Nursing Fundamentals Chapter 9 Recording

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Nursing Fundamentals Chapter 9Recording
Reporting
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Why do we chart?

• 1. Legal evidence as to what weve done. A chart
  or case can be subpoenaed to court. Anyone who
  writes in a chart is responsible for what they
  write. Errors in charting or scribbles or erased
  info. Make for a poor legal defense. A chart can
  be used as legal evidence for 1 year (in adults)
  in Ohio (medical malpractice). Children have 18
  yrs.
• 2. Its a permanent account and a record for
  future use. Records are kept and all are sent
  with the pt. For a baseline or history of illness
• 3. It allows for the sharing of information
  between health care workers, its organized and
  prevents the duplication of care and reduces the
  chances of error

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Why do we chart?

• 4. Charts are used to measure quality assurance.
  This is to make sure pts are staying on track for
  insurance and payment needs. Its also to
  improve quality of care and to maintain that a
  standard of care has been used
• 5. Accreditation of JCAHO, they make sure we are
  following the written standards to ensure whole,
  quality care
• 6.Reimbursement related to insurance, theres
  always a watcher out there

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Why do we chart?

• 7. Education Research the primary resource for
  health education is textbooks. We can utilize
  real life charts to expand our knowledge base.
  Formal permissions must be met by the pt

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What Do We Chart With?

• ltltltltINKgtgtgtgt
• Pen black or blue
• NEVER use Red ink
• NEVER use Pencil
• NEVER use liquid white-out

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What to do if you make a mistake?

• NEVER erase your entry, even if it is in the
  wrong place or on the wrong pt
• NEVER white-out your entry
• NEVER scratch out or make many lines through an
  entry. ONE LINE THROUGH THE MISTAKE ONLY
• Lawyers, Drs. And others, must be able to see
  what you wrote

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What to do when you dont have much to write?

• Always start as far over to the left as possible
  and then keep writing. If you stop before the
  end of the paper, put a line through the rest of
  the paper so another person will not add to your
  note

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Writing a note

• 0700 nurse enters room to find pt in cheerful
  mood-----------------------K. NyeRN
• Not this
• 0700 pt in cheerful mood NyeRN

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ERRORS

• 1000 pt arrived to hospital with daughter. Pt
  AOx3. Pt has large wound to left hip.
• (show how to make an order invalid)
• Dont forget to write error and initials with one
  black/blue line

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Can a patient view their own chart anytime?
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Yes and No

• Since 1996 when HIPPA legislation was passed.now
  states that clients have the right to see their
  own medical and billing records.
• Pts have the right to request changes to anything
  they feel is inaccurate and they are allowed to
  be informed as to who has seen their records
  however

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• Many institutions have their own written policies
  that describe the guidelines by which pts can
  access their own medical records
• Policies range from institution to institution
• Many facilities want the Physician or hospital
  administrator to be present while the chart is
  being read
• NURSES SHOULD NOT BE DOING THIS

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Bill of Rights

• Every patient of every race and creed has rights
• The Bill of Rights lists 12 basic rights that
  must be upheld (know 12 for the test)
• (See bill of rights Box 3-5 for reference)

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• Cleveland Clinic Patient Rights and
  Responsibilities
• As a patient, you have the right
• Personal Privacy/Security
• To have your personal dignity respected.
• To be free from all forms of abuse or
  harassment.
• To enjoy personal privacy and a safe, clean
  environment and to let us know if you would like
  to restrict your visitors or phone calls.
• To access protective and advocacy services.
• To know that restraints will be used only when
  necessary.
• To confidentiality of your identifiable health
  information

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• Cultural and Spiritual Values
• To have your cultural, psychosocial, spiritual,
  and personal values, beliefs and preferences
  respected.
• To have access to pastoral and other spiritual
  services.
• Access to Care
• To receive care regardless of your race, creed,
  color, national origin, gender, age, sexual
  orientation, disability or manner of payment.
• To ask for a change of provider or a second
  opinion.

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• Access to Information
• To make advance directives and have them
  followed.
• To have your family or a representative you
  choose and your own physician, if requested, be
  informed of your hospital admission.
• To know the rules regulating your care and
  conduct.
• To know that Cleveland Clinic hospitals are
  teaching hospitals and that some of your
  caregivers may be in training. To ask your
  caregivers if they are in training.
• To know the names and professional titles of
  your caregivers.
• To have your bill explained and receive
  information about charges that you may be
  responsible for, and any potential limitations
  your policy may place on your coverage.
• To be told what you need to know about your
  health condition after hospital discharge or
  office visit.
• To be informed and involved in decisions that
  affect your care, health status, services or
  treatment.
• To understand your diagnosis, condition and
  treatment and make informed decisions about your
  care after being advised of material risks,
  benefits, and alternatives.
• To knowledgeably refuse any care, treatment and
  services.

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• To say yes or no to experimental treatments
  and to be advised when a physician is considering
  you to be part of a medical research program or
  donor program. All medical research goes through
  a special process required by law that reviews
  protections for patients involved in research,
  including privacy. We will not involve you in any
  medical research without going through this
  special process. You may refuse or withdraw at
  any time without consequence to your care.
• To legally appoint someone else to make
  decisions for you if you should become unable to
  do so, and have that person approve or refuse
  care, treatment, and services.
• To have your family or representative involved
  in care, treatment and service decisions, as
  allowed by law.
• To be informed of unanticipated adverse
  outcomes.
• To have your wishes followed concerning organ
  donation, when you make such wishes known, in
  accordance with law and regulation.

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• Communication
• To receive information you can understand.
• To have access to an interpreter and/or
  translation services.
• To know the reasons for any proposed change in
  the attending physicians/professional staff
  responsible for your care.
• To know the reasons for your transfer either
  within or outside the hospital.

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• Pain Management To have pain assessed and
  managed appropriately. Disclosures To request a
  listing of disclosures about your healthcare, and
  to be able to access and request to amend your
  medical record as allowed by law. To know the
  relationship(s) of the hospital to other persons
  or organizations participating in the provision
  of your care. Recording and Filming To provide
  prior consent before the making of recordings,
  films, or other images that may be used
  externally.

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• Concerns, Complaints, or Grievances To receive a
  reasonably prompt response to your request for
  services. To be involved in resolving issues
  involving your own care, treatment and services.
  To express concerns, complaints and/or a
  grievance to your providing hospital personnel.
  You may do this by contacting your Ombudsman
  office at Ashtabula County Medical Center,
  440.997.6633 Childrens Hospital, Shaker Campus,
  216.444.2544 Cleveland Clinic, 216.444.2544
  Euclid Hospital, 216.692.7888 Fairview Hospital,
  216.476.4424 Hillcrest Hospital, 440.312.9140
  Huron Hospital, 216.761.3300 Lakewood Hospital,
  216.529.7049 Lutheran Hospital, 216.363.2360
  Marymount Hospital, 216.587.8888 Medina Hospital,
  330.721.5330 South Pointe Hospital, 216.491.6299

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Types of Client Records

• Source-Oriented Records
• Problem-Oriented Records

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Source-Oriented Record

• This is organized according to the source of
  documented information
• Contains lots of the same kind of paper (green at
  CCF)using as many sheets as necessary on which
  Drs., nurses, dieticians, P.T. and so on, can
  make entries about their own specific activities
  in relation to the pts care
• It appears that these team members are working
  independently of each other and their fragments
  of written info. Is difficult to follow at times,
  you have to flip back to read what others wrote.

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Problem-Oriented Record

• This is organized according to the pts problems
• This type of record contains 4 major components
• 1. Data base
• 2. Problem list
• 3. Plan of care (POC)
• 4. Progress notes

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Problem-oriented record

• The information is compiled and arranged to
• emphasize goal-directed care
• Promote recording of pertinent information
• To facilitate communication among health care
  professionals

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Methods of Charting

• 4 types are used across the nation, you must use
  your facilities type
• 1. Narrative
• 2. SOAP
• 3. Focus
• 4. PIE

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Narrative Charting

• Used in source-oriented records
• Involves writing info. About the pt and their
  care in chronological order
• There is no format, only a story or narration of
  the events that have occurred
• This type of charting is time consuming to write
  and read
• At times, the writer of this type of note omits
  pertinent info. Or includes insignificant info.

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SOAP Charting

• Ssubjective date
• Oobjective data
• Aanalysis of the data
• Pplan of care
• Used in problem-oriented record
• This type focuses on the pertinent information
• This type helps to bring all teams together
  because everyone involved in the care, makes
  entries in the same location in the chart, they
  are likely to read this well-written plan

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Focus Charting

• Modified form of SOAP charting
• Uses the word focus rather than problem which
  can indicate negativity
• A focus can be a pts current or changed
  behavior, a significant event in the pts care,
  or a NANDA diagnosis
• Can enter the info. As DAR data, action,
  response, similar to the Nr. Process

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PIE Charting

• Pproblem
• Iintervention
• Eevaluation
• Similar to SOAP charting
• PIE charting prompts the nurse to address
  specific content in a charted progress note

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PIE Charting

• The nurse documents her assessment on a separate
  form and gives the pts problem a corresponding
  number. This number is used in the progress note
  when referring to interventions and the pts
  response

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PIE Charting

• ___________________________________
• DATE Nurses Remarks Signature
• ______________________________________________
• 6/19 P 1 crackles heard on inspiration in
  bases of
• ___________right and left lungs________________
• I 2 Incision splinted with a pillow.
  Instructed
• to breathe deeply and to
  cough at the end of ______________________________
  ________expiration
• E3 Lungs clear with
  coughing____________

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Charting by exception

• Nurse only charts IF there is a problem
• Lake Hospital and CCF do this however..
• Be prepared to write a lot more in clinicals. We
  need to make sure you can chart

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Computerized Charting

• Supposed to be easier to access information and
  it is legible however
• Information is vague and standard. If you dont
  find something that is applicable to your patient
  thats already in print, WRITE A NARRATIVE NOT.
  Legal nurse consultants and Lawyers recommend
  this. Nurses dont see the info. In print, they
  dont check the block and they dont bother to
  wrote a note, if its not written somewhere, ITS
  NOT DONE

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Abbreviations

• Its difclt to shortn. Mny wrds still let thm
  have mng. Nrsg notes r imprtnt we mst do a grt
  job all the tme.
• We are not text messaging, we are recording
  important information.
• This IS NOT COMPUTER OR I.M. or texting
  COMMUNICATION
• You could cause harm to a pt. By misinterpreting
  the abbreviation

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Morphine versus Magnesium

• MSO4 vs. MgSO4.big trouble if you goof
• Morphine sulfate vs. magnesium sulfate

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Using Abbreviations in the institutions

• New Nurses today are getting away from using
  abbreviations
• Students are not being taught all of the
  abbreviations
• In this class, we will use some (see
  abbreviations sheet)

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Military Time

• Military time is used in the Military today
• Other medical and health professionals use
  military time
• There are NEVER mistakes in what time it was when
  military time is used

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Military time

• Is a matter of counting from 1-24 versus using 12
  midnight and counting 1-2-3-4-5-till midnight
  again

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Military Time

• Always starts at midnight
• Midnight is 0000 or 2400
• You never repeat numbers like 10am and 10pm
• You dont use a colon ( ) or am or pm

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• 100 am 0100
• 200 am 0200
• 300 am 0300
• 400 am 0400
• 500 am 0500
• 600 am 0600
• 700-1159 am 0700-1159

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12 NOON

• 12 noon is 1200pm
• In military time , it is 1200
• 1pm 1300 7pm 1900
• 2pm 1400 8pm 2000
• 3pm 1500 9pm 2100
• 4pm 1600 10pm 2200
• 5pm 1700 11pm 2300
• 6pm 1800 12am or midnight
• 2400

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Basically

• Military time is based on counting
• You use minutes as you would normally 315 pm
  1515
• Once you pass noon, you count upward 13-23

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Communication for continuity of care

• Nursing Care Plans
• Nursing Kardex
• Check lists
• Flow Sheet
• MAR- medication administration record

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Nursing Care Plans

• Is a written, organized list of client problems,
  goals, and nursing orders for pt care
• They are sort of like a recipe on how to care
  for a pt and return them to optimal health
• We learned the NANDA diagnoses, use them often

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Nursing Kardex

• Is a quick reference for current information
  about the pts care, it tells
• Pt name tells the level of activity
• Diagnosis clinic
• Lab tests that are due
• Allergies
• Admit date
• Appointments that pt will go to such as P.T.,
  x-ray

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Check list

• Used instead of writing, one can simply check the
  boxes next to the activity to be done.
• Saves time on writing, if pt stays in the
  facility for a length of time, and not much
  changes, simple check mark system is acceptable

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Flow sheet

• This type of documentation is used for recording
  frequency repeated assessment data like
  neurochecks
• Allows the nurse to view trends because all of
  the info. Is there in columns

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M.A.R.

• Medication administration record
• This is the med sheets, many facilities use
  different forms.
• Some facilities use a yellow pencil or crayon to
  color over orders that are no longer in effect

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What to do with all of these papers..

• A pts chart becomes filled and overflowing if
  the pt is admitted to the institution for a
  length of time
• Many institutions are applying all of their forms
  and paperwork to computer programs

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How Important is charting

• Extremely important
• Charting becomes part of the legal documents
• You must complete ALL charting before a pt leaves
  the floor or heads out the door

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What To Do If Your Pt Leaves the Floor?

• If you havent charted completely before your pt
  leaves the floor to go to surgery or a test, what
  do you do?
• Use a new nursing form and add your notes there
  and be sure to place your new notes in a place
  where they can be added to the chart when the pt
  returns to the floor
• REMEMBERif it wasnt charted, then it
  _________________

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Interpersonal Communication

• In addition to recording information in writing,
  verbal communication between staff members is
  extremely important

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Change of shift report

• This is a discussion between nursing staff when
  one shift is ending and another shift is
  starting. Shift report is done in different ways
  according to the facilitys choice

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Report

• In ICUs the charge nurse pre-assigns pts for
  each individual nurses
• When you enter the report room, you find your pt
  assignment and then find the nurse who cared for
  that pt all day.not always effective
• What is the nurse you are looking for is already
  giving report to another nurse about her 2nd pt,
  you have to wait until she is done
• This form of reporting doesnt allow for the
  entire staff to become familiar with all pts on
  floor

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Report

• Some nurses sit in a faculty lounge while the
  charge nurse from the previous shift discusses
  ALL the pts in order to ALL of the staff that is
  coming on.
• ALL staff becomes familiar with potential
  problemsteam approachused a lot

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I am going to give report, ready?

• Get a pen and blank paper out and hold
  on.

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Take report seriously

• Be prompt to work so report can start on time
• You dont want to mosey on in at your leisure and
  disrupt the whole report
• Come prepared with a pen and paper or your
  floors report sheet

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In this team approach type report

• Once the report is completed, and assignment is
  made based on pt acuity
• It is important to not assign all of the
  difficult pts to one nurse or the new nurse
• Nurses usually like to focus on a few pts and
  continue that continuity of care by taking the
  same pt throughout their whole admission
• Pts like this continuity in care, they get to
  know that nurse and build a trusting relationship
  with that nurse

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Conferences

• Some facilities like to round in groups including
  all services that could potentially care for the
  patient
• This could include
• Drs Nurses
• P.T. O.T.
• Pharmacist clergyman
• Dietician social work

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Grand Rounds

• Usually held in a large room
• A few patients cases are discussed in detail
• It offers advantage of group decision making, and
  professional opinions are given
• It puts the pt 1st, trying to meet all of their
  needs or demands
• Difficult to get many services together at once,
  everyone is busy

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Telephone report

• Some institutions will not allow LPNs to take
  report by phone
• RN will do this then
• It is important to get the report givers name and
  a phone number of where they can be reached for
  questions
• Some facilities will have a designated telephone
  report formuse it. It prompts you to ask all of
  the important questions

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What to ask in taking report?

• Name of person giving report to me
• Phone number where they can be reached
• VSalways get these. Indicates how sick the pt
  is
• A weight on the pt. Why should you have to look
  through their paperwork and try to read their
  writing, they can just tell you this over the
  phone
• last time pt urinated
• Condition of pt
• What labs and other tests were already done
• Who is with pt, you may needs a sitter and you
  have to arrange this before the pt arrives

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When you report is completed

• Start to organize your thoughts on how you will
  prepare to care for your patients
• Discuss individually with previous nurse, the
  care to be given for your shift
• If you are unfamiliar with equipment or
  medication, spend a few minutes reviewing this
  with the new nurse coming to take care of the pt
• Nothing is worse than to be nervous or afraid to
  care for your pt

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BE KIND TO ONE ANOTHER

• Reports show that nurses eat their
  young????????????? What does this
  mean?????????????

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BE NICE

• EVERYONE was new once
• Nobody is perfect
• Everyone makes mistakes AND YOU WILL TOO
• Dont be rude to each other. Its better to
  educate someone rather than to put them down

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Teaching-learning

• Nursing is an ongoing teaching-learning process
• You will learn new things everyday
• Be open to learning and educating others
• YOU ARE NOT ABOVE ANOTHER

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THE END be nice and help each other