursing, PT11/12/01The dates are entered if the focus is resolved or resinstatedThe discipline entering the focus should identify themselves.
49 The Focus ListAdditional Information about the Focus ListFocus Lists must be regularly updated and expanded as the patient’s condition changesAt discharge, focus list needs to be checked to ensure that all the foci have been addressed and / or resolved.
50 Once a focus has been identified, a plan of care needs The Use of Care PlansOnce a focus has been identified, a plan of care needsto be documented.All disciplines should have a plan of care.“Care Plans” are included either as a standard nursing care plan or as an entry in the progress notes under the “A”.Standardized care plans should be activated with the patient and/or significant other’s input in order to make it individualized.Care plans should be regularly updated as required.
51 Flow SheetsThere are numerous pre-printed flow sheets available at WRHThese are helpful in accurately and concisely documenting routine and frequently collected dataUse flow sheets whenever it is logical and helpful to do so. For example: Any documentation which is required on a regular basis by hospital policy or standard.Any nursing care activity which is provided on a regular basis i.e. activities of daily living
52 Flow Sheets Examples of Flow sheets are: vital signs record, medication record,intake and output,post op flow sheet,wound assessment record
53 Flow SheetsAll flow sheets must be correctly dated and must contain the patient’s name on both sides.All entries on the flow sheets must be initialed (no use of check marks) by the person who assesses or provides the care and must have initials with full signature on a master copy.Any variances from normal should be recorded in DAR format01/12/02JS
54 Flow Sheets Do’s Don’ts Charting on the flow sheets should be done as the care is delivered or patient data observedDevelop assessment parameters that have meaning to everyone for example: Check abd incision q2h for drainage, redness, tenderness versus check incisionMake the flow sheets reflect the care needs of the patientBe conciseAnalysis of the trends in the patient data to assess if there are changes in the patients conditionWrite legiblyDon’t leave blanksDon’t squeeze data into spaces provided. If not adequate space it is necessary to progress noteDouble document in various parts of the charting systemDon’ts
55 Progress Notes Are Used to: Provide detail to data in a flow sheet. Document patient response to care.Record an unusual or unexpected event. record changes in patient condition and notification to the MDDescribe the status of the patient at the time of admission, transfer from one nursing unit to another, or at the time of discharge.
56 Progress NotesWhen writing progress notes you should include information about:The details about the patient’s condition (assessment data)The interventions or nursing actions implemented and their effectivenessThe patient’s response to care
57 How to Complete a Progress Note Notes are chronologically entered. The date and time is documented in the columns provided. The time and date you are actually writing the note is used.Nov. 12/011400O.T.#1 -Swollen painful left handD - Assessment done as per referralLeft hand swollen. Digits in extension.---Painful to passive rangingA - Discussed splint use and benefits with Pt.Splint molded. On-off schedule developed.R - Pt. concerned splint will be painful------The service or discipline writing the note is recordedK. Smith O.T.In focus charting the structure of the progress note that follows the focus uses a DAR outline: Data, Action ResponseWhen starting a note the focus is documented first
58 How to Complete a Progress Note D.A.R.Is an acronymDData - subjective & objective patient assessment data that supports the Focus Statement or describes observations of a significant eventAAction - immediate or future actions or plans of action or care based on the evaluation of assessment dataRResponse - the patient response to the action taken.
59 Progress NotesThe Response may not need to be immediately charted. There may not be an immediate response, therefore, only Data and Action may be charted Eventually, there should be a Response entered to that action takenJoan Smith R.N.Joan Smith R.N.There may be more than one focus that requires charting at one timeProgress notes must have a signature after each entry
60 Progress NotesDateTime22 June 981500Nrsg.#1 pneumoniaD - pt. c/o of chest pain on inspiration, fatigue.T-39.5 at 1515, wheezy breath sounds, productivecough for purulent tenacious sputum. IV infusing.A - 02 at 3 litres, chest x-ray this am, sputumfor C&S referral for chest physio. Tylenol ii forelevated temp at Fluids encouraged.Amy Nurse, RPNWrite patient progress notes only when necessary. The goal is to minimize duplication of information and to save time.
61 Focus Charting Do’s and Don’ts Progress notes can be improved by choosing language which is:ObjectivePreciseSpecificThoroughInconsistencies in documentation can leave you and the health care facility open to accusations of incompetence.A medical record containing inconsistencies can be difficult to defend in court.DO NOT use words like confused, uncooperative and depressed. These words may be interpreted in different ways and are not specific in accurately describing the patient
62 Focus Charting Do’s and Don’ts Poor WordingGood WordingEats poorlyPatient confusedUncooperativePatient complaining of painGood dayDiuresing wellWalking ad libAte 1/2 the meal and drank 80 ml fluidPatient unable to recognize familyRefuses to assist with am careComplaining of constant, sharp RUQabd. PainPatient states has been pain freewithout medication and still able tocomplete activities of daily livingLasix 10 mg IV at 1430 resulted in1000 ml of clear, yellow urine.Walks around the unit, up to the elevatorand back to room without any discomfort
63 Avoid Summarizing or using Value Judgements In SummaryBe FactualBe SpecificBe PreciseBe ThoroughAvoid Summarizing or using Value Judgements
130 รูปแบบการวางแผนจำหน่ายในปัจจุบัน รูปแบบ A professional-patient partnership model of discharge planningรูปแบบ The partners-in-care model of collaborative practiceรูปแบบ Structured discharge procedureรูปแบบ The A-B-C of Discharge Planningรูปแบบ METHOD
131 รูปแบบ A professional-patient partnership model of discharge planning รูปแบบนี้เน้นการพัฒนาความสัมพันธ์ระหว่างบุคลากรในทีมสุขภาพและผู้รับบริการ เพื่อจุดประสงค์ในการ พัฒนากระบวนการวางแผนจำหน่ายและผลที่ได้รับจากความร่วมมือของทุกฝ่ายจากการศึกษาของ Bull และคณะ (2000) พบว่า จากการใช้รูปแบบนี้ ผู้รับบริการและญาติผู้ดูแลมี ความรู้สึกว่าข้อมูลที่ได้รับมีความต่อเนื่องในการดูแลรักษา และเชื่อมั่นว่าตนเองอยู่ในสภาวะที่มีสุขภาพดี มากกว่าและใช้ระยะเวลาในการกลับมารักษาซ้ำสั้นกว่า
132 รูปแบบ The partners-in-care model of collaborative practice รูปแบบ The partners-in-care model of collaborative practice มุ่งผลของการ ใช้ผู้จัดการทางการพยาบาล (Nurse case manager) ในการประสานการดูแล ระหว่างแพทย์เฉพาะสาขา แพทย์ทั่วไป และทีมในการดูแลผู้รับบริการทั้งใน สถานะผู้รับบริการในและผู้รับบริการนอกรูปแบบนี้รวมถึงการเยี่ยมผู้รับบริการในโรงพยาบาลและที่บ้าน ตลอดจนการ โทรศัพท์ติดตามเยี่ยม ระยะเวลาตามความจำเป็น โดยหวังผลในการลด ค่าใช้จ่าย เพิ่มคุณภาพชีวิต กิจวัตรประจำวันเพิ่มมากขึ้น อัตราตายหรือความ เจ็บป่วยลดลง ดังเช่น การศึกษาในผู้รับบริการที่มีภาวะหัวใจล้มเหลว เป็นต้น