NURSING DOCUMENTATION

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1 NURSING DOCUMENTATION OBJECTIVES 1. The learner will be able to state 2 components of documentation that meet the 2. The learner will be able to identify 4 characteristics of a complete skin assessment 3. The learner will be able to identify 4 characteristics of a complete wound assessment DOCUMENTATION IS Ø Something you learn in nursing school Ø Something you do everyday at work Ø How you record patient vitals, diet, meds THE permanent record of nursing assessment and care provided 1

2 DOCUMENTATION Ø any written or electronically generated information about a patient that describes the care or services provided to that patient SOME EXAMPLES Skin intact, red, and broken The skin was moist and dry Pulses are probably in both feet 2

3 Examination of genitalia reveals that he is circus-sized 300cc PWISOTF (Plus what I spilled on the floor) Patient found dead: felt cold, blanket added, voiced no complaints 3

4 She has no rigors or shaking chills, but her husband states she was very hot in bed last night Large brown stool ambulating in the hall Documentation is the process of recording the patient assessment and the care provided It MUST demonstrate that the has been met 4

5 STANDARD OF CARE What is it and who decides? STANDARD OF CARE Ø Guidelines used to determine what a nurse should or should not do Ø Model of established practice that is commonly accepted as correct Ø Basis for nursing care that draws on the latest scientific data from nursing literature Ø Based on the premise that the registered nurse is responsible for and accountable to the individual patient for the quality of nursing care he or she receives STANDARD OF CARE The nurse has a professional responsibility, and is held accountable to document patient data that accurately reflects: Ø Nursing assessment Ø Plan of care Ø Appropriate interventions Ø Evaluation of the patient s condition 5

6 STANDARD OF CARE Developed and implemented to define the quality of care provided Ø Federal / State laws, rules and regulations Ø Professional organizations establish norms for the average practitioner Ø The ANA and Joint Commission on Accreditation of Healthcare Organizations (JCAHO) have established nationally recognized Standards of Care POLICY AND PROCEDURE In addition- Ø Nurses must understand and follow the policies and procedural guidelines of their individual facilities LEGAL CONSIDERATIONS The healthcare industry can be a minefield of litigation when patients Ø Don t heal as expected Ø Develop unexpected complications or infections which can lead to prolonged recovery or even death Lawsuits often involve all those who cared for the patient, including the nurse 6

7 WOUND LITIGATION ON THE RISE Ø Increasing elderly population Ø Regulatory climate Ø Misunderstanding by families as to the cause of wounds Ø Perceived as bad care Ø Public opinion that wound cases are an easy target LEGAL CONSIDERATION Ø Nursing documentation Ø often starting point in malpractice cases Ø can either deter a plaintiff from filing a lawsuit or provide the leverage that is required to initiate one Jurors and attorneys view what is written in the patient record as the best evidence of what really occurred PRESSURE ULCERS The incidence of Hospital acquired pressure ulcers (HAPUs) is considered a quality indicator of patient care Ø Quality care should not result in a HAPU Ø A Never Event Ø High public awareness Ø Frequent involvement in litigation Ø Reimbursement issues 7

8 The reality is that not all pressure ulcers are preventable. The nurse MUST be able to show that all appropriate assessments and interventions were done. That the was met DOCUMENTATION THAT MEETS THE STANDARD OF CARE Ø Timely Ø Accurate Ø Comprehensive Ø Complete DOCUMENTATION THAT MEETS THE STANDARD OF CARE ASSESSMENT, ASSESSMENT, ASSESSMENT.. ü SKIN ASSESSMENT ü WOUND ASSESSMENT ü RISK ASSESSMENT 8

9 SKIN ASSESSMENT 1. TIMELY ü ON ADMISSION ü EVERY SHIFT OR VISIT ü FOLLOW FACILITY POLICY SKIN ASSESSMENT 2. ACCURATE / COMPREHENSIVE / COMPLETE ü INTEGRITY- Alteration in Epidermis or Dermis ü COLOR- Erythema, Pallor, Cyanosis ü TURGOR- Dehydration ü MOISTURE STATUS- ü TEMPERATUREü HIGH RISK AREAS- SKIN ASSESSMENT DOCUMENT AND REPORT ABNORMALITIES 9

10 WOUND ASSESSMENT 1. TIMELY ü ON ADMISSION ü EVERY SHIFT OR VISIT ü UPON TRANSFER / DISCHARGE ü PER FACILITY POLICY WOUND ASSESSMENT 2. ACCURATE / COMPREHENSIVE / COMPLETE ü Wound Type ü Location ü Measurement ü Undermining / Tunneling ü Wound Bed Appearance ü Drainage ü Odor ü Surrounding Skin WOUND DOCUMENTATION Paints the picture & tells the story WOUND TYPE SURROUNDING SKIN LOCATION ODOR WOUND MEASUREMENT DRAINAGE APPEARANCE UNDERMINING TUNNELING 10

11 WOUND TYPE FOR PRESSURE ULCERS: Ø If you know how to stage it-do it! Ø If you are uncertain-describe it! LOCATION, LOCATION COCCYX SACRAL AREA TROCHANTER ILIAC CREST Sacrum Coccyx GLUTEAL FOLD ISCHUIM Correctly identify wound location MEASUREMENT LENGTH X WIDTH X DEPTH Longest point Head to toe direction Perpendicular to length Widest point 90 degree angle Deepest point Document on Admission and per facility policy 11

12 UNDERMINING / TUNNELING UNDERMINING TUNNELING Document with measurement APPEARANCE GRANULATION TISSUE SLOUGH ESCHAR Document tissue type or describe color DRAINAGE How much and what does it look like? 12

13 ODOR Document presence of SURROUNDING SKIN Document condition of skin surrounding wound REALITY Audits are enlightening Ø Wrong location Ø Wrong wound type Ø Wrong pressure ulcer stage Ø Ever changing pressure ulcer stage Ø Missing assessment data Ø Inconsistencies from shift to shift and day to day 13

14 Common Liability Issues ü Lack of documentation ü No admission assessment ü Discrepancy with prior / post facility assessment / staging ü No measurements ü Lack of interventions ü Specialty support surface ü Off-loading ü Documentation of turning / repositioning MORE Liability Issues ü Failure to identify skin breakdown ü Failure to notify doctor of changes in wound ü Failure to apply proper treatment ü Failure to obtain wound care consult ü INCONSISTENCY IN DOCUMENTATION AUDIT EXAMPLE Date 2/28 2/ 2/ 2/ 3/1 3/ 3/2 3/2 3/3 3/3 3/4 3/4 3/ 3/5 3/6 3/6 3/7 3/7 Wound Consult Time 10Am Pm Am Pm AM Pm Am Pm Am PM Am Pm Am Pm Am PM Am Pm AM PU Stage III III III III SDTI I III II Unstageable Measure 4X2 4x2 4x2 3 x 1.2 x.2 Undermining Tunneling Wound color Pink yellow White / White / Red / Pink / Pink / Green Pink UTA UTA White / yellow yellow yellow yellow yellow yellow Incis edges approx separated Separated Separated Separated NA UTA UTA NA Exudate amt Small None None None None None UTA UTA Small Exudate type Serous None None None None None UTA UTA Serous Odor Absent Absent Absent Absent Absent Absent Absent Absent Absent Absent Surrounding Intact Intact Intact Intact Intact Intact Intact UTA UTA Intact skin Intact Closure None None None None None None None None None NA Liquid None tissue Dressing Changed Changed Changed Changed WDP Changed No WDP WDP Changed Change assess/changed Wnd cleanser NS NS NS NS NS NS Dressing applied Gauze Gauze Hydrogel Gauze Hydrocolloid Hydrogel Hydrogel Hydro- Hydrocolloid Hydrogel Foam Gauze Foam Foam gel Foam Hydrocolloid Secondary None None other None Foam None Other dressing Secured with Paper Paper Paper tape Paper Paper Paper tape tape tape tape tape Good News: Wound is noted on admission Not So Good News: No Charting: for the next 3 days Staging: Inconsistent (IIIà SDTIà Ià IIIà II)-actually Unstageable Measurement: noted on day 3 / Stage III, no depth documented, ever Incision edges: Documented consistently (in a pressure ulcer?) Closure: liquid tissue? Dressing: Not assessed consistently-dressing type changes shift to shift 14

15 DOCUMENTATION TIPS Documentation should include: Ø Data from Nursing Assessment Ø Nursing actions / interventions taken Ø Individuals notified about concerns / issues Ø Evaluation of actions DOCUMENTATION TIPS Ø Document within timeframe outlined per facility policy Ø Correctly identify LEFT and RIGHT Ø Correctly identify LOCATION, especially Ø SACRAL Ø COCCYX Ø Correctly stage all PRESSURE ULCERS Ø Do NOT stage wounds that are NOT pressure ulcers GENERAL CAUTION Spell correctly: Ø Fecal heart tones heard Use appropriate words and grammar: Ø The pelvic exam was done on the floor Avoid inappropriate comments: Ø Patient received insufficient care today because nurse patient ratio was 1:7 15

16 Don t Forget RISK ASSESSMENT ü Evidenced based tool: Braden / Norton ü Follow facility policy for frequency ü INTERPRET RESULTS ü Implement appropriate interventions ü Use score to adjust the plan of care IMPROVING COMPLIANCE Ø Staff education and support related to wound ID, pressure ulcer staging, wound assessment.. Ø Tools and visuals to assist staff in wound identification and staging WOUND DOCUMENTATION FORMAT SUGGESTIONS Ø Nurse friendly Ø Contain all components necessary for complete documentation Ø Improves probability of comprehensive doc Ø Visual 16

17 EXAMPLE 1-INDICATE LOCATION OF WOUND (S) ON BODY DIAGRAM X #1 2-DOCUMENTATION FOR: ALL WOUNDS EXCEPT INTACT SURGICAL WOUNDS Wound Location Wound Type / Wound Appearance Drainage Odor Cleansed Dressing # Pressure Ulcer Measurement with Applied Stage Click boxes for smart text options PRESSURE 1 Left SCANT ULCER STAGE 2 X 2 X.2cm RED ABSENT NS Hydrocolloid ILIAC SEROUS II SMART TEXT OPTIONS Wound# à choose smart textà (1 / 2 / 3 / 4 / 5 / 6 / 7 / 8 / 9 / 10) Location à choose smart textà (coccyx, ischial, scaral ) Wound Type / à choose smart textà (arterial, diabetic, PU stage I, PU stage II, PU stage III ) Measurement à choose smart textà (length 1 / 2 / 3 ) (Width 1 / 2 / 3 ) (Depth 1 / 2 / 3...) Appearance à choose smart textà (red / pink / yellow / gray.) Drainage à choose smart textà (none, scant, small ) Odor à choose smart textà (absent, present) Cleansed with à choose smart textà (NS, wound cleanser...) Dressing à choose smart textà (Calcium alginate, gauze, hydrocolloid ) 3-DOCUMENTATION FOR INTACT SURGICAL WOUNDS ONLY A-Intact surgical incisions # through # (choose smart textà (1 / 2 / 3 / 4 / 5 / 6 / 7 / 8 / 9 / 10) B-Incision Appearance (choose smart textà (clean / dry / well approximated / without erythema / without drainage / without odor) C-Closure (choose smart textà staple / sutures / glue / other / none) BOTTOM LINE Every nurse is responsible for the patient care provided and the DOCUMENTATION to support it SOME OPTIONS 17

18 NURSING TOOLS Ø Nurse cheat sheet Ø Pressure ulcer staging analogy Ø PU staging algorithm Ø Musical wound assessment Cheat Sheet for Nurses Pressure Ulcer Analogy Nursing Tools Baker Pressure Ulcer Staging Tool Musical Wound Assessment 18

19 Thank You Wound Care Nursing 19

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