Documentation: The Good, The Bad and The Hilarious!

Transcription

1 Documentation: The Good, The Bad and The Hilarious! How to document the care you provide in an objective format so that your patient looks the same on paper as what you assess on your visit. Revised September 2014

2 Introduction Diane Noah, BSN, RN, MBA Executive HomeCare of Mid-Missouri Please feel free to ask questions as we go along?

3 Learning Objectives 1. Understand that good objective documentation provides the best protection against liability. 2. Understand that good documentation can improve the quality of your communication. 3. Know specific examples of objective documentation versus subjective documentation.

4 But patient Care is what we do! Documentation of care we provide in the home is harder than it looks.. Documentation must be: objective and complete. It must explain what we did and why. Who we contacted and what for, as well as family issues. It must stand up in a court of law. It must be clear and concise. AND.It must be done timely.

5 What is documentation and why is it important? The medical record chronologically documents the care of the patient and is an important element in contributing to high quality care. The medical record promotes communication and continuity of care among all health care professionals involved in the patient s care. The medical record is complete and legible. The medical record facilitates accurate and timely claim review and payment.

6 What should good documentation include? The documentation of each patient encounter should include the reason for the encounter and relevant history, head to toe assessment findings, vital signs, clinical impressions, any family/patient issues, any specific physician ordered treatments, plan for next visit, nurse must date and sign the medical record. Sounds easy doesn t it????

7 Good Documentation cont: At its best medical documentation reflects a clear and complete assessment that legibly communicates pertinent patient information. Your documentation needs to describe what you were doing in the home and why; not just checkmarks that look the same every visit with no changes or narrative. A. Ex: Patient failed to take meds, meds left in med planner.

8 Good Documentation cont: At its best medical documentation reflects a clear and complete assessment that legibly communicates pertinent patient information. Your documentation needs to describe what you were doing in the home and why; not just checkmarks that look the same every visit with no changes or narrative. A. Ex: Patient failed to take meds, meds left in med planner. B. Ex: Better- Patient failed to take Lanoxin, left in med planner x 3 days, Dr. notified as not taking meds could be life threatening. Family contacted to come over in PM to make sure meds in planner taken by patient.

9 If it was not documented it was not done! When you document use specific patient quotes. Document patients competency, affect and attitude. Document all patient concerns, ask the patient, Do you have any concerns? Then document them- this demonstrates your thoroughness in obtaining the patient information/assessment and avoids later charges that the patient brought an important issue or symptom to your attention that you did not address, ignored or neglected: because you documented it.

10 How in the world are we going to get it all done right and timely? Documentation must be objective not totally subjective. A. Ex: The patient looks like she has some pain in her leg. (This is a vague subjective statement by the nurse.) B. Ex: The patient reports her pain on a 1-10 scale as a 4. She is grimacing and holding her right knee with movement. (This is verifiable objective documentation by the nurse based on the patient report and nurse observation.) It does take longer to do this but a complete assessment will hold up in a court of law. As well as be more specific for the physician and any monitor/funding source looking at your record.

11 Advantages of Timely and Effective Documentation 1. Evidence of appropriate home care. 2. Improved coordination of patient care services. 3. Improved productivity due to decreased time spent on rectifying errors. 4. Decreased risk of liability or loss of license. 5. Justification for reimbursement. 6. Decreased problems with monitors/surveyors. 7. Able to complete your paperwork timely.

12 What is Objective vs. Subjective Documentation? Objective: Information in a patients chart that is verifiable and measurable. This includes information from exams, tests, assessments, observations, lab results and vital signs. There is no guessing or hearsay, as all information is observable by everyone. Subjective: Information obtained from the family, patient, significant other about existing problems. This includes complaints, statements, perceptions, and feelings. This information may not be verifiable.

13 Effective, Objective Documentation Instead of using discussed, used instructed or evaluated. Instead of using generalized weakness document what the symptoms were that caused the weakness, ex: unable to walk without assist, short of breath on exertion, can only sit up x 30 min, chair bound, bedbound, these are just a few examples. Instead of patient seems to be improving, be specific what is she improving at.

14 Effective, Objective Documentation Instead of documenting reinforced teaching, use continues to need instructions as patient is a slow learner due to recent illness. Instead of using stable, document appears to be responding to treatment ordered by physician. Instead of pulse irregular, document specifics about the pulse thready, weak, bounding skipped beats, etc. Instead of reviewed a skill such as diet document that the patient continues to need instruction on diet due to noncompliance. Patient ate 3 donuts for breakfast.

15 Can you ever use subjective data? You can document subjective data, but there had better be objective data in your note to collaborate that you did assessment and what the verifiable data is. All pertinent information should be documented in the clinical note. Leave extra fluff or unimportant items out. For example: On arrival at the patient s home, patient was sitting in her chair wearing a green bathrobe and purple socks. Be specific, brief, concise and consistent while documenting in the clinical record.

16 The Good, The Bad and the Ugly! Good Patient states chest tight and can t breathe. B/P 160/100, P 110, R 30. Patient exhibits dyspnea and nasal flaring. Respiratory wheeze evident with auscultation left lower lobe. Patient coughed up 10 ml of thick, tenacious yellow mucus. RN administered 2 puffs bronchodilator medication Albuterol per physician orders with patient exhibiting immediate relief. Patient states no difficulty breathing now. B/P 130/90, P 82, R 22. Will continue teaching patient pulmonary exercises after rested.

17 The Good, The Bad and the Ugly! Bad Examples- actual patient charts: Levaquin 500 mg QD x 7 days, Darvocet N tabs Q4 hours prn pain, med box set up due Friday. (Nurse failed to write an order for the new drugs and sentence not complete, clear or concise) Call MO heart continue Zocor 80 mg HS-Dr. Woods called 12:40p 8/7/08 (Not a complete sentence, not clear and concise, Left the regarding totally out of sentence) Wife doing 7 units Novolog to 7 from 6 wife adjusted, instructed family to call endocrinologist 8/7/98. Add Lantus 40 u at HS everyday(not a complete sentence, not clear and concise, left out the RE completely)

18 The Good, The Bad and the Ugly! Ugly: actual patient charts Husband at bedside, patient easily aroused. The patient lives at home with his parents and pet turtle, who is presently enrolled in daycare three days per week. Cat in home wearing med alert pendant. Nonverbal, non-communicative and offers no complaints. Family at bedside attempted to urinate. This is a 981 YO female with a host of medical problems.

19 State Board for Nursing Disciplinary Actions that effect our industry Censure Documented that she had received a physician s order and had read back and verified the order with the physician, when in actuality, the conversation never took place. Licensee failed to correct errors Licensee failed to see her patients and return calls to them. Took a loan from a resident Failed to chart a restraint Failed to properly waste a medication

20 State Board Continued: Probation The patients glucometer levels in the machine did not match what the nurse had written in her documentation. Nurse failed to notify the primary care physician that her patient had an elevated temp it was documented in her notes, the patient died. Failed to document vital signs. Failed to follow physicians order. Nurse called physician but call was not documented as well as transfer of a patient to a higher level of care was not documented.

21 State Board continued: Probation continued: Failed to actively and effectively chart. Failed to document medication administration. Nurse fell asleep at a patients home without other adults present to supervise. Nurse pre documented patients vital signs when the record showed the patient had passed away 3.5 hours earlier. Nurse received disciplinary action for sharp and discourteous behavior toward her co-workers. Nurse extremely rude to patient and his wife. Gave med without physician order. Nurse turned off alarm monitors on patient machine that would alert her of problems.

22 State Board continued: Probation continued: Nurse falsified records. Nurse did not contact Dr. and treated the patient without orders. Documentation was not clear, descriptive, or thorough. Nurse used and unapproved abbreviation and the meaning could not be ascertained.

23 State Board continued: Voluntary Surrender: Failed to notify the physician of changes in a patient condition and the patient died 10 days later. Failed to properly or timely document the assessment or interventions of her care of her patients. Failed to follow through on physician orders. YOU CAN LOSE YOUR ABILITY TO PRACTICE BASED ON WHAT YOU DOCUMENT!

24 Whose responsibility is it? Does it make sense? Does it read like a novel or a cliff note? Can you read it? Does it describe what happened when the nurse was in the home? Is it complete? Is there narrative documentation? OR is it just checkmarks on a form that look the same for every visit?

25 Whose responsibility is it? YOURS

26 Comedy Corner An actual sign at a Zoo! Please Be Safe. Do not stand, sit, climb or lean on fences. If you fall, animals could eat you and that might make them sick. Thank you.

27 Questions????? Open forum THANK YOU FOR YOUR TIME- I KNOW IT IS VALUABLE!

28 Sources Talk the Talk and Walk the Walk workshop- Charly D Miller University of North Texas Regulatory Compliance Office Lori Rupp, Connie Thompson, Janet Hackward, HCMM The Home Care and Documentation Guide, Huebner and Harrison, Aspen