Healthcare Core Curriculum Competency 5: Report & Documentation Dede Carr, BS, LDA Karen Neu, MSN, CNE, CNP 1 “This workforce solution was funded by a grant awarded by the U.S. Department of Labor’s Employment and Training Administration. The solution was created by the grantee and does not necessarily reflect the official position of the U.S. Department of Labor. The Department of Labor makes no guarantees, warranties, or assurances of any kind, express or implied, with respect to such information, including any information on linked sites and including but not limited to, accuracy of the information or its completeness, timeliness, usefulness, adequacy, continued availability, or ownership. This solution is copyrighted by the institution that created it. Internal use, by and organization and/or personal use by an individual or non-commercial purposes, is permissible. All other uses require the prior authorization of the copyright owner.” 2 Explain the components of accurate and appropriate documentation and reporting including common medical abbreviations 3 Report: An oral, written or computer-based communication intended to convey information to others (Ramont & Niedringhaus, p. 85) Record: Written or computer-based collection of data (Ramont & Niedringhaus, p. 85) Medical or Clinical Record: ◦ Collection of all documents that are filed together to form a complete chronological health history of a particular patient (Juliar) ◦ Formal, legal document that provides evidence of the client’s care (Ramont & Niedringhaus, p. 85) Charting/Recording/Documenting: Process of making an entry into the client’s clinical record (Ramont & Niedringhaus, p. 85) 4 Notes and documents that health care workers add to the medical records Medical documentation is crucial for medical care and health care services. Aids in standard of care. Allows proper reimbursement for treatment. Neglecting to document a patient’s condition or treatment may have serious consequences in the future. “If it is not documented, it didn’t happen.” (Juliar) 5 Communication Planning client care Legal documentation Education, research, & healthcare analysis Auditing Reimbursement (Ramont & Niedringhaus, p. 86, 88) 6 Communication Vehicle or way by which different healthcare professional who interact with the client communicate with each other Prevents fragmentation, repetition, and delays in client care Record also provides a central location for notifying health professionals of the client’s needs, progress, & current status (Ramont & Niedringhaus, p. 85) 7 Planning Client Care Each healthcare professional uses data from client’s record to plan care for the client Example: Physician may determine that laboratory values indicate presences of certain microorganisms causing infection so orders an antibiotic Nurses use baseline & ongoing assessments to determine effectiveness of interventions & the nursing care plan Record provides a base from which all healthcare disciplines (workers) may coordinate client’s care (Ramont & Niedringhaus, p. 85) 8 Legal Documentation Record is a legal document & admissible in court In some jurisdictions, it may be inadmissible in court if the client objects, because information given to a physician or nurse practitioner is confidential (Ramont & Niedringhaus, p. 85) 9 Education, Research, & Healthcare Analysis Students use client’s records as an essential educational tool Record can be a comprehensive view of the client, illness, treatment strategies, & factors that affect outcome of illness Record information can be valuable source of data for research Review of treatment plans for clients with similar health problems can yield helpful information when treating new patients with same problem May assist healthcare planners to identify agency needs (can highlight overused or underused services Can identify services that cost agency money & those that generate revenue (Ramont & Niedringhaus, p. 85) 10 Auditing An audit is a review of records Client’s records are audited for quality improvement Example: Joint Commission (JCAHO) may review client's records to determine if a particular health agency is meeting its stated standards (Ramont & Niedringhaus, p. 85) 11 Reimbursement Documentation helps a facility receive reimbursement (payment) from the federal government Example: For a facility to obtain payment through Medicare, client’s clinical record must contain certain diagnosis-related group (DRG) codes & reveals that the appropriate care was given (Ramont & Niedringhaus, p. 85) 12 History, Physical, and Consultations ◦ Report on the initial finding of all physicians seeing the patient. Includes personal, family and social history of the patient. Physician’s Orders ◦ Written record of all medications & treatments prescribed for the patient. Diagnostic Tests ◦ Any report that includes findings in an attempt to diagnosis the patient (Juliar) 13 Admissions ◦ Completed forms and consent Surgical Procedures ◦ Consents for and reports related to any surgical procedures performed. Medication Record ◦ Includes all the medications that the patient is taking Progress Notes ◦ A written chronological statement about a patient’s care (Juliar) 14 Because client’s record is legal document & may be used to provide evidence in court must consider many factors in recording. Health care workers must maintain ◦ Confidentiality of clients’ record ◦ Legal standards in process of recording (Ramont & Niedringhaus, p. 85) 15 Date and time Timing of documentation Legibility Permanence Accepted Terminology Correct spelling Signature Accuracy Sequence Continued notes Appropriateness & completeness Conciseness Legal prudence Additional tips for documentation (Ramont & Niedringhaus, p. 85) 16 Date & Time Document date & time with each entry Make entries as soon as possible after performing observation/assessment; task/intervention Record time using either conventional time denoting AM or PM, or using 24-hour clock (military time) Avoid block-style charting in which an entire shift is documented under one date & time (Ramont & Niedringhaus, p. 85) 17 Timing of Recordings Follow agency policy regarding frequency of documenting Adjust frequency of documentation as client’s condition indicates--an unstable client requires more frequent observation & documentation (client in restraints needs frequent checking, observation, & documenting) NEVER record nursing care before it is provided (Ramont & Niedringhaus, p. 86) 18 Legibility Make all entries legible & easy to read to prevent interpretation errors Print your entries if cursive writing is difficult to read Follow agency policy regarding handwritten recording of healthcare worker’s notes Permanence Make all entries on client’s chart permanent, nonerasable blue or black ink according to policy Ensure record is permanent & changes can be identified (Ramont & Niedringhaus, p. 86) 19 Accepted Terminology Use commonly accepted abbreviations, symbols, & terms specified by agency policy Write a term out in full if in doubt about whether to use an abbreviation Correct Spelling Use correct spelling to ensure accuracy in documentation Look words up in a dictionary or other resource book if unsure of correct spelling Spell similar medication names correctly to avoid medication errors (Ramont & Niedringhaus, p. 86) 20 Signature Sign entries made in notes at the time you make the entry Use name & title in the signature-Example: J. Green, CNA would be correct, depending on facility policy Full signature should appear at least once on each page Use correct title abbreviations: RN=registered nurse; LPN=licensed practical nurse; SN=student nurse in RN program; SPN=student nurse in practical nurse program (Ramont & Niedringhaus, p. 86, 88) 21 Accuracy Check that you have correct chart by verifying client’s name & identification information stamped or written on each page before making an entry or filing a report Make accurate notations—ones that consist of facts or observations rather than opinions or interpretations [Describe what you see & hear, not what you think or interpret for client actions] Quote client directly in client’s exact words when documenting client’s concerns (Ramont & Niedringhaus, p. 86) 22 Accuracy Chart specific data rather than using general terms, such as large, good, or normal that can be misinterpreted [Example: “2 cm by 3 cm bruise”] Document a description of behavior you observed rather than using terms such as anxiety or agitation Document objectively-what you see, hear, feel by touch, smell Correct an error in documentation by drawing a single line through it & writing the word error above it, with your initials, or name, depending on agency policy (Ramont & Niedringhaus, p. 86, 88) 23 Accuracy Do not erase, overwrite, blot out, or use corrective fluid Write on every line but never between lines Draw a line through any blank space & sign the notation. In this way no additional information can be recorded at any other time or by any other person Never leave a blank lines about your entry or between your entries (Ramont & Niedringhaus, p. 86, 88) 24 Sequence Document events in order in which they occur: observations, tasks/interventions, & client’s responses Make a late entry by clearly labeling your entry as late according to facility policy ◦ Example: “Late entry [date] [time]” or ‘[date] [time] Late entry” Do not make a late entry more than 24 hours after the event. This is usually not permitted (Ramont & Niedringhaus, p. 86, 88) 25 Continued Notes Continue entries to another page by indicating that note continues & signing the entry. On next page, enter date/time of note & start it by indicating that it is a continuation Appropriateness & Completeness Record only information that pertains to client’s health problems & care Record all observations, dependent & independent interventions, client’s problems, progress toward goals, & communication with other disciplines (Ramont & Niedringhaus, p. 88) 26 Appropriateness & Completeness Document any care that was omitted & include why it was omitted & who was notified Use descriptions that are appropriate & accurate [avoid stereotyping] Conciseness Do not use client’s name when charting [since this is client’s chart you do not need to use terms such as client, resident, & patient (Check facility’s policy & procedures End each thought or sentence with a period; it is not necessary to use full sentences Write notes so that data that follows comma is associated with data that preceded it (Ramont & Niedringhaus, p. 88-89) 27 Legal Prudence Document accurately & completely to protect healthcare staff, the facility, & client Clinical record is legal document that provides proof of the quality of care given to the client Follow general principle, “If its not charted, it’s wasn’t done.” Follow agency policy & procedures for intervention & documentation in all situations, especially highrisk situations (Ramont & Niedringhaus, p. 89) 28 Client’s clinical record is legal document & admissible in chart which can be scrutinized by attorneys, Client may object because of confidential information Client’s record is property of facility Client has right to a copy of information, but will need to make a written request & pay for copying When charting, be sure to use objective, factual information rather than opinions & interpretations (Ramont & Niedringhaus, p. 90) 29 When charting, be sure to use objective, factual information rather than opinions & interpretations Not all data about a client should be recorded; any personal information that client shares & does not pertain to health problems or cares is inappropriate for the record Documentation is the determining factor in a great percentage of malpractice cases involving client care Important that you document client care clearly, concisely, & accurately (Ramont & Niedringhaus, p. 90) 30 Accuracy – Just the facts. Only the facts and not opinions or feelings. Legible – Make sure that whatever is charted can be clearly read Date – Be aware of what format is to be used. Example: 01/25/11 or 25/01/11 Time – 12 hour clock or 24 hour clock Full signature and title Correct spelling Because each healthcare facility may have their own abbreviations, avoid using them (Juliar) 31 Never erase, use white out, or corrective tape Draw a single line through the error Write in the correct information Date and initial the correction (Juliar) 32 Client’s record private & access restricted to health professionals directly involved in giving care to client Insurance companies have not legal right to demand access to medical records, even though they may be determining compensation to client. Therefore a client who is making a claim for compensation may ask to have medical history as evidence. In order for an agency to provide requested information, client must sign an authorization for review, copying, or release of information from the record. This form must specifically indicate what information is to be released & to whom (Ramont & Niedringhaus, p. 90) 33 Each healthcare worker has a password to enter & sign computerized files [Do not share these] After logging on, never leave a computer terminal unattended [If handheld, do not leave either] Do not leave client information on monitor where others can see it Follow agency procedures for documenting sensitive material Conditions for confidentiality same for computer records as they are for paper (Ramont & Niedringhaus, p. 90) 34 Either oral or written Purpose: to communicate specific information to person or group of people Report should be concise with only pertinent information Change-of-Shift Report: report given to all nurses on next shift—To provide continuity of care for clients to provide new caregivers with quick summary of clients’ needs & detail of care given May be written or oral, either face-to-face exchange or by audiotape recordings; sometimes given at bedside so all can participate (Ramont & Niedringhaus, p. 90) 35 Health professionals give reports about clients to healthcare providers and visa versa, to family members, and patients When receiving a telephone message, one should document: Date & time Name of person giving the information What information was received Sign notation Person receiving the message should repeat the information back to the sender to ensure accuracy 36 Juliar, K. (2003) Minnesota Healthcare Core Curriculum (2nd ed.). Clifton Park, NY: Delmar Publishers Ramon, P.R. & Niedringhaus, D. M. (2008). Client communication. Fundamental nursing care (2nd ed.). (pp. 226-242). Upper Saddle River, NJ: Person Prentice Hall 37
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