Shirley P. Roth, MSN, RN. DDA Health Initiative

Transcription

1 Shirley P. Roth, MSN, RN DDA Health Initiative

2 » Describe at least three key features of correct documentation when providing nursing care.» Articulate at least three important don ts when documenting nursing care.» Describe pertinent facts that must be included when documenting verbal orders with the individual s physician.» Identify specific documentation requirements of the DDA Health and Wellness Standards.

3 If it wasn t documented, it wasn t done!

4 » Documentation on the health record begins with date and time and ends with the recorder s signature and designation Example: 9/19/2013 9:15 am Mary Johns, RN Write clear, concise, unbiased, and accurate Objective vs. subjective Avoid generalizations Avoid bias and labels

5 » Use correct spelling and legibility for nursing documentation to prevent misinterpretation and errors Eg. Digitoxin and digoxin Use of black ink Do not change pens while writing an entry Do not leave blank space on documents or use ditto marks.

6 » Use abbreviations, symbols, and acronyms that are widely accepted and preferably on approved agency list. Consider referring to list of unsafe abbreviations developed by the Institute of Safe Medication Practice in your agency approved abbreviation list.

7 » Verbal orders and telephone orders Write down the time and date on the physician s order sheet. Write down the order exactly as given by the physician. Read the order back to the physician to ensure it is accurately recorded. Record the physician s name, telephone order, print your name, and sign the entry, along with designation (e.g. RN).

8 » When collaborating with members of the IDT document: Date and time of contact Name(s) of people involved Pertinent information provided by team members Responses from team members Suggestions/interventions resulting from the collaboration The agreed upon plan of action Anticipated outcomes

9 » Don t chart a symptom, e.g. c/o headache, without also charting what you did about it, and individual s response to treatment.» Don t alter a client s record...this is a criminal offense. Red flags for chart altering: Don t add information at a later date without indicating that you did so. Don t date the entry so that it appears to have been written at an earlier time. Don t add inaccurate information. Don t destroy records.

10 » Don t use abbreviations that aren t widely accepted or at least from an approved listing in your agency.» Don t write vague description, e.g. large amount of drainage.» Don t give excuses, e.g. Medicines not given because not available.» Don t chart your opinions.

11 » Don t chart ahead of time.» Don t record staffing conflicts or problems.» Don t use language that suggest a negative attitude towards a client, e.g. nasty, weird, crazy, etc.» Don t give the name of another individual... doing so violates confidentiality. If you have to refer to a second individual, do so by using the word roommate.

12 » Accepted practice for correcting an error or making changes/additions on paper-based documentation Agency policy must guide practice Failure to correct an error appropriately or correcting or modifying another s documentation may be interpreted as falsification of a record. Falsifying records is considered professional misconduct according to the nurse s practice act.

13 Health Passport Health Form 1 Nursing Assessment & HCMP Quarterly Nursing Assessment MARs Critical Incident Report Psychotropic Drug Review Form Seizure Activity Logs

14 » Variances in health & wellness services Rationale for variance Discussions between the individual, health care provider, support team, and health care decision maker Actions or plans taken to address the variances

15 » Coordination of health services Write evidence of coordination of care + Phone calls + In-person meetings + Transition of care guides + Training activities (oral and written)

16 » Medical consents Ensure treatment is not delayed because of lack of signed medical consent Functional assessment of behavior - must precede the development of a behavior support plan

17 » Management of Infections Information related to the management and plan of care Document the individual response to treatment Request assistance from the Transition Nurse Specialist

18 » End-of-life discussions» Hospice services changes to HCMPs

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20 NURSING DOCUMENTATION METHODS ARE EVOLVING Electronic health records are being implemented Computerized forms and reports are now standard Information is transmitted via

21 PURPOSE OF NURSING DOCUMENTATION The methods of documentation may have changed but the purpose has not. Nursing documentation is used for: Communication Continuity of care Evidence of quality of care Legal protection

22 AS WE ALL KNOW.. If it was not documented it was not done

23 PROTECTING YOUR DOCUMENTS Once you have created your electronic documents, you will probably have to share them with other authorized personnel. Before sending out your document think about who will be receiving it, how they may be using it and who they may distribute the document to. Remember, you are the author and are legally responsible for the contents of your documents.

24 SIMPLE STEPS Never send out documents in Word! This leaves your document wide open to anyone that wants to make changes that now have YOUR name and signature associated with them. Convert files to pdf format. If you don t have Adobe already installed on your computer you can download it for free.

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26 MORE ADVANCED Scan your document, and save it in pdf prior to sending. This makes it very difficult to cut, paste or copy from your documents. This is effective but takes a little more time.

27 GUIDELINES FOR COMPUTER CHARTING Double-check that you are entering the data for the right person at the right part of the file. Never tell anyone your password. Change it often. Tell your immediate supervisor if someone is using your code. Don t allow anyone else to use the computer with your password logged in.

28 GUIDELINES FOR COMPUTER CHARTING CONTINUED... Don t leave client info displayed on the computer screen. Retrieve any printouts immediately. Log off the computer when you are not using it. Follow your agency s policies and procedures for computer entries and error corrections. Ensure that appropriate backup files are kept.

29 GUIDELINES FOR COMPUTER CHARTING CONTINUED... If you are using a laptop to document at work and you are allowed to take it home with you, do not be tempted to let members of the family use it for personal reasons. Once notes are entered into the computer, they become a permanent part of the medical record and shouldn t be deleted or edited at a later time without an explanation that s documented, signed and dated. Do not use access health information over unsecured WiFi connections or in public places where your screen could be viewed by unauthorized individuals

30 ELECTRONIC SIGNATURES An electronic signature is used to authenticate the sender or author of a document. It can be as simple as a scanned version of the authors handwritten signatures. Centers for Medicare and Medicaid Services (CMS) states: In cases in which facilities have created the option for an individual s record to be maintained by computer, rather than a hard copy, electronic signatures are acceptable. Electronic Signature Guidance - Clarification

31 SCENARIO 1 You have recently taken on a new caseload of individuals at your agency. The previous nurse did an excellent job of keeping documents updated and even left all the documents on the laptop that you are now using. You receive a call from a DDS Service Coordinator that you will have two ISP s tomorrow for two of your newly assigned individuals. The SC has made it clear that ALL documents must be ready and presented to her at the meeting. It is 5:00pm and your meetings will start at 9:00 am in the morning. How will you handle the situation?

32 SCENARIO 2 You recently attended an ISP meeting for one of your individuals. You completed all the necessary paperwork and submitted them to the Service Coordinator via . You receive a call the following day from the SC. He is uploading the ISP and asks that you re-send the documents in Word format so he can cut and paste directly into MCIS. How would you handle the Service Coordinators request?

33 QUESTIONS?

34 REFERENCES: Challenges and Opportunities in Documentation of the Nursing Care of Patients. Retrieved from: Carrington, Jane M. PhD, RN; Effken, Judith A. PhD, RN, FACMI, FAAN Strengths and Limitations of the Electronic Health Record for Documenting Clinical Events Electronic Signature Guidance Clarification. Retrieved from: Certification/SurveyCertificationGenInfo/downloads/SCLetter05-14.pdf