Transcript for:
Nursing Documentation Fundamentals

okay hey everybody this is your fundamentals documentation chapter this is chapter three in your fundamentals book let me share my screen we'll get started okay so the first thing documentation this this is so critical in nursing I cannot even tell you how critical it is it's right behind actual patient care so so documentation should be concise not you're not going to write you know a dissertation or anything it should be concise to the point accurate and a permanent record of past and present medical and nursing problems um it should also include the plans of care the care given the patient response to treatment just everything about any type of care this client receives anytime we add any type of information to the Chart we call it charting or documentation good documentation should always reflect the nursing process and we've already been through the nursing process um or we're going through it with this test so you should know those six different steps so basically let me switch slides basically these are the main documentation purposes first is communication so that's communication between all Health Care um providers or team members so all the way from your providers your nurses your uh lab your you know everybody um therap Radiology it's it's just all the members of The healthc Care team now um accountability so documentation shows what you have done for this client all right but it also holds us accountable for what we have done for the client so we use um these things are used for auditing to make sure that we are doing what what we're supposed to do in the different circumstances as well as monitoring to make sure that we're documenting comprehensively are we doing something wrong what's going on okay now the um the thing to remember is that documentation includes the intervention itself the time when the care was done and that is so critical that you get the time correct so when you're in the client's room if for some reason you don't have your um the computer on Wheels the cow um then make sure you jot a time you know like let's say you were putting in a catheter make sure you put the time that you put in the catheter so that when you get out to where you're going to document you have the time that actually occurred and the reason why that's so important well one it helps show a timeline and that's so critical to show what we did and in what order but also remember respiratory therapy is recording or documenting in here you know all these other people the different different nurses if they're involved in the care so you want your time to be as accurate as possible because something's wrong if let's say you're in a code and um the resport therapist documents that 3:00 was when the patient was intubated by them and then you've got you know 3:30 or something like that so make sure that y'all keep up with those times and that they are accurate don't just guess and say somewhere around 245 or something like that because if you happen to end up in court the prosecutor is going to point out all these inconsistencies in the record so make sure that you are very concise uh And Timely with your documentation uh it should also include of course your signature now if it's a written documentation then you're going to of course sign it and then if it's an electronic health record it automatically puts in there the time that you make that documentation now let's say that you go in and you put that catheter in at 3:00 pm. well let's say for whatever reason you have another patient that's vomiting or something you have to go take care of them before you can chart and you sit down in front of the chart make sure if you're doing a computer chart that you actually go in there and change the time of that documentation that it occurred at 300 p.m. if you just go in there and start typing it's going to record it done at the time you started your documentation so do y'all see what I mean so if you're not recording at the bedside when you do something then you need to change the time to reflect when it actually occurred that's very very very important now so we got the Intervention when the care was done your signature and of course your title and for nursing school you'll be SPN all right let's see what else I've got on here um all right accountability so accountability we said audit and monitoring so the auditor we we will have internal Auditors and we will have exter internal auditor so the auditor will examine the patients charts and health records they'll see if their orders were documented um were the responses to interventions documented and I think that's probably one of the things that nurses do the worst on is that we may have a person who says you know I'm hurting we may correctly document their Pain Scale um are their pain level it's a numerical guide that we're going to get to soon but we never go back after we get we give the pain medicine and we never go back in about 30 minutes to see is their pain relieved and did we document it see a lot of times we go back in there like how's your pain oh it's so much better it's uh let's say it's a four now and where it was an eight um but if we don't document it it wasn't done so and you can't sit in court and say well I asked her and she said it was fine I mean really are you going to remember that from a year ago so make sure that you document those follow-ups that's super important um it's also used for medical peer review sometimes used by government and other agencies such as insurance Medicare Medicaid it can also be used for accreditation purposes like accrediting for the hospital or the longterm Care Facility or whatever place you were working for um let's see it also has to do with reimbursement or money for the care provided so if you do not document that you put in a fley then the facility loses the money that they should have received for you doing this procedure and all the um all the um equipment you use so they just lose that money so and I always think about it that could have been my raise like I want my raise so I need to document everything that I do so that you know the facility is in good Financial shape um let's see what else uh I said accreditation okay so inhouse auditors also like our people in that facility also do audits um they see if um again the provider uh prescriptions or orders so you're going to hear that physician orders are now called physician prescriptions or provider prescription so it's not just medicines anymore if they order a fly catheter then that is a prescription so are all the things that you're doing documented um are you documenting their responses are you documenting um when you take them to uh x-ray in back and stuff like that so we got to make sure that we have concise complete and accurate documentation right it is a legal record and it can be used in court that's important to know um charting uh is the only proof that you have that you provided the care that meets the patient needs and the standards of care that we talked about earlier in the legal and ethical um chapter and like I said it can be used in court now the provider or the facility actually owns that chart but it can be subed by lawyers as well as the court to be used in legal proceedings now the one misnomer is the patient thinks they own the chart and that's not true the patient is not own the chart but they can get a copy of their chart but they have to follow um whatever the protocol is most of the time the protocol is you know they'll they'll get it within so many days like they can't just walk in and say I want a copy that doesn't work that way you have to request it in writing usually they have a policy that says it has it can be given to you within such and such days like a week or a month or whatever and then usually there is a charge per page that has to be um paid so you can't just go get 200 pages of chart you know you have to pay per page all right so Financial billing is the next thing so insurance companies will go um buy the documentation to pay for bills like if if the um business office sends in that they had you know 12 nebulizer treatments where they're going to go look and see were 12 nebulizers treatments documented um the facility will also review documentation for charges to make sure that everybody's capturing it so when it comes down for them to actually come in and do an audit for medic Medicare Medicaid Insurance things like that that everything is being captured now hospitals are reimbursed by drgs that's diagnosis related groups and so it basically means if somebody has pneumonia then you're going to get probably this much money or if somebody has this you're gonna get this much money so on and so forth and of course then you have to prove that you provided the care under that drg testing and research I mean teaching and research sorry um teaching of course to provide examples and you will hear all of us give you um examples things that have happened to us in our nursing practice um that will teach you things not to do or things to do so you'll hear a lot of that and also um research uses uh charts to gather um information like if they're doing a research on let's just say how Lasix um affects output which is really simplistic but then they can get this documentation from all these charts that people have been on Lasix so um that's really a good thing now um most places now have gone to an electronic uh health record or you'll see electronic medical record most common is EHR and um so you'll see the majority of that they are very expensive on the front end those um documentation um platforms like epic and things like that but uh as you go along not having to print all the paper um All That is supposed to decrease the cost in the long run so it does increase efficiency consistency and accuracy and I'll tell you it is really good to increase the level of charting that you do for example um you'll you'll be you know when you collect data on your patient you do that head-to toe assessment you're going to go in your document a lot of times they have flow sheets that have drop- down buttons that you choose the appropriate what you found in your client you choose it okay so um and then they'll have like subcategories and stuff something you may think I forgot I forgot about that so I do need to document that so it increases the accuracy and much more um detailed um documentation than what we had back when we just did narrative charting now sometimes there are facilities that have paper charting but it's not that often um because they're supposed to all be under computer charart in now if the if the electricity goes out or the computer charting goes down then you do have to document um written so just be prepared for that okay it does help with leg legibility because let me tell you some people can't write and you have to decide and that's doctors as well as nurses you have to decipher what it means which is really bad if you're trying to prove something in the court and you can't even read it so it does help greatly with legibility now um there are things that are really nice about the EHR is that you have um a lot of facilities have point of care documentation where you can actually document at the bedside like if you just put in that FY catheter you document it right there um on your little um computer on wheels or they sometimes they'll call it workstation on wheels so a cow or a wow but anyway you'll take that and drag it around with you as you do your uh care so that's really good um because it's much more accurate because you're documenting right when you did it which is what you're supposed to do now there's also um voice charting now it has not been quite as um it has not been quite as as um popular because there's a lot of trouble with um like the computer having to um learn the voice for we had that a facility I was do in at and I know we had to like train the computer in our um how we sound you know our dialect and things like that it had to learn us it was really nice because we could just hit and say you know room 202 gave a bath blah you know whatever and it would document these things but there were a lot of problems with incompatibility between the actual speaking and the documentation but there are those out there so the big thing about EHR is is what they're wanting what they're wanting to do is they're wanting to and you'll see that now within Health Systems like let's say you go to I go to my doctor here you know and I have a UTI or whatever and I'm on this antibiotic and then let's say for whatever reason I'm admitted to a hospital in Jackson in the same system well they already have my records from my home place because they're all in the same system the same um whatever and then let's say I have thyroid problems so then I go see my thyroid doctor and they're in the same system and so they have the record of my UTI they have it of my hospitalization and they have it now and now they're entering the stuff about the thyroid which is really nice they foresee that all these systems are going to become linked at one point is what they're hoping so that everybody's records are available wherever they happen to go so if I happen to go to um you know California and have a stroke or whatever ever my records would then be able to be pulled up there but yet I'm from Mississippi so you know they're hoping that it'll get there we'll see I don't know but they have made great strides already okay um some can uh some systems can pull up information from electronic devices so let's say we're in the hospital a lot of times like for example um if you check a glucose on a glucometer a blood sugar then um a lot of those devices will send that information right to the Chart like you don't have to then go over here and document that your uh glucose was 20 whatever five milligrams per deciliter it sends it directly there which is fantastic same thing for Vital Vital Signs machine sometimes it'll send it directly to the Chart or say you have a monitor and you've got you know heart rate blood pressure um oxygen saturation so on and so forth a lot of those will automatically document so those are all good things about electronic charting okay patient portals just a quick little thing I feel like everybody has probably gotten something about a patient portal if you go to the doctor now um most of the time you're going to get an email that says um your visit today view the notes from your visit today or view the lab from your visit today or you have test results and so you log in and voila there you go and a lot of these same portals will allow you to send messages to the um provider well it goes to the nurse and then the nurse asks the provider and they they so they you can communicate with them without having to call wait for a call back it's much more efficient it's quicker so that's some benefits from uh that type okay um the SAR so we used to use the SAR only now we have the SAR which is just a little bit more uh detailed and so here is an example that um we have so you have the I is identification and introduction and so here's an example um from Miss Bel hello Dr Green this is Mary Clayton Bel I'm a nurse at Baptist at Jackson then s is the situation I am calling you about Mr Walter's pre-discharge lab results then the background all his labs are within normal limits except his potassium is 3.1 which is low a as for assessment when I was speaking to him about his home medicines he said he hasn't been taking his potassium supplement for two weeks he says he forgot to refill that as and has continued taking his Lasix and you'll learn that Basics causes us to lose pottassium so that's why this is relevant and then R is the recommendation um could we give him a new prescription and include the details on his discharge instructions and then um the last one that's really important is to remember anytime you're getting an order um like they say they send a an order back then you need to read it back to the phys position so prescription for this Mr Walters date of birth 5565 pottassium 10 mli equivalent poid and including discharge instruction so you read it back and that is a clarification that you got the message correctly so um these things um this isbar is great way uh to communicate between healthcare workers you can also send these to like therapy and things things like that uh but it does improve communication makes it um much more clear so it is considered a safety measure to prevent erors from poor communication it is recognized by The Joint Commission who is one of the top accreditors in the United States uh as a method of meeting patient safety goals when this occurs over the telephone with the healthcare provider a facility often mandate mandates um using an acceptable communication exchange that includes a readback like we said at the very bottom and so the nurse has to readback that order to verify that it's correct so we don't make mistakes it's just a check and balance okay General documentation guidelines so um our documentation should be factual you don't put your opinion you don't tell what you think about this person or who the family or whatever it should be factual and it should include subjective as well as objective so remember subjective the patient has to tell you objective is something you can measure see taste touch you know whatever um no judgments um or unclear documentation everything should be very con concise very accurate um if the client states something then we need to document um indirect quotes so don't say something like patient stated that he will get his um prescription when he goes home okay that's not a direct quote a direct quote you would say that the client states and then quotation marks I will get my prescription when I get home End quotes so it has to be exactly what they say if you say stated and you're doing a direct quote it's got to be in quotations and it's got to be what they say verb verbatim if you are summarizing then you don't put it in quotes you know you just put what they the ass summation of what they said okay all right so let's see we said accurate and concise quality and accuracy of nurses notes are extremely important this is our legal defense remember you know how text messages can be misleading and that's a good point you know I might take something one way and you might take something another way so uh it's very important that we are very concise and clear clear and we don't use jargon and when I say jargon that means like nurse speak you wouldn't say po bid they'd be like what I don't know what that means you would put by mouth twice a day okay spelling and correct English so we do not chart in full sentences no we do not do that but we do have to pay attention to spelling and that's why in the program you are going to be required to spell stuff correctly um so you know you'll be taken off of if you don't spell it correctly so you need to make sure you start working on that you should use good grammar and punctuation is so important um all of all of your documentation says something about you so you want people when they read your document documentation to say oh she knows what she's talking about he is very uh professional and he is very competent now do I know that he's competent based on his documentation well I can get an idea but if there's bad grammar and they can't spell whether you want to or not people are going to get a bad um impression of you as a nurse Okay so make sure that you use good spelling grammar and punctuation okay punctuation let me give you an example so let's say that um you read this there's no punctuation okay so you read um large BM ambulating in the hall what what is that what does that say it tells me that there's a large BM walking down the hall okay what if it says large BM period ambulating in Hall then they're saying that this client has a l had a large bow bow movement they really should give more details but large bow movement and then the client ambulated in the hall so that's kind of a humorous one but see if you get my point okay so we're we're charting in fragments not complete sentences or you'll never finish your documentation so documentation is about the client and their condition the entry should be made when the condition um of the patient changes so when when you get there you're going to do a comprehensive head-to-toe assessment okay you're collect all the data from head to toe and you're going to document it and then at least every two hours you've got to have some sort of documentation in that chart to let us know that they're okay and that they're alive don't just say you know sleeping or good hours or something terrible like that say something that tells something about it so if the patient is in the hospital for pneumonia then we need to say something about why they're there you know you can say resting quietly with eyes closed respirations even and unlabored um rate 16 per minute um no uh coughing noted or you know whatever so I don't just say they're good or whatever so make sure that you document and document to why they're there unless of course something additional happens then you've got to add it but just you know we have to have something in that chart at least every couple of hours and then anytime something of the patient changes then you need to document or if you do any type of procedure or if they leave the um unit you have to document how they left where they went you have to leave when they came back how they came back that type of stuff so it's best uh documented when it's it's done you know when it immediately occurs so again reminder the RN is responsible for the initial admission assessment charting as well as the care plan and the LPN does contribute to that documentation so record all assessments interventions referrals any instructions or teaching that was given as well as the patient response remember the saying is if it didn't I mean if it's not documented it didn't happen if it's not documented it didn't happen so you've got to document everything that decreases a nurse's liability whereas poor documentation causes an increase in a chance that the nurse will get a malpractice charge okay so on page uh 44 box 32 are the basic rules for documentation so um we're going to go through them real quick all documents should have the correct patient name identification number date of birth date and time if appropriate so if you are doing written documentation and you get a new nurses note you have to stay stamp that page with the clients they they will each have a label that you've got to put on there so go get the label usually they're in the chart pull a label off and make sure you put it on there and that it'll it'll all have all this stuff on there avoid use of General empty phrases and I just said that like status unchanged good hours don't ever document that don't ever document that be objective in charting only what you see hear feel or smell so concise objective information you don't say well I think blah blah blah exactly what you see uh another example of this is a lot of people like let's say a patient falls okay you walk in there and you see that there's urine beside this patient okay well it's very easy to say the client got up walking to the bathroom had an ex accident and fail okay that's not objective you say client states or you go in and say found client on the floor next to the client was a um you know large area of uh urine you know so you just say precisely what you observed not any any extra information like this is what I think happened or and I have actually read stuff like that this in other charts if that if if um if this nurse and they would put their name had not um left the client in the bathroom they wouldn't have fallen or something like that W you never put that you put exactly what you see CU you don't know that you have no idea what happened so just put precisely What You observe okay um oh let's see where was I make sure that it is timely specific accurate complete chart care after it's provided not before and I have seen some people document medications as well as care like they just went in and documented all the stuff that they were GNA do and then maybe the patient died or maybe the patient was vomiting and couldn't take any medications or maybe and this has happened at one time the Attorney General was going around in the middle of the night checking to see if nurses had pre-doc and if they found they had predent they brought them up on charges for fraudulent documentation and they lost their license so don't ever chart before something is done even if you have all the intentions in the world of doing it that's great but don't chart until it's actually been done and don't chart everything at the end of the shift that's also bad so don't say well I'll just document you know my last hour and you'll see nurses do that and that is absolutely Incorrect and it can also get you in trouble don't wait till the end of the shift to document you don't remember what this patient especially if you have a lot of patients okay uh chart chart all ordered care as given or explain the deviation um like let's say that um they came to draw blood on the client and the client refused okay so that's a deviation so you need to chart that that the patient refused to allow lab to draw the blood and you need to go in there and try to find out why they are um refusing it because you may uh be able to show them that they need this lab chart as soon and as often as necessary chart facts no judgment no placing blame on other people chart only your own care observations and teaching never chart for anybody else if somebody says hey will you chart um whatever don't do it the only time you can do that is if you actually observed whatever they're wanting you to chart about you actually observed it so you can chart it but don't chart for somebody else that's very bad and it can get you in trouble don't do that kind of like U people asking you to um clock them in that's a big no no you don't ever clock in for anybody else either okay describe each item as you see it um and then this is really important so it says for example white metal ring with clear Stone don't say it's a diamond ring do you know that's a diamond ring you don't know that's a diamond ring even if the patient says this is a diamond ring you just describe it don't say that because then the hospital or the long-term care facility could be held liable for a diamond ring that really was not a diamond um document only What You observe not opinions never use charting to accuse someone else and I have seen that fill all spaces leave no empty Lines no empty space and chart consecutively so if you're using written charting and let's say you have you don't have enough room to have the word that you're gonna put on the next line draw a line through it because you don't want somebody inserting there write in something that you didn't do and go line by line never skip don't indent um never leave space follow each institution's policies and procedures for charting grammar punctuation I already said that if a charting era is made identify the era according to the facility policy and make the correct entry typically if you write something wrong you put one line through it and put void and your initials um don't scribble it out you have to use permanent ink so you can't use erasable ink so you can just you know uh erase something you have to put one line through it or whatever if you scribble it out or whatever it looks like you're trying to hide what you put so you just put one line void and CB or whatever your initials are okay um if you question an order so let's say that um you have an order that you think is potentially wrong like um this patient has been receiving Lasix 20 milligrams but the doctor this time ordered 100 milligrams or 200 milligrams then you should call and clarify that order with the provider and so you always have to chart that because if you don't then the next shift is probably going to do the same thing and that doctor's going to get mad everybody keep calling so you document in the chart and you uh put in a doctor's uh prescription in the chart showing clarification so you put clarification order las6 20 milligrams PID or whatever it is and then you know whoever the doctor is and who you are okay so um always write a clarification order don't forget to do that and then make a note also in the nurse's note we already talked about uh documenting the response to um treatments like we said if they're having pain did you go back and make sure that the pain is relieved and document it sign each um chart charting um section so you would you would sign each section so you had you would put the date the time now this is written date time and then write out your section and then you're going to put like I would put C Blair RN whereas you would put C Blair SPN so you're a student practical nurse okay so you always end each section that way if it's electronic charting it will automatically sign for you so you do not have to type your name in in each section if you're doing electronic charting it will automatically put Christy Blair documented this at this time on this day okay so you don't have to do the date and time either use direct quotes when appropriate use only approved abbreviations in medical terms we're going to talk about that more um use only um hard pointed permanent black ink pens no erasing um you know the erasable ink no white out should ever be used because it looks like you're hiding something that's absolutely against the rules uh for written charts when a patient leaves the unit then you chart the time and the method of transportation where they went and then how they came back the time you know and all that good stuff when making a late entry note it as a late entry and then proceed with your documentation so you would say like like let's say that um it's the end of your shift so it's 7 pm and you realize oh my gosh I forgot to document that um they vomited what blood or whatever so you would go you would under that last charting you made you put um the date the time late entry and then put when it should have been and then make the entry okay and you do not need you need to do that as soon as possible don't wait till the next day or whatever but as soon as you remember you forgot to document it make that entry and of course write legibly if it's written documentation okay legal um guidelines for documentation so follow along on page 45 table 32 um so you always begin with the time and date um a lot of places require military time the majority require military time but there are some exceptions um make sure that it's ible non- erasable Ink No blank spaces no correction fluid no blackened out correct per protocol um so we've already I've already gone over late entry now if it's an electronic health record um and you have missed information then what you do is kind of like I said earlier you would go in there like I said 7 P p.m. but you did it at 2 p.m. so you would um change the time to 2: p.m. okay like when you do a new note it pops up and it has a little thing about time and you put the time that it occurred okay and then so once you document that it's going to show that you entered this at 7 p.m but it will say that it's actually actually an entry for 2 p.m. that you had forgotten okay okay so that's it's easier with electronic charting but just remember it's going to tell it's going to show exactly when it was entered and the reason I say that is because some people think they can go back like let's say that they did something wrong and they were trying to cover their tracks they might go back and document something from a week ago well you know you should that's going to be a lot of red flags right there and so they'll bring that out so don't do that okay sign each entry with the name and title it's automatic if it's EHR remember you don't have to do that reflect assessments interventions and evaluations and then make sure that you keep your password private if you are using electronic health record all right so let's see um I already said chart only for yourself if you have to chart something for whatever reason that someone else told you then you would say um you know um such and such whoever the person is Susie Joe um LPN stated blah blah blah blah blah and that way you are showing who said that they did that so then they would go to that person to find out about you see what I'm saying if you have to make sure that you credit that other person and that's a very rare thing that happens okay oh oh another thing be very careful about abbreviations like BS can be breath sounds bowel sounds blood sugar so you you wanna if you're doing electronic you're going to want to write that out same thing with the written okay best to chart immediately make sure you document the right time we've been over that we've been over clarification okay on page 45 I told y'all to look at it let's see if there's anything that we did not cover in this we did the first one no critical comments we did that record all the facts no blank spaces legibly we talked about clarification chart only for yourself okay we did all that perfect okay this is just a reminder of military time I know y'all been through that in live right the different documentation formats you have traditional or Nar charting which we've been talking about it's recorded in sequence know your facility's policy whether they require this some facilities will have a flow sheet that you fill out and then they also want um narrative charting also um so make sure that you follow the policy I personally believe the more you document the better off you are because you're covering yourself so um you will have to do an assessment once every shift at the beginning of the shift GI or when you receive a patient and then um you will you know do focused assessments like if something happens during the the shift um say they start having shortness of breath and you're going to focus in on that respiratory system so make sure that you show you know you did that head to toe assessment first and you document all of that in the time and then as you're doing those additional assessments you know if something comes up you charge about that so at least something every two hours or sometimes it's more often than that if there's a lot going on with your client just document everything that you do um also you want to document um safety like that the bed is in the low position the wheels are locked the call light is in reach those things should also be documented um sometimes they're on flowcharts uh and sometimes you actually have to write them out in narrative charting so traditional narrative is divided into sections or blocks with specific sections so um the chart is made up of tabs so they'll have a tab like they'll have provider orders they may have history and physical nurses notes lab x-ray so on and so forth so they'll have tabs to the side um but in the nurses note of course you will um and this is for EHR as well as written you will um cluster data by symptom by symptom by System okay so all the neuros should be first and then as you come down you know then you whatever's going on you know with this patient all the respiratory should be together heart should be together G should be together you see what I'm saying as you go down make sure you cluster all the day data together it reads better it's much easier to follow and and it's the way you should do it correctly um let's see in sequence assessments any patient needs anytime you call the provider you need to document that you call the provider and then when they call back or whatever they said any new order so absolutely document that if you notify the charge nurse of anything document that you notifi the charge nurse any care treatments Etc and all responses now another type of charting is pomar which is problem oriented medical record and so it's according it's organized according to scientific problem solving [Music] on page 46 figure 33 you'll see part of it's like a little Master list and you put like if something's been resolved then we resolve it a certain day or whatever I don't most people don't use pomar um it's kind of not necessarily used now there is another type that's kind of a subcategory of pomar and that's your soap or soapy um documentation we're going to get to in just one second Focus charting is a modified list of patient problem statements and is used as an index and they document that as dare and so d stands for date a stands for Action R is response or evaluation and E is education and patient teaching and that is in your book on page 48 flowchart are like the ones I was talking about where they have the little drop- down boxes and you choose whichever one is correct some of them also like they may have an an intake an output flowchart and so you would actually if they urinated 220 CC's at you know 9:00 you would go and document that at 9:00 they had 220 cc's of urine or if they had a bow movement at such and such a time or output or whatever so those are also flow sheets charting by exception is um something that uses standardized forms so identifying norms and allowing selective documentation of abnormal findings so the the reason they some people like this is if it wasn't charted then it's considered within normal limit limits um I like to just put everything again just to cover myself but these charted by exception they chart one complete assessment at the beginning of the shift and then the rest of the assessments are charted by exception so you would just document abnormals any changes any new concerns um of course we've been talking about computerized charting um ongoing now look on page 47 uh box 33 and you'll see soapy and soapier documentation formats let me see scoop scoop scoop like right here here's an examp example of soapy charting so the S is subjective data and so this is what the patient reports um o is objective data so that's things that you have measured or can see or whatever smell a is assessment what's your assessment of the situation p is the plan that you're going to do based on what the problem is e is evaluation see how we evaluate it and then the soapier I is for interventions that you do e is for evaluation and R is for revision so again those are on page 47 if you want to look at examples of that all right so different facilities have different forms um so it depends on where you're working some of these forms help with preventing duplication so it's unnecessary to chart a narrative note every time you give a med and take Vital Signs so for example if you're given medicines then you document those on the medication administration record or Mar you don't have to then go to the nurse's note and write out that you gave this med this med this med this med so you don't need to chart that in two different places so the mar takes care of that you know you don't have to redo so there are different forms like I said there's nurses notes and that's of course where you'll do your primary documentation progress notes is typically where the provider documents their daily notes graphic sheet is typically um like a log of their Vital Signs and it's uh visual so that they can see if the temperature is spiking at night or whatever and the heart rate and so on and so forth so so they show Trends some places have gotten rid of the graphic sheet but some providers still like it and want it um Physicians orders um it should be now provids orders of course that's where all their prescriptions go admin admission summary this is where the uh re will document the admission assessment discharge summary uh we're going to go over that shortly it's just specific paperwork for discharge the bedside flow record are the flow sheets like we talked about previously there may be one called daily assessment um that's where you document each system and then sometimes those are found um under the nurses note it just depends on the system that you're using and then the Vital sign flow record where the Vital sign actually the numbers go not the visual thing okay so here are the dues of charting and it's a big thing that students do uh incorrectly in the um clinical setting is that they um start documenting and they don't make sure they're in the right chart if they have an electronic chart even if it's written I've had students they'll just grab a chart they'll be thinking about Miss Smith but actually they have Mr Jones so make sure that you have the correct chart before you begin writing or typing and then make sure your documentation reflects the nursing process and your professional capabilities write legibly chart the time you gave the medication the administration route and the patient's response that would be on the mar um if you give a PRN medicine which is an as needed medication and typically those are in response to something that happened in addition to the normal medicines that they take like pain then um you know you would have to chart this additional information and it depends on the facility a lot of times you chart all of that in the M then occasionally you'll have a system a documentation system where you have to also make a narrative note so just whatever the facility policy is is what you need to follow chart precautions and preventative measures Ed such as bed rail um anytime you call a provider include the exact time the message and what their response is Charter patient refusal for a treatment or a medication and make sure that you report that to the charge nurse Andor the provider um chart patient care at the time you provide it and if you remember a late Point remember do the late entry so again so important chart the patient's response such as did it work okay the don'ts of charting don't chart a symptom such as complaints of pain unless you chart what you did about it so um this I see this a lot in student charting they'll chart um that the patient had um a Pain Scale of eight on a scale of Zer to 10 and then they keep right on trucking and then I look to see under that is there another you know note that says you know um that a pain medicine was given or that they reposition the patient or whatever it is that's causing the pain did they correct it if they can correct it um so make sure that you document what you did don't alter the patient's record it's a criminal offense like if you're trying to cover something up nope don't use shorthand or abbreviations that aren't widely accepted only the actual docu um the abbreviations that are approved don't write imprecise description such as bed soaked or large amount be as precise as possible don't give excuses such as medication not given because not available get up and go get the medication go to the pharmacy if they don't have a pharmacy long-term care facility ities should have a um um like a kit that has medications that get you know ordered over like in off times like if the provider orders an antibiotic then usually they have them in this lock box that you can get for after hours but don't say it's just not available do something about it don't chart with somebody else heard felt smelled unless the information is critical and then remember attribute it to that person and I've already talk to you about charting ahead of time now here's an example of a nurse's note now I want to point out this is probably an electronic charting right here if it was a written charting well first nurse's note wouldn't be here but you would put the date the time and then you would start documenting okay and then at the very end you would put your first initial last name and SPN okay and so if you look um you'll see that um they're charting in fragments okay it it's not whole sentences complete sentences is fragments right so that's just an ex example already looked at soapie soop all right special forms your cardex your cardex is on page 53 and and I will say most facilities have gotten away from using card X's now um because nurses often don't update them when they're supposed to or you know whatever they're supposed to be written in pencil so that they can be updated these are not part of the permanent chart it's just basically an area or a paper where information about the client is um all in one place like new orders so on and so forth if they have a caer you know whatever um so it's just a central I concise way of putting all the information together in days gone by we used to use cardex to give report for the next shift and we usually used to actually record them on a you know cassette so a lot of people a lot of places are not using these anymore but some are so I just wanted to let you know what a cardex is and it just if you'll look on that picture on page 53 you see it just puts like what's applicable and what's going on with that patient as of right there but it's really critical that anytime you have a change that occurs not only do you have to put in the chart but you've also got to update the cardex all right an incident report um look on page 54 for an example of an incident report now let me say this is not part of the chart not part of the chart this is used for documenting unusual events so if the patient fail or maybe let's say you had some visitors that got into a fight well you would use an instant report let's say that um somebody got a chemical in their eye you know or something splashed in somebody's eye then that's an incident that would need to have an incident report so it's an unusual event and this is a facility form form you do not do not chart that an incident report was filed out in the chart you do not chart in the nurse's notes or in the chart that an a incident report was filled out because this is an internal document not part of the chart it is for riskmanagement purposes it helps the facility track and correct problems um it is to be written also like charting non-judgmental and factual um let's see put in the exact stuff that you found like we talked about earlier with the fall you would put exactly what you see don't infer what you think happened or that whatever happened was somebody else's fault don't do that that just put put factual stuff that you observed so never ever ever put an incident form has been filled out okay AMA against medical advice um typically this is leaving against medical advice and so they're if they say I'm out of here y'all aren't doing anything for me or whatever they get mad at something that's happened they say I'm going to leave you have well there's a form that they're supposed to sign now some will say I'm not signing that form and if they won't sign the form then you have to actually document that they refuse to sign the form basically um this is just a form saying if you leave against medical advice you know you could have bad Health outcomes what for whatever reason so it's it's a form um that they are supposed to fill out again now if they're confused we can stop them from leaving but if they're of their sound mind then they can they do have the right to refuse any treatment and leave you know make sure that we pull out any IVs and stuff like that catheters so on and so forth we don't let them go anywhere with anything in their body consent forms um if they're going to have an invasive procedure like a c surgery or um you know whatever then they have to have a consent form and so um the provider is responsible to come in and explain to them what they're doing the risk the benefits so on and so forth answer all their questions and then the only thing that the nurse does is that we bring the form to them and we watch the the patient sign the form and then we sign as a witness the only thing we're witnessing is that they signed the form we're not witnessing what the doctor told them we probably weren't even in there when they went through it all now if when you go in there to get them to sign the consent form and they say well what about um you know could could this happen Okay we don't we're not supposed to answer all that you go back and you get the provider and say the client has additional questions that they need you to answer and they'll go back in and answer those questions might not be happy about it but they'll go back in and do it now if it's just something simple that you can clarify then absolutely clarify it but if it's something big then the provider needs to go back and then after the provider answers the questions then you go in and get the consent form signed and witness it okay the discharge summary form um so discharge planning begins at admission so as soon as they come in we are planning okay so if they come in and on the admission assessment the RN notes that um the family wants them to be in long-term care or maybe they tell us that they've been on um home health or whatever then we're already thinking okay so you know we're going to have to Rec contact UM home health and we need you know if they're going to long-term care there are certain things that we have to do so you're already thinking when they are admitted about their discharge because we have to make sure you can't just do all this on the day they're discharged now sometimes it begins before they're admitted so like if they're having outpatient surgery then probably at the clinic or wherever they saw the provider they've you know been playing in and so on and so forth there or if they're having a baby they've already filled out all their admission paperwork and you know all that they require so some of it's before they actually get there um always involve the patients as well as the family significant others um this gives info regarding their health care after discharge so they should always get a copy of this discharge form and you should always go over it verbally so you don't just hand it to them and like good luck you know go over everything with them so if they have medication changes you know okay the doctor does not want you to take um the amoxicillin anymore um instead they want you to take whatever and that's on that sheet of paper you're not going to take this anymore but you're going to start taking this and make sure you put it in um lay people's language so we don't write that you're going to you want them to take you know singular um 10 milligrams P qhs what what what does that mean so you would write out take one 10 milligram tablet of singular by mouth at bedtime or in the evening whatever the the doctor prescribed okay so don't use jargon um let's see no abbreviations right out okay yep got all that okay um also on here you would include like if they're restarting Home Health if they're going to like a long-term care facility typically we send this discharge form form to the long-term care facility so they can see all the changes in orders right there's the cardex we already looked at there's the um incident report all right the next thing is long-term care documentation so this is a nursing home is what I'm saying when I say long-term care that's a nursing home so I have a few things that I just want to go over with y'all about long-term care documentation and you'll learn more as we go it's a little bit different than Acute Care in the hospital so in long-term care the patient is called a resident because this is where they live and they're they're planning to live there you know this is their house that's the way you got to think about it this is their house so there are Medicare and Medicaid requirements for long-term care documentation and they have something called the MDS which is is a minimal minimum data set and that is regulated by the State Department of Health each state governs their own and how often these need to occur and so when I was do in of a long-term care facility like they would say you know if this patient is um here on skilled days then they should have an assessment here here here and here if they're not skilled patients then they can do them here here and here okay so um the minimum data set is just it's in it's electronic and um you go in and you have to put the the it's a nurse who does this and they have the chart and they have to fill out this major document online based on what they did or what was what the care that was provided and that's how they are reimbursed so again you got to make sure you document everything so that you can get um you know information that is correct and get reimbursement um now it supports a m multidisciplinary approach and and so does in the hospital but in the hospital therapy charts their thing nursing charts their thing respiratory charts their thing and so on for the MDS like nursing has to document um that they're going to therapy that they're receiving occupational therapy speech therapy Physical Therapy whatever they're getting and then have they seen uh improvements based on that therapy so are they now able to walk um you know if they're no longer unsteady or they are able to use her walker appropriately so that's really important um skilled days like I mentioned earlier or if a patient comes in and they require a higher level of care and it requires that they are in the hospital for three midnights and then they come into the long-term care and like it can be for therapy because they had a fall or a hip replacement it can be if they're have a UTI and they're receiving IV antibiotics and they're going to continue them in the long-term care facility so that's what a skill dat is skill care means a higher level of care and they can only get that for a certain amount of time according to the government and then they go back to being a regular resident okay and of course documentation is key key key right reporting formats um report is an exchange of client information from a health care provider to another is typically given at a change of shift given uh by the nurse that's leaving to the nurs nurse that's coming on and taking responsibility of the clients once a nurse receives report then they are then responsible for the care of that client it can be either face to face it can be recorded which you really don't see anymore so most of the time it's face to face it may even be where they walk to the room and they give report in front of the in front of the patient um and that lets the patient know what's going on any changes the family so on and so forth so to be effective it must include objective data about their health problems it should be logical in order no opinions no gossip Lord she was on the light all night long you know or whatever be factual and be professional it should include recent changes in medication treatments procedures or the discharge plan now when do you do a report you should do a report um if there's anything new going on you may have to call the provider and Report you may have to report to the charge nurse this change in the the client's um um like changing their uh condition I guess you could say change of shift we've already said if you leave the unit like let's say you're going to lunch then you need to have a nurse to watch your patient and so you give them a report this is what's going on with my patients I need to go to to lunch would you mind watching them while I'm gone okay don't just leave and you know good luck while you're gone okay if you're transferring the client wherever you're transferring them whether it's inside the hospital from say the ER to the um unit or whether you're sending them to a whole another hospital in another town they have to call a report to that receiving nurse also of course during rounds um with the provider or change of shift um okay reporting for formats so um you can uh use telephone to contact the primary health care provider or other me members of the healthcare team so you can call them and you're calling them because you need something okay you need an order for something or a prescription for something so before you call make sure you have all the DAT data you need so get a set of Vital Signs know what's going on with the client have the chart in front of you know have the mar where you can see what they've received so have all the data the the providers will get very upset with you if they call and say okay you tell them this is going on and they okay what's their blood pressure and you say well let me run take it have all that data ahead of time make sure you're very professional when you call make sure you give exact relevant accurate data and then document the name of the person that you called the time what message was given and then you know whatever and then when they call back you make a note about what they said in response to your phone call also follow institutional guidelines when reporting uh critical information such as lab values if somebody if lab calls and they say there's a critical potass level then you just don't you don't just say well okay I'll call that later or I'll tell them when they get here whatever most facilities have a policy that say they have to be called to the provider within such and such a time 15 minutes or whatever and make sure you document what you did about those sometimes you have to document in a book about it so find out what is the protocol okay telephone orders uh and they're written t or verbal orders V they really suggest that these be avoided if at all possible because there's a there's a risk for error if the person has to call and get an order or a prescription then remember we're supposed to repeat back that order if they tell you an order then you repeat it back and say okay so my order is for Mr Johnson blah blah blah blah blah and the uh provider should say yes that's correct or no I said whatever it's best to have a second nurse listen in to the telephone order if at all possible and then you document that you did the readback of the order to the prescriber that's that's to cover you and that's important um any order that seems like it's not right or it you know something doesn't seem right always question that prescription like because they're human too we're human they're human they may be tired they may be thinking about another client so make sure that you question or clarify those orders transfer reports um a lot of times you have to send the information electronically to that other hospital or unit but particularly the other hospital they may want the front sheet which has all their demographic information um their name their age their address what insurance they have so on and so forth um their medical diagnosis the provider's name an overall um overview of the condition or progress so you could send the pro uh providers progress notes any essential needs they have within the next few hours so if they need blood you need to advise them that they're going to that they have a hemoglobin of this m of this and that um you anticipate that they're going to need blood um what their most recent vital signs are what medications they've had it's important to send a copy of the M after you've given that last medication make a copy of it because you know the people that you're sent them to you know they'll say well have they have this medicine yet have they had this medicine yet or whatever so make sure you send what they've had any allergies that they have any diet um or activity that's ordered special equipment adaptive devices Advanced directives code status do they have a health care proxy what's the family's involvement so send all of that okay record ownership we went over that remember the provider of the facility owns it but but other people can get copies of it if they follow the protocol we've already discussed confidentiality um we have a law called the health insurance portability and accountability act or Hippa and it says the things that we can and can't do so we are never to share information with anybody who doesn't have a need to know so if somebody's just being nosy and they want to know something about the client let's say they're somebody in the ER is calling because they saw their neighbors in here and they want to know why they're in here you can't tell them that it's none of their business they have nothing to do with taking care of that client okay other nurses on the on the unit if they're not taking care of the client they're not on a need to know basis so it's a need to no basis no information is to leave the site so if you have a copy of the report sheet that should be shredded before you leave that includes students um make sure that you don't share information if somebody calls there are typically uh protocols for if a phone call is received about finding out about the client a lot of places they have to have a code before you can give them any information um you have to check and make sure that they're the responsible party um so there's a lot of rules for that and follow the facility protocol okay um computers just basically keep your password private always close um out your charting every time you leave that computer because if you leave it up somebody walking down the hall could see oh he he's here oh gosh you know so and don't leave like if it's written charts don't leave written charts open like on where other people can walk up to the nurs station look down and be like who Okay um on page 56 uh there are guidelines to Safe computer documentation again don't share your password never leave the computer without logging off um follow the protocol for correcting errors um make sure that the stored records have backup files and that's really more of a um a fac facility issue don't leave information about a patient displayed on a monitor follow the confidentiality procedures and any printouts should be protected they either have to be shredded or they have to be in you know a special place we don't just leave them laying around okay also one thing I just saw I wanted to point out go back and read homepage 54 examples of incident report entries in table 33 just to have um some examples for y'all okay if you have to fact which we don't fax as much anymore but if you have to fact you have to use the facilities cover page and then make sure you double and trip triple check the number that you're faxing it to because you don't want to be sending health information you think you're sending it to a hospital in Jackson you send it to somebody else's office or something okay more on Hippa um some of these we've already gone over let's see um we've already I've already told you clients have a right to read and obtain their medical recor but they have to follow the facility protocol they should be in a secured area never copied without authorization protect your password don't let anybody see your screen log off um please log off because a lot of times y'all will all be sharing you know maybe one or two computers and so if somebody doesn't log off and you go up and you don't you not even think about and you just click on your patient or whatever and you start documenting you'll be documenting under that other student's name so make sure when you get there that you whoever if they have not logged off log them off and log you in okay um communicate client information in a private setting don't ever talk about a client in the cafeteria you think you're being quiet people can hear you don't talk about um clients like in an elevator like one time I could hear people talking about a client in the elevator that were on the second floor and I'm standing on the first floor and I could hear everything they said and don't do it if somebody else is around you you may not know that might be the the patient's uncle or wife or whatever so don't only do it in areas that there's only health care workers and then of course shred any printed or written client information okay and that's the end of this section