Standard for Documentation: Inpatient Care Units DRAFT 8/28/2012 #2

Transcription

1 Standard for Documentation: Inpatient Care Units DRAFT 8/28/2012 #2 POLICY: The patient record is the legal document which captures care provided and the patient s response to that care. The documentary role of nursing is to record all nursing care and treatment and the effectiveness of nursing interventions. A nurse sets patient centered goals, outlines expected outcomes, plans nursing interventions and selects interventions that will resolve the patient s problems and achieve the goals and outcomes. Documentation in the patient record is, therefore, an essential means of communication with healthcare team members. At the Massachusetts General Hospital, we believe that the source of truth for the continuous understanding of patient care delivery and the patient s response to care is the progress note. All patients will have: A Nursing Data Set An admission note Progress notes Discharge note Transfer note (as needed) Description of elements: 1. NURSING DATA set is the initial nursing assessment. The purpose of this assessment is to gather data related to a patient s health status and to be used to identify actual or potential problems a patient may have at admission, during hospitalization or at discharge. a. The data set is completed for each patient by a Registered Nurse within 24 hours of admission b. Information should still be obtained and documented as soon as possible. All information obtained after the initial entries (but within 24 hours) can be documented on the data set form and will be dated, timed and initialed. c. Any information obtained after 24 hours of admission, should be documented in the patient progress notes. d. When a patient is unable to provide information and family is not available to provide information to the nurse, the RN must document this on the last page of the data set, check the appropriate box, and write signature, date and time of entry. Refer to Nursing Data Set Form: instructions for use (Nursing Procedure Manual: Trove)

2 PROGRESS NOTES will be written upon admission, shift, transfer and discharge.. 1. Admission note: Written at the time of admission in the progress note by the 2. registered nurse admitting the patient. The registered nurse will document the patient s problems based on information obtained in the data set, patient diagnosis, and the clinical assessment of the RN. 3. Shift Nursing: Progress notes are written at least every twelve hours and or when there is a transfer of accountability between nurses (e.g., 4-hour shift, 8-hour shift or 12-hour shift) and as the patient condition warrants, by the RN caring for the patient. 4. TRANSFER NOTE: Written when a patient is transferred from one unit to another or when the patient leaves for a procedure by the nurse transferring the patient. The note will outline the active patient problems and current interventions. 5. Discharge note: A discharge note will be written on-line at the time of discharge by the registered nurse discharging the patien. a. The note will include patient condition, person accompanying the patient, mode of transportation, prescriptions and follow-up appointments scheduled. b. There will be a notation of resolution of problem (nursing diagnosis/collaborative problem) and plans for follow-up. All progress notes entries will contain the patient s plan of care: 1. Patient s problems including: a. Patient education b. Discharge planning 2. Patient centered goal and outcome with anticipated timeframe for achievement 3. Interventions 4. Patient progress toward goals and plan 1. Patient s Problems a. For each patient there will be problems identified based on the nursing assessment (dataset and physical assessment). b. The problems may be written as nursing diagnoses and/or medical diagnoses. A nursing diagnosis is a clinical judgment about actual or potential individual, family, or community experiences/responses to health problems/life processes. A nursing diagnosis provides the basis for selection of nursing interventions to achieve outcomes for which the nurse has accountability

3 c. Diagnostic reasoning is the process used to reflect on information that the nurse utilizes to identify patient problems and design interventions toward achievement of outcomes. 2. Patient centered goal and outcome with anticipated timeframe for achievement. a. A patient centered goal is a specific and measurable behavioral response that reflects a patient s highest possible level of wellness and independence in function. The goal should be realistic, observable and involving only one behavior or response. b. An expected outcome is a specific measurable change in a patient s status that you can expect in response to nursing care. c. Patient Centered goals and expected outcomes serve to provide a clear direction for the selection and use of nursing interventions and to provide focus for evaluating the effectiveness of the interventions. The time frame assists in determining the progress toward the goal. 3. Interventions will address the identified problem and will assist the patient to reach the goal There are three types of interventions a. Independent nursing interventions i. Nurse initiated interventions ii. Do not require orders from other health professionals b. Dependent nursing interventions iii. Physician initiated interventions iv. Require orders or directions from physicians or other health care professionals c. Collaborative interventions v. Therapies that require combined knowledge, skill and expertise of a number of health care professionals Interventions should be based on the following: a. nursing diagnosis b. goals and expected outcomes c. evidence based i.e. research or practice guidelines d. feasibility e. acceptability to the patient 4. Patient progress and response to the interventions should be described. Based on the description and assessment, the RN will continue with the current interventions (plan) or change the interventions (plan) so goal can be met. Additional information: All entries will include date, time, full name and title or licensure. Entries will be written in black or blue ink.

4 Errors in documentation will be corrected by putting a single line through the incorrect information, writing error, dating and initialing. For an error that covers a larger area, a large parenthesis may be put around the section in error, or an X mark through the area, write error, date and initial. No whiteout, cross outs or erasures is permitted. When an entry has been omitted and it is necessary to document after others have charted, the nurse should designate the note late entry and note the date and time of the omission. Nursing activities generated by the nursing and medical plan of care will be recorded on the Treatment Record and One Time Treatment Record. Clinical Associates, Unlicensed Nursing Students (while in their clinical rotation) and all other non-licensed personnel may document on specified forms those measurements and treatments performed within the scope of their position description or clinical rotation objectives. Clinical Associates and Unlicensed Nursing Students (while in their clinical rotation) may also write progress notes and transfer notes co-signed by a registered nurse (Co-signer is usually a staff nurse or the clinical instructor). Approved: Council on Practice 2/94 Approved: Nursing Executive Committee 4/94 Revised: Nursing Practice Committee 6/97, 9/02, 8/05, 11/08, 3/09, 5/09, 6/09, 5/10 Approved: Nursing Executive Operations 4/12 Revised: Practice and Quality Oversight Committee : 5/2012 Under review: 9/2012

5 Appendix A- Example of progress note. Brief summary of patient s reason for admission and pertinent past medical history Problem with Goals for this hospitalization: Describe the goal for this problem and the timeframe for achieving the goal. e.g. patient will maintain a numeric pain scale score of 5 or below first day post op. Interventions provided: describe interventions and patient response to the interventions. How is patient progressing toward stated goals. Plan: A nursing care plan outlines the nursing care to be provided to an individual/family. It is a set of actions the nurse will implement to resolve/support nursing problems identified by nursing assessment. It guides in the ongoing provision of nursing care and assists in the evaluation of that care. Example: 8/6/2012 1:00 pm The patient is a 78 year old women who was hit by car 8/4 as she was walking across street. Sustaining R femur and R ulnar fracture. PMH includes HTN, cataract surgery-both eyes, and s/p colectomy 10 years ago for colon CA. Patient last hospitalized 10 years ago, lives independently, is a community ambulator. Has 2 daughters both in visiting and wanting to be involved with patient s care. Pain: Goal; patient to rate pain (using visual analog scale) 5 or below today post op day #2. Patient stating pain 6/10 this morning. Patient utilizing morphine PCA, however, patient stating it not providing much relief. Because patient eating well, discussed with patient the transition to PO pain medications. Patient stated she remembered having good pain relief with Percocet with last operation, so oxycodone given to patient at 9 am. Morphine PCA discontinued. Pain assessment at 9:45-4/10 with no stomach upset from oxycodone. Patient out of bed with nursing to chair x2, with pain assessment 5/10 when moving. Patient stated once in chair, pain decreased to 3/10. Right arm elelvated on pillows at all times. PLAN: continue with oxycodone every 4 hours.and coordinate medication with mobility. Continue to elevate arm. Alteration in mobility: Goal; patient will be able to get out of bed to chair for all meals today (8/6) with one to two assist and utilizing platform walker. Patient will utilize bedside commode today. Patient out of bed for breakfast and lunch today- touch down wgt bearing to RLE, and non wgt bearing to RUE. Requiring 2 assist and platform walker. Patient moving slow, but motivated to move. Remained in chair for 30 minutes each time. Not able to ambulate to the bathroom, bedside commode utilized x1. Bedpan utilized at other times. PLAN: continue to assist patient out of bed for dinner tonight. Encourage patient to utilize bedside commode for elimination. Initiate toileting schedule to commode. Risk for falls due to secondary diagnosis-opioids, ambulatory aid- platform walker, gait/transferringrequiring 2 assist. Goal; prevent patient fall this hospitalization. Instructed patient to call for assistance before getting out of bed. Patient stated understanding and has called for all assistance. Area kept clutter free, bed in lowest position, non slip slippers in use, patient in high visible bed (close to the desk), bed locked. PLAN: Continue above interventions, OOB with assist of 2.

6 Patient Education: Goal; Patient will verbalize and demonstrate understanding of pain medication, wgt bearing instructions, and the need to reposition in bed to decrease risk of skin breakdown. Reviewed with patient the following: pain management and PO pain medication, side effects and schedule; respositioning in bed- small shifts and changing position every 2 hours; wgt bearing status- non wgt bearing and partial wgt bearing. Patient s questions answered and demonstrated wgt bearing status, and shifting in bed. PLAN: review pain medication information and reinforce above. Tomorrow will focus on anticoagulation medication and wound care. Risk of impaired skin-decreased mobility and incision lines. Goal: patient s skin will remain intact during hospitalization. Patient s skin is intact-no redness on pressure points. + CSM to all extremities. No edema noted in RLE or RUE. Patient assisted in turning every 2 hours. Prevalon boots in use to both heels. Patient out of bed 30 minutes at time, and then placed in bed with HOB at 30 degrees or less. Gaymar chair cushion in use when in chair. PLAN: continue to reposition every 2 hours, increase frequency if redness noted. Constipation: Goal: patient will move bowels by 8/7. Patient states she has not moved bowels since 8/3. Bowel sounds present, patient states passing gas. Patient eating ½ tray. MOM administered at 2 pm, senekot initiated. PLAN: encourage increase in fluid intake. Patient states prune juice has helped in past at bedtime. Provide glass at 8 pm. Assist to bedside commode. Discharge Planning: Goal: Patient will be discharged to acute rehab facility 8/8. Patient lives alone, and will benefit from a short rehab stay. After rehab her daughters will be available to assist. CM involved and family has requested Spaulding Boston. Awaiting decision. Plan; Assure all discharge information is provided to patient and her daughters. Joanne Empoliti, RN

7 APPENDIX B : Progress note template. Brief summary of patient s reason for admission and pertinent past medical history Problem with Goals for this hospitalization: Describe the goal for this problem and the timeframe for achieving the goal. e.g. patient will maintain a numeric pain scale score of 5 or below first day post op. Interventions provided: describe interventions and patient response to the interventions. How is patient progressing toward stated goals. Plan: A nursing care plan outlines the nursing care to be provided to an individual/family. It is a set of actions the nurse will implement to resolve/support nursing problems identified by nursing assessment. It guides in the ongoing provision of nursing care and assists in the evaluation of that care.