Nursing Documentation and Informatics Overview

 
Documentation
& Informatics
 
1
 
What is Documentation?
 
Any thing written
 or printed within a 
client
record
Provides written evidence of quality of client
care provided
Written evidence of client’s response to
diagnostic tests and interventions
Record or chart is a permanent, legal,
comprehensive account of client’s health status
Reports are oral, written, or audiotape
exchanges of information between care-givers
 
2
 
Confidentiality
 
Nurses are legally and ethically obligated to keep client
information confidential.
Nurses are responsible for protecting records from all
unauthorized readers.
HIPAA act requires that disclosure or requests regarding
health information are limited to the minimum neccessary –
need to know only.
What structured data elements do you need to provide you job
function?
 
Standards
 
The Joint Commission requires each client have an assessment:
Physical, psychosocial, environment, self-care, client education, and
discharge planning needs
Requires documentation within context of nursing process including
teaching & d/c planning
Evaluation of outcomes
Federal and state regulations, state statutes, standards of care,
and accreditation agencies set nursing documentation
standards.
Nurses must document in accordance with standard of care &
facility’s policy.
 
Multidisciplinary Communication
Within the Health Care Team
 
Records or chart:
Confidential permanent legal document
Reports:
Oral, written, audiotaped exchange of information
SBAR:
Situation
Background
Assessment
Recommendations
Consultations:
A professional caregiver providing formal advice to another caregiver
Referrals:
Arrangement for services by another care provider
 
Purpose of Records
Documentation
 
Communication
Legal documentation
Financial reimbursement
Education
Research
Auditing and monitoring
 
6
 
Guidelines for charting
 
1.
Be sure that client’s name and medical
record number are on each page of the
chart
2.
Date and sign each entry
3.
Chart relevant and appropriate data
4.
Avoid use of negative terms to describe
client’s behavior
5.
Do not write about other staff members
6.
Record facts clearly and accurately
7.
Omit unnecessary words or vague terms
8.
Use only standard abbreviations
 
7
 
Guidelines for charting
cont’d
 
Use black ink
Write legibly, briefly and neatly
Use correct grammer, spelling and punctuation
Sign each entry with your name and title
Never skip a line or leave a line blank
Correct errors by drawing a line through the entry,
don’t erase or use ‘white-out’
Chart information as soon as possible
 
 
8
 
Quality Documentation and
Reporting
 
Factual
Accurate
Complete
Timely
Organized
 
9
 
Military Time Only
 
10
 
Methods of Recording
 
Narrative:
The traditional method
Story like format, time consuming., replaced by other formats
Problem-Oriented Medical Record (POMR):
Database
Problem list
Nursing care plan
Progress note
 
Methods of Recording:
Progress Notes
 
SOAP:
Subjective, objective, assessment, plan
SOAPIE:
Subjective, objective, assessment, plan, intervention,
evaluation
PIE:
Problem, intervention, evaluation
Focus Charting (DAR):
Data, action, response
 
BOX 26-2 for examples of each
 
Methods of Reporting
 
Source records:
A separate section for each discipline
Charting by exception (CBE):
Focuses on documenting deviations
Case management plan and critical pathways:
Incorporates a multidisciplinary approach to care
Review Care Map for Pneumonia: Fig 26-3 pg 395 & 396
 
Common Recording
Keeping Forms
 
Admission assessment or nursing history forms
Flow sheets and Graphic records
Kardex or client care summary
Acuity Records
Standardized care plan
Discharge summary form
 
14
 
Home Care Documentation
 
Medicare has specific guidelines for establishing eligibility for
home care.
Documentation is the quality control and justification for
reimbursement from Medicare, Medicaid, or private
insurance.
Nurses need to document all their services for payment.
 
Long-Term Health Care
Documentation
 
Governmental agencies are instrumental in determining the
standards and policies for documentation.
The Omnibus Budget Reconciliation Act of 1987 includes
Medicare and Medicaid legislation for long-term care
documentation.
RAI: Resident Assessment Instrument
The department of health in states governs the frequency of
written nursing records.
 
Reporting
 
Change of shift
Table 26-4
Telephone reports
Verbal )VO) or telephone orders (TO)
Box 26-8
Transfer reports
Incident reports
 
Computerized Documentation
 
Software programs allow nurses to enter assessment data.
Computers generate nursing care plans and document care.
A complete computer-based patient care record (CPCR) is not
without legal risks
Stores and retrieves client data fast and easily
Uses standardized nursing care plans
Charting is always legible
Facilitates transmission of information from one care setting to
another
Improves communication through use of standard terminology
 
18
 
Examples of Documentation
 
“Pt. Requesting Demerol.  Looks like he needs it.”
Subjective:  “Bitten by a snake.  No movement, 17 in,. Multicolored,
flat head.”
“Pt. States she is vomiting.  Will observe for truth.”
“Two valium missing from stock.  Supervisor notified that I didn’t do
it.”
Skin‑ somewhat pale but present
Both the nurse and the patient reported passing
  flatus
 
 
 
 
 
 
19
 
 
 
 
This work is licensed under a 
Creative Commons Attribution 4.0 International License
.
 
Except where otherwise noted, this content by Southern Regional Technical College is licensed under the Creative Commons
Attribution 4.0 International License. To view a copy of this license, click 
https://creativecommons.org/licenses/by/4.0/
 
Healthcare Careers Work!(HCW) is sponsored by a $2.3 million grant from the U.S. Department of Labor, Employment &
Training Administration. TAACCCT Grant #TC- 26488-14-60-A-13.  Southern Regional Technical College is an equal
opportunity employer and will make adaptive equipment available to persons with disabilities upon request.
 
This workforce product was funded by a grant awarded by the U.S. Department of Labor’s Employment and Training
Administration. The product was created by the grantee and does not necessarily reflect the official position of the U.S.
Department of Labor. The U.S. 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.
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Nursing documentation is essential for providing written evidence of quality client care, client responses to interventions, and maintaining confidentiality. It includes standards set by regulatory bodies like The Joint Commission and involves multidisciplinary communication within healthcare teams. Records serve various purposes such as communication, legal documentation, education, and research. Guidelines for charting emphasize clarity, accuracy, and confidentiality.


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  1. Documentation & Informatics 1

  2. What is Documentation? 2 Any thing written or printed within a client record Provides written evidence of quality of client care provided Written evidence of client s response to diagnostic tests and interventions Record or chart is a permanent, legal, comprehensive account of client s health status Reports are oral, written, or audiotape exchanges of information between care-givers

  3. Confidentiality Nurses are legally and ethically obligated to keep client information confidential. Nurses are responsible for protecting records from all unauthorized readers. HIPAA act requires that disclosure or requests regarding health information are limited to the minimum neccessary need to know only. What structured data elements do you need to provide you job function?

  4. Standards The Joint Commission requires each client have an assessment: Physical, psychosocial, environment, self-care, client education, and discharge planning needs Requires documentation within context of nursing process including teaching & d/c planning Evaluation of outcomes Federal and state regulations, state statutes, standards of care, and accreditation agencies set nursing documentation standards. Nurses must document in accordance with standard of care & facility s policy.

  5. Multidisciplinary Communication Within the Health Care Team Records or chart: Confidential permanent legal document Reports: Oral, written, audiotaped exchange of information SBAR: Situation Background Assessment Recommendations Consultations: A professional caregiver providing formal advice to another caregiver Referrals: Arrangement for services by another care provider

  6. Purpose of Records Documentation 6 Communication Legal documentation Financial reimbursement Education Research Auditing and monitoring

  7. Guidelines for charting 7 1. Be sure that client s name and medical record number are on each page of the chart 2. Date and sign each entry 3. Chart relevant and appropriate data 4. Avoid use of negative terms to describe client s behavior 5. Do not write about other staff members 6. Record facts clearly and accurately 7. Omit unnecessary words or vague terms 8. Use only standard abbreviations

  8. Guidelines for charting cont d 8 Use black ink Write legibly, briefly and neatly Use correct grammer, spelling and punctuation Sign each entry with your name and title Never skip a line or leave a line blank Correct errors by drawing a line through the entry, don t erase or use white-out Chart information as soon as possible

  9. Quality Documentation and Reporting 9 Factual Accurate Complete Timely Organized

  10. Military Time Only 10

  11. Methods of Recording Narrative: The traditional method Story like format, time consuming., replaced by other formats Problem-Oriented Medical Record (POMR): Database Problem list Nursing care plan Progress note

  12. Methods of Recording: Progress Notes SOAP: Subjective, objective, assessment, plan SOAPIE: Subjective, objective, assessment, plan, intervention, evaluation PIE: Problem, intervention, evaluation Focus Charting (DAR): Data, action, response BOX 26-2 for examples of each

  13. Methods of Reporting Source records: A separate section for each discipline Charting by exception (CBE): Focuses on documenting deviations Case management plan and critical pathways: Incorporates a multidisciplinary approach to care Review Care Map for Pneumonia: Fig 26-3 pg 395 & 396

  14. Common Recording Keeping Forms 14 Admission assessment or nursing history forms Flow sheets and Graphic records Kardex or client care summary Acuity Records Standardized care plan Discharge summary form

  15. Home Care Documentation Medicare has specific guidelines for establishing eligibility for home care. Documentation is the quality control and justification for reimbursement from Medicare, Medicaid, or private insurance. Nurses need to document all their services for payment.

  16. Long-Term Health Care Documentation Governmental agencies are instrumental in determining the standards and policies for documentation. The Omnibus Budget Reconciliation Act of 1987 includes Medicare and Medicaid legislation for long-term care documentation. RAI: Resident Assessment Instrument The department of health in states governs the frequency of written nursing records.

  17. Reporting Change of shift Table 26-4 Telephone reports Verbal )VO) or telephone orders (TO) Box 26-8 Transfer reports Incident reports

  18. Computerized Documentation 18 Software programs allow nurses to enter assessment data. Computers generate nursing care plans and document care. A complete computer-based patient care record (CPCR) is not without legal risks Stores and retrieves client data fast and easily Uses standardized nursing care plans Charting is always legible Facilitates transmission of information from one care setting to another Improves communication through use of standard terminology

  19. Examples of Documentation 19 Pt. Requesting Demerol. Looks like he needs it. Subjective: Bitten by a snake. No movement, 17 in,. Multicolored, flat head. Pt. States she is vomiting. Will observe for truth. Two valium missing from stock. Supervisor notified that I didn t do it. Skin- somewhat pale but present Both the nurse and the patient reported passing flatus

  20. Creative Commons License This work is licensed under a Creative Commons Attribution 4.0 International License. Except where otherwise noted, this content by Southern Regional Technical College is licensed under the Creative Commons Attribution 4.0 International License. To view a copy of this license, click https://creativecommons.org/licenses/by/4.0/ Healthcare Careers Work!(HCW) is sponsored by a $2.3 million grant from the U.S. Department of Labor, Employment & Training Administration. TAACCCT Grant #TC- 26488-14-60-A-13. Southern Regional Technical College is an equal opportunity employer and will make adaptive equipment available to persons with disabilities upon request. This workforce product was funded by a grant awarded by the U.S. Department of Labor s Employment and Training Administration. The product was created by the grantee and does not necessarily reflect the official position of the U.S. Department of Labor. The U.S. 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.

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