logging in or signing up Documentation Fall 2009 taylor1297 Download Post to : URL : Related Presentations : Share Add to Flag Embed Email Send to Blogs and Networks Add to Channel Uploaded from authorPOINT lite Insert YouTube videos in PowerPont slides with aS Desktop Copy embed code: (To copy code, click on the text box) Embed: URL: Thumbnail: WordPress Embed Customize Embed The presentation is successfully added In Your Favorites. Views: 2159 Category: Entertainment License: All Rights Reserved Like it (9) Dislike it (0) Added: January 11, 2010 This Presentation is Public Favorites: 3 Presentation Description No description available. Comments Posting comment... By: cmy7777 (13 month(s) ago) A very usefull presentation for nurses Saving..... Post Reply Close Saving..... Edit Comment Close By: shivaprasadhalemani (13 month(s) ago) hello sir/Madam, the ppt on documentation is very nice so please make this to help us Please send me the ppt of documentation for study purpose. 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Edit Comment Close Premium member Presentation Transcript Kozier - Chapter 15Documenting and Reporting : Kozier - Chapter 15Documenting and Reporting Purposes of Patient Records - chart : Purposes of Patient Records - chart Communication Record of diagnostic and therapeutic orders Care planning Tracking progress QA Legal and historical documentation Reimbursement Formats for Nursing Documentation : Formats for Nursing Documentation Initial nursing assessment Kardex and patient care summary Plan of nursing care Critical collaborative pathways Progress notes Flow sheets Discharge and transfer summary Home healthcare documentation Long-term care documentation Types of Flow Sheets : Types of Flow Sheets Graphs VS 24-hour I&O Medication record - MAR 24-hour patient care records and acuity charting forms Methods of Documentation : Methods of Documentation Source-oriented records Problem-oriented medical records - SOAP PIE charting Focus charting Charting by exception Case management model Computerized records Major Components of POMR : Major Components of POMR Defined database Problem list Care plans Progress notes SOAP Notes – POMR : SOAP Notes – POMR Subjective – what patient says – Use quotes Objective Assessment Plan SOAPIE Implementation Evaluation Kozier p. 251 Examples Sample PIE Patient Care Note : Sample PIE Patient Care Note Sample Focus Patient Care Notes : Sample Focus Patient Care Notes Sample PCC NURSES NOTE : Sample PCC NURSES NOTE QUIZZZZZ : QUIZZZZZ 1. In Problem Oriented Medical Records, which type of format is used for documentation? a. DAR-Data, Action, Response b. CBE- Charting by exception c. SOAP- Subjective, Objective, Assessment, Plan d. PIE- Problem, Intervention, Evaluation Slide 13: 2. An advantage to CBE (charting by exception) would be: a. Focus is on patient concerns b. Useful in proving competence c. Each discipline can find easily d. decrease in charting time Slide 14: 3. Which of the following are important to document for the Home health care nurse? a. That the patient remains homebound b. Rehabilitation potential is good c. The patient is not stable d. All of the above Slide 15: 4. If you were looking for trends in a patient’s vital signs what form should you consult first? a. Graphic sheet b. Nursing Assessment c. Admission sheet d. Flow sheet Slide 16: 5. All nursing data relating to patient care must be integrated into the patient record. This is specified by the agency known as a. HIPAA b. JCAHO c. OSHA d. AARP Characteristics of Effective Documentation : Characteristics of Effective Documentation Consistent with professional and agency standards Complete Accurate Concise Factual Organized and timely Legally prudent Confidential Record Factual Information : Just the facts Head to Toe Nursing Assessment What is seen What is heard What is palpated Record Factual Information Slide 20: What is done for the patient The patient’s response to the action The patient’s experience (quotes) Rule of Thumb: : Rule of Thumb: If it wasn’t documented, it wasn’t done REMEMBER Using the 24-hr Cycle Military Clock for Documenting Times : Using the 24-hr Cycle Military Clock for Documenting Times Charting : Charting Record all information in ink The date & time you are charting Slide 24: Entries out of sequence must be identified as “Late Entry” Document in chronological order Error Notation – Follow the agency policy : Error Notation – Follow the agency policy Typical hospital error notation: Draw a single line through the error Write “error” above it Sign (or initial) and date the error Do’s & Don’ts of Documentation : Do’s & Don’ts of Documentation Avoid Generalized terms - be specific and clear Avoid words like “appears” Always use black - never use erasable ink Slide 27: Never make assumptions about an incident - only document the facts Never falsify information Never pre chart your care Never leave blank spaces Slide 28: Write neatly & legibly Sign name and title Document significant observations & events State the facts not interpretations Use only hospital approved abbreviations Slide 29: Document notification of the M.D., data reported, and physician recommendations Never include personal opinions Never make judgment statements Never assume anything Include quotes when appropriate Include the patient’s perspective Slide 30: Record and identify all patient education and observations Do not include “Incident Report submitted” Never erase an entry or use white out Distinguish between the charting time & the time of an event if different Remember that a complete and honest record is absolutely necessary. : Remember that a complete and honest record is absolutely necessary. : Subpoena Any alteration may result in an allegation of fraud. Alterations, unclear or improper documentation, incorrect abbreviations, biased statements…. : Alterations, unclear or improper documentation, incorrect abbreviations, biased statements…. May lead to a case that is impossible to defend because of the damage to your credibility. : May lead to a case that is impossible to defend because of the damage to your credibility. What Is Confidential? : What Is Confidential? All information about patients written on paper, spoken aloud, saved on computer Name, address, phone, fax, social security Reason the person is sick Treatments patient receives Information about past health conditions Slide 36: In other words, All information about the patient is confidential Health Insurance Portability and Accountability Act of 1996 - HIPAA : Health Insurance Portability and Accountability Act of 1996 - HIPAA Provides individuals with more control over their health information. Establishes limits for appropriate use and release of health care information. Requires the majority of health care providers and their agencies to comply with safeguards to protect individual privacy related to health care information. Delineates a set of civil and criminal penalties holding HIPAA regulation transgressors accountable for actions if the client’s health care privacy is violated. Kozier – p. 110 HIPAA Compliance and Nursing Practice : HIPAA Compliance and Nursing Practice Patient’s name cannot be posted near or on door. Charts should be in secure, nonpublic areas. Printed copies of protected health information (PHI) not left unattended on printers or faxes Access to health information limited to need to know Health care providers required to have passwords to access patient’s electronic chart Notice of Patient’s privacy rights must be posted. Voice levels kept low when discussing patient’s information. Health care providers must follow current HIPAA regulations. Kozier p. 71 Potential Breaches in Patient Confidentiality : Potential Breaches in Patient Confidentiality Displaying information on a public screen Sending confidential e-mail messages Sharing printers Discarding patient information in trash cans Overheard conversations Faxing to unauthorized persons Overheard on pagers Patient Rights : Patient Rights See and copy their health record Update their health record Get a list of disclosures Request a restriction on certain uses or disclosures Choose how to receive health information Policy for Receiving Verbal Orders in an Emergency : Policy for Receiving Verbal Orders in an Emergency JCAHO – patient safety goals Record the orders in patient’s medical record Read back the order to verify accuracy Date and note the time orders were issued in emergency Record VO, the name of the physician followed by nurse’s name and initials Policy for Physician Review of Verbal Orders : Policy for Physician Review of Verbal Orders Review orders for accuracy Sign orders with name, title, and pager number Date and note time orders signed Duties of RN Receiving a Telephone Order : Duties of RN Receiving a Telephone Order Record the orders in patient’s medical record Read orders back to practitioner to verify accuracy Date and note the time orders were issued Record TO, full name and title of physician or nurse practitioner who issued orders Sign the orders with name and title Change of Shift Report : Change of Shift Report Basic identifying information about each patient Current appraisal of each patient’s health status Changes in medical conditions and patient response to therapy Where patient stands in relation to identified diagnoses and goals Current orders (nurse and physician) Summary of each newly admitted patient Report on patient transferred or discharged Two Nurses Confer at Change of Shift Report : Two Nurses Confer at Change of Shift Report Methods of Reporting : Methods of Reporting Face-to-face meetings Telephone conversations Messengers Written messages Audio-taped messages Computer messages Conferring About Care : Conferring About Care Consultations and referrals Nursing and interdisciplinary team care conferences Nursing care rounds Quizzzzzzzzz : Quizzzzzzzzz 1. When documenting it is important for the nurse to include a. the facts b. personal opinions c. abbreviations d. your interpretation Slide 49: 2. Which of the following would be considered confidential about the patient a. diagnosis b. treatment plan c. address d. all of the above Slide 50: 3. When receiving a verbal order in an emergency situation the nurse must a. Record the order on the order sheet in the patients chart and read it back to doctor to check accuracy. b. Refuse to accept a verbal order c. Record TO and the name of the physician on the progress sheet. d. Write the order on a scrap piece of paper and later write it on the chart for neatness. Slide 51: 4. When giving a shift report which of the following information would you want to include a. How many times the patient had his nurses light on b. Why you did not like caring for the patient c. Changes in the patients vital signs d. What the physician said about the patients family Slide 52: 5. When a group of nurses visit selected patients this is know as a. A referral b. Consultation c. Nursing Conference d. Nursing Care rounds Slide 53: A student has reviewed a patient’s chart before beginning care. Which of the following actions violates patient confidentiality? a. writing the patient’s name on the student clinical log. b. providing the instructor with the nursing diagnosis. c. discussing patient’s medications with the nurse. d. providing care information to the nurse tech. You do not have the permission to view this presentation. In order to view it, please contact the author of the presentation.
Documentation Fall 2009 taylor1297 Download Post to : URL : Related Presentations : Share Add to Flag Embed Email Send to Blogs and Networks Add to Channel Uploaded from authorPOINT lite Insert YouTube videos in PowerPont slides with aS Desktop Copy embed code: (To copy code, click on the text box) Embed: URL: Thumbnail: WordPress Embed Customize Embed The presentation is successfully added In Your Favorites. Views: 2159 Category: Entertainment License: All Rights Reserved Like it (9) Dislike it (0) Added: January 11, 2010 This Presentation is Public Favorites: 3 Presentation Description No description available. Comments Posting comment... By: cmy7777 (13 month(s) ago) A very usefull presentation for nurses Saving..... Post Reply Close Saving..... Edit Comment Close By: shivaprasadhalemani (13 month(s) ago) hello sir/Madam, the ppt on documentation is very nice so please make this to help us Please send me the ppt of documentation for study purpose. Saving..... Post Reply Close Saving..... Edit Comment Close By: KramerII (18 month(s) ago) very good presentation Saving..... Post Reply Close Saving..... Edit Comment Close Premium member Presentation Transcript Kozier - Chapter 15Documenting and Reporting : Kozier - Chapter 15Documenting and Reporting Purposes of Patient Records - chart : Purposes of Patient Records - chart Communication Record of diagnostic and therapeutic orders Care planning Tracking progress QA Legal and historical documentation Reimbursement Formats for Nursing Documentation : Formats for Nursing Documentation Initial nursing assessment Kardex and patient care summary Plan of nursing care Critical collaborative pathways Progress notes Flow sheets Discharge and transfer summary Home healthcare documentation Long-term care documentation Types of Flow Sheets : Types of Flow Sheets Graphs VS 24-hour I&O Medication record - MAR 24-hour patient care records and acuity charting forms Methods of Documentation : Methods of Documentation Source-oriented records Problem-oriented medical records - SOAP PIE charting Focus charting Charting by exception Case management model Computerized records Major Components of POMR : Major Components of POMR Defined database Problem list Care plans Progress notes SOAP Notes – POMR : SOAP Notes – POMR Subjective – what patient says – Use quotes Objective Assessment Plan SOAPIE Implementation Evaluation Kozier p. 251 Examples Sample PIE Patient Care Note : Sample PIE Patient Care Note Sample Focus Patient Care Notes : Sample Focus Patient Care Notes Sample PCC NURSES NOTE : Sample PCC NURSES NOTE QUIZZZZZ : QUIZZZZZ 1. In Problem Oriented Medical Records, which type of format is used for documentation? a. DAR-Data, Action, Response b. CBE- Charting by exception c. SOAP- Subjective, Objective, Assessment, Plan d. PIE- Problem, Intervention, Evaluation Slide 13: 2. An advantage to CBE (charting by exception) would be: a. Focus is on patient concerns b. Useful in proving competence c. Each discipline can find easily d. decrease in charting time Slide 14: 3. Which of the following are important to document for the Home health care nurse? a. That the patient remains homebound b. Rehabilitation potential is good c. The patient is not stable d. All of the above Slide 15: 4. If you were looking for trends in a patient’s vital signs what form should you consult first? a. Graphic sheet b. Nursing Assessment c. Admission sheet d. Flow sheet Slide 16: 5. All nursing data relating to patient care must be integrated into the patient record. This is specified by the agency known as a. HIPAA b. JCAHO c. OSHA d. AARP Characteristics of Effective Documentation : Characteristics of Effective Documentation Consistent with professional and agency standards Complete Accurate Concise Factual Organized and timely Legally prudent Confidential Record Factual Information : Just the facts Head to Toe Nursing Assessment What is seen What is heard What is palpated Record Factual Information Slide 20: What is done for the patient The patient’s response to the action The patient’s experience (quotes) Rule of Thumb: : Rule of Thumb: If it wasn’t documented, it wasn’t done REMEMBER Using the 24-hr Cycle Military Clock for Documenting Times : Using the 24-hr Cycle Military Clock for Documenting Times Charting : Charting Record all information in ink The date & time you are charting Slide 24: Entries out of sequence must be identified as “Late Entry” Document in chronological order Error Notation – Follow the agency policy : Error Notation – Follow the agency policy Typical hospital error notation: Draw a single line through the error Write “error” above it Sign (or initial) and date the error Do’s & Don’ts of Documentation : Do’s & Don’ts of Documentation Avoid Generalized terms - be specific and clear Avoid words like “appears” Always use black - never use erasable ink Slide 27: Never make assumptions about an incident - only document the facts Never falsify information Never pre chart your care Never leave blank spaces Slide 28: Write neatly & legibly Sign name and title Document significant observations & events State the facts not interpretations Use only hospital approved abbreviations Slide 29: Document notification of the M.D., data reported, and physician recommendations Never include personal opinions Never make judgment statements Never assume anything Include quotes when appropriate Include the patient’s perspective Slide 30: Record and identify all patient education and observations Do not include “Incident Report submitted” Never erase an entry or use white out Distinguish between the charting time & the time of an event if different Remember that a complete and honest record is absolutely necessary. : Remember that a complete and honest record is absolutely necessary. : Subpoena Any alteration may result in an allegation of fraud. Alterations, unclear or improper documentation, incorrect abbreviations, biased statements…. : Alterations, unclear or improper documentation, incorrect abbreviations, biased statements…. May lead to a case that is impossible to defend because of the damage to your credibility. : May lead to a case that is impossible to defend because of the damage to your credibility. What Is Confidential? : What Is Confidential? All information about patients written on paper, spoken aloud, saved on computer Name, address, phone, fax, social security Reason the person is sick Treatments patient receives Information about past health conditions Slide 36: In other words, All information about the patient is confidential Health Insurance Portability and Accountability Act of 1996 - HIPAA : Health Insurance Portability and Accountability Act of 1996 - HIPAA Provides individuals with more control over their health information. Establishes limits for appropriate use and release of health care information. Requires the majority of health care providers and their agencies to comply with safeguards to protect individual privacy related to health care information. Delineates a set of civil and criminal penalties holding HIPAA regulation transgressors accountable for actions if the client’s health care privacy is violated. Kozier – p. 110 HIPAA Compliance and Nursing Practice : HIPAA Compliance and Nursing Practice Patient’s name cannot be posted near or on door. Charts should be in secure, nonpublic areas. Printed copies of protected health information (PHI) not left unattended on printers or faxes Access to health information limited to need to know Health care providers required to have passwords to access patient’s electronic chart Notice of Patient’s privacy rights must be posted. Voice levels kept low when discussing patient’s information. Health care providers must follow current HIPAA regulations. Kozier p. 71 Potential Breaches in Patient Confidentiality : Potential Breaches in Patient Confidentiality Displaying information on a public screen Sending confidential e-mail messages Sharing printers Discarding patient information in trash cans Overheard conversations Faxing to unauthorized persons Overheard on pagers Patient Rights : Patient Rights See and copy their health record Update their health record Get a list of disclosures Request a restriction on certain uses or disclosures Choose how to receive health information Policy for Receiving Verbal Orders in an Emergency : Policy for Receiving Verbal Orders in an Emergency JCAHO – patient safety goals Record the orders in patient’s medical record Read back the order to verify accuracy Date and note the time orders were issued in emergency Record VO, the name of the physician followed by nurse’s name and initials Policy for Physician Review of Verbal Orders : Policy for Physician Review of Verbal Orders Review orders for accuracy Sign orders with name, title, and pager number Date and note time orders signed Duties of RN Receiving a Telephone Order : Duties of RN Receiving a Telephone Order Record the orders in patient’s medical record Read orders back to practitioner to verify accuracy Date and note the time orders were issued Record TO, full name and title of physician or nurse practitioner who issued orders Sign the orders with name and title Change of Shift Report : Change of Shift Report Basic identifying information about each patient Current appraisal of each patient’s health status Changes in medical conditions and patient response to therapy Where patient stands in relation to identified diagnoses and goals Current orders (nurse and physician) Summary of each newly admitted patient Report on patient transferred or discharged Two Nurses Confer at Change of Shift Report : Two Nurses Confer at Change of Shift Report Methods of Reporting : Methods of Reporting Face-to-face meetings Telephone conversations Messengers Written messages Audio-taped messages Computer messages Conferring About Care : Conferring About Care Consultations and referrals Nursing and interdisciplinary team care conferences Nursing care rounds Quizzzzzzzzz : Quizzzzzzzzz 1. When documenting it is important for the nurse to include a. the facts b. personal opinions c. abbreviations d. your interpretation Slide 49: 2. Which of the following would be considered confidential about the patient a. diagnosis b. treatment plan c. address d. all of the above Slide 50: 3. When receiving a verbal order in an emergency situation the nurse must a. Record the order on the order sheet in the patients chart and read it back to doctor to check accuracy. b. Refuse to accept a verbal order c. Record TO and the name of the physician on the progress sheet. d. Write the order on a scrap piece of paper and later write it on the chart for neatness. Slide 51: 4. When giving a shift report which of the following information would you want to include a. How many times the patient had his nurses light on b. Why you did not like caring for the patient c. Changes in the patients vital signs d. What the physician said about the patients family Slide 52: 5. When a group of nurses visit selected patients this is know as a. A referral b. Consultation c. Nursing Conference d. Nursing Care rounds Slide 53: A student has reviewed a patient’s chart before beginning care. Which of the following actions violates patient confidentiality? a. writing the patient’s name on the student clinical log. b. providing the instructor with the nursing diagnosis. c. discussing patient’s medications with the nurse. d. providing care information to the nurse tech.