STANDARDS AND GUIDELINES Guidelines for Documentation in the Gastrointestinal Endoscopy Setting Disclaimer The Society of Gastroenterology Nurses and Associates, Inc. assumes no responsibility for the practices or recommendations of any member or other practitioner, or for the policies and procedures of any practice setting. The nurse and associate function within the limitations of licensure, state nurse practice act, and/or institutional policy. This guideline is based on current understanding and practice in the field. Each gastrointestinal/endoscopy unit is responsible for establishing its own documentation procedures and for creating its own forms, allowing for the differences in operation of each unit. The sample forms illustrated herein are not necessarily suited for any unit other than the unit that developed each form. They are printed here with the permission of the contributing facilities. Preface Documentation development is guided by the use of the nursing process (assessment, planning, intervention and evaluation) to establish an individualized plan of care for the patient while in the endoscopy unit. This guideline is intended to provide direction for individual endoscopy units in establishing consistent patient care documentation. These documentation guidelines meet requirements for patients receiving sedation. A reduced requirement for documentation may apply dependent onyou institutional policy for non-sedated patients. Documentation should clearly and uniformly record details that closely describe situations or events occurring to patients undergoing endoscopy or related procedures. This guideline incorporates Centers for Medicare and Medicaid Services (CMS) requirements and Joint Commission on Accreditation of Healthcare Organizations (JCAHO) recommendations. Various members of the healthcare team may be responsible for documenting specific items in the patient record. In order to provide information that is easily adaptable to each patient care environment, the guideline is divided into three major components: Pre-Procedure, Procedure and Post-Procedure. The intent of the guideline and the accompanying outline is to provide information and criteria that can be selected in formulating an individualized document that meets the needs and requirements to conform to institutional policy and to the particular endoscopy setting. Definition of Terms For the purpose of this document, the following terms are defined: Vital signs: temperature, heart rate, respiratory rate, blood pressure, pain, and oxygen saturation assessment. 57
JCAHO: Joint Commission for Accreditation of Healthcare Organizations. CMS: Centers for Medicare and Medicaid Services. AAAHC: Accreditation Association for Ambulatory Health Care. Pre-Procedure Phase: the period of time prior to the beginning of the procedure. Procedure Phase: from the initiation of sedation and analgesia, when used, or the initial step of an invasive procedure, until completion of the diagnostic or therapeutic intervention. Post-Procedure Phase: from the completion of the diagnostic or therapeutic intervention until the patient leaves the facility. Section 1: Pre-Procedure Phase An age-specific patient assessment is performed and documented by a registered nurse. The assessment factors should include physical, psychosocial, current medications, treatment, and previous medical, anesthetic and drug history. Review of the patient s symptoms and history will supply any pertinent information to be documented. All documentation should include time of performance and name of person performing the assessment or intervention. The frequency of the assessment is determined by institutional/departmental policy, the patient condition, the physician and/or the registered nurse. JCAHO recommendations and CMS requirements for the Pre-Procedure Phase are included in the following: 1. Time of assessment 2. Telemetry, if applicable. 3. Oxygen saturation if sedation or analgesia is anticipated. 4. CO2 monitoring (optional) 5. Level of consciousness/mental status 6. Disposition of patient valuables (i.e. glasses, jewelry,etc.) 7. Baseline pain assessment using institutionally approved pain scale with identification of area, duration and type of pain 8. Warmth, dryness and color of skin 9. NPO status 10. Bowel prep compliance (if applicable) 11. Current medications and time of last dose(s) including aspirin, non-steroidal antiinflammatory drugs, anticoagulants, sleeping medications, tranquilizers, over-the-counter drugs, herbal agents or illicit drugs. 12. Allergies and reactions to medication, food, contrast or latex including OTC and herbals 13. Presence of removable dental appliances, loose teeth, glasses/contact lenses, hearing aids 14. Presence of prosthetic devices (e.g., hip replacement, valves) 15. Airway assessment (e.g., jaw and neck mobility) 16. Intravenous line: type, site, inserted by, rate of IV solution or presence of venous access device 17. Pregnancy status 18. Physical assessment appropriate to the patient s age, individual needs, and procedure to be performed 19. Labs or previous procedures results (if applicable) 58
20. Patient concerns 21. Emotional status, psychological, spiritual, cultural status 22. Assessment for potential abuse 23. Educational needs assessment with identification of barriers to learning 24. Known significant medical diagnoses and conditions including current status of infectious disease/exposure, physical disabilities, and conditions 25. Known significant surgical and invasive procedures, history of complications or reactions to previous sedation, analgesia, or general anesthesia 26. Validation of correct patient/correct procedure 27. Admitting registered nurse signature/time Section 2: Procedure Phase Every patient undergoing a diagnostic or therapeutic, or invasive procedure requires monitoring by a registered nurse or other qualified personnel. Whatever method is employed, documentation should include event, intervention (if necessary) and outcome. Each facility must comply with applicable regulations and guidelines, including state regulations, JCAHO guidelines, CMS requirements, and the facility s standards for monitoring of patients. JCAHO recommendations and CMS requirements for the Procedure Phase are included in the following: 1. Vital signs 2. Telemetry, if applicable 3. Baseline and ongoing pulse oximetry is required for patients undergoing sedation and analgesia. 4. CO² (optional) 5. Level of consciousness/mental status 6. Continuous pain assessment using institutional approved pain scale with documented response to intervention 7. Warmth, dryness, and color of skin 8. Procedure(s) performed 9. Physician(s), registered nurse(s) and support staff involved in the procedure 10. Name and dosage of all drugs and agents used (including oxygen), time, route of administration, by whom, and patient s response 11. Type and amount of all fluids administered (including blood and blood products) 12. Equipment/accessories used (i.e. cautery, laser,etc.) 13. Implantable devices (i.e.stents, tubes, etc.) 14. Unusual events, interventions and outcomes 15. Patient status at the end of procedure 16. Type of specimen(s) obtained and disposition 17. Post-Procedure findings 18. Signature(s) required 19. Time Out initiated by the physician to confirm the right patient/right procedure 59
Section 3: Post-Procedure Phase The frequency of the assessment is determined by institutional/departmental policy, the physician and/or the registered nurse. JCAHO recommendations and CMS requirements for the Post-Procedure Phase are included in the following: 1. Time of arrival in post-procedure area 2. Vital signs 3. Pulse oximetry is required until return to pre-procedure baseline for patients who received sedation and analgesia. 4. Continuous pain assessment using institutional approved pain scale with documented response to intervention 5. Level of consciousness/mental status 6. Warmth, dryness and color of skin 7. Name and dosage of all drugs used (including oxygen), time, route of administration, by whom, and patient s response 8. IV fluids administered and/or discontinued including blood and blood products 9. Unusual events, interventions, and outcomes 10. Physical assessment appropriate to age, patient needs, and procedure performed 11. Disposition of patient (hospital room, home, x-ray, etc.), and with whom 12. Report given to subsequent caregiver 13. Mode of transportation (ambulatory, stretcher, wheelchair, etc.) 14. Name of person responsible for outpatient at discharge 15. Age specific discharge instructions and educational materials given to outpatient and/or accompanying adult, who verbalizes or demonstrates understanding and signs form. 16. Discharge criteria applied 17. Time of discharge 18. Signature of discharge nurse 19. Discharge instructions per institution policy to include follow-up and specific patient orders written by the physician. Conclusion By combining the JCAHO recommendations and CMS requirements for documentation along with published data and input gathered from the membership, SGNA anticipates that these recommendations will provide guidance to each endoscopy unit staff in establishing a comprehensive institutional documentation policy. References American Society of Anesthesiologists. (2001). Updated practice guidelines for sedation and analgesia by non-anesthesiologists. [Practice guideline]. Park Ridge, IL: Author. 60
Committee on Drugs of the American Academy of Pediatrics. (1992). Guidelines for monitoring and management of pediatric patients during and after sedation for diagnostic and therapeutic procedures. Pediatrics, 89, 1110-1115. Health Care Finance Administration. (1993). Generic Quality Screen Guidelines, Exhibit 37. Washington, DC: Author. Joint Commission on Accreditation of Healthcare Organizations. (2003). Comprehensive Accreditation Manual for Hospitals: The Official Handbook. Oakbrook Terrace, IL:Author. Kost, M. (1999). Conscious sedation: Guarding your patient against complications. Nursing. 29 (4): 34-39. Standards of Practice Committee of the American Society for Gastrointestinal Endoscopy. (2002). Sedation and monitoring of patients undergoing gastrointestinal endoscopic procedures. Gastrointestinal Endoscopy, 2, 626-629. Society of Gastroenterology Nurses and Associates, Inc. (2000). Guidelines for nursing care of the patient receiving sedation and analgesia in the gastrointestinal setting. [Guideline]. Gastroenterology Nursing. 23:125-129. Acknowledgments First edition 1989, revised 2003. Prepared by the Education Committee of the Society of Gastroenterology Nurses and Associates, Inc. (SGNA) chaired by Trina Van Guilder, RN,BSN,CGRN. Adopted by the Society of Gastroenterology Nurses and Associates, Inc. Board of Directors 2003. Published as a service to members by the Society of Gastroenterology Nurses and Associates, Inc. Copyright 2003, Society of Gastroenterology Nurses and Associates, Inc. 61
Outline for Form Preparation The following outline is included to ease the preparation of a form to be used for the acquisition of data, procedure and post-procedure documentation and statement of patient s disposition I. Pre-Procedure Phase Scheduled Procedure B. Patient identification 1. Demographic data a. Name b. Date of birth c. Unique patient identification number d. Phone number 2. Physician 3. Referring physician 4. Time of arrival 5. Communication barrier 6. Impairments 7. Responsible adult for discharge/accompanied by C. Health History 1. Past procedure(s) 2. Previous problems with anesthesia or sedation 3. Chief complaint 4. Present illness 5. Allergies including reactions: food, medication, latex 6. Current medication, time of last dose(s) 7. Level of consciousness/ mental status 8. Level of comfort 9. Bowel preparation 10. NPO status 11. Baseline vital signs and pulse oximetry 12. Weight in pounds/kilograms Airway assessment (neck and jaw mobility, dentition) D. Medical History 1. Heart disease, pacemaker, implanted cardioverter defibrillator, dysrhythmias, valvular heart disease 2. Hypertension 3. Lung/breathing problems (e.g., asthma, COPD, sleep apnea) 4. Liver disease (e.g., jaundice, hepatitis, cirrhosis) 5. Pancreatic disorders (e.g., pancreatitis, diabetes) 6. Neurological disorders (e.g., seizures, CVA, ALS, MS) 7. Kidney disease 8. Cancer 9. Bleeding or blood disorders, including transfusion history 10. GI problems (e.g., peptic ulcer disease, hiatal hernia, IBD/IBS, diverticulosis, polyps) 11. Arthritis 12. Pregnancy status 13. Glaucoma 14. Pain (using institutional scale, duration, location) 15. Other E. Surgical 1. Implanted prosthetic devices (e.g., stents, valves, joint replacements) 2. GI surgeries F. Family History 1. Colon cancer 2. Polyps 3. IBD 62
G. Social History 1. Substance abuse ( e.g., ETOH, illicit drugs) 2. Smoking history H. Venous Access Device 1. Time started 2. Site 3. Type of device used 4. Solution and rate/flush 5. Inserted by I. Laboratory Test Results J. Patient Teaching 1. Patient knowledge of procedure 2. Barriers to learning 3. Interventions to learning barriers 4. Methods (e.g., pamphlet, video) 5. Demonstrates understanding K. Pre-Procedure Nursing Notes L. Informed Consent Obtained M. Presence and Disposition of Appliances (e.g., dentures, hearing aids, contacts, glasses) N. Vulnerable Adult yes/no; Social Services Notified yes/no O. Admitting Nurse Signature II. Procedure Ph ase Procedure Time Started Completed B. Validation of correct patient/correct procedure ( Time out ) B. Staff Physician(s) Registered nurse(s) Support staff Technicians C. Medication (including oxygen) 1. Time administered 2. Dosage/liters 3. Route/method 4. Administered by 5. Patient response D. Vital Signs 1. Blood pressure, heart rate, respirations 2. Oxygen saturation 3. Warmth, color and dryness of skin 4. Level of consciousness/mental status 5. Level of comfort/response E. Equipment/Accessories 1. Endoscope 2. Monitoring equipment 3. Therapeutic modalities (examples) a. Cautery: type, setting, grounding pad site & pre/post skin condition b. Laser: type, settings, safety procedures followed c. Argon plasma coagulator: settings, flow rate, grounding pad site & pre/post skin condition d. Band ligators: number placed e. Injection device: purpose (e.g., sclerotherapy, tattooing, contrast medium) f. PEG/PEJ, stents, feeding tubes: size, type, manufacturer, lot number g. Dilators: size, type h. Other (e.g., snare) 4. Diagnostic modalities (examples) a. Probes (e.g, ph, rectal) b. Manometry catheter c. Other (e.g., biopsy forceps) d. Documentation of any indwelling devices left in patient 63
F. Fluoroscopy 1. Time G. Imaging 1. Method (e.g., videotape, photography) H. Specimens 1. Biopsy 2. Cytology 3. Microbiology 4. Other I. Procedure Performed and Post-Procedure Diagnosis J. Nursing Observation Notes 1. Unusual events, interventions and outcomes 2. Toleration of procedure 3. Post-procedure assessment before transfer to recovery K. Nurse/Staff Signature(s) Physician s signature III. Post-Procedure Phase A. Time of Arrival to Post-Procedure Area B. Vital Signs and oxygen saturation for patients who received sedation C. Level of Consciousness/Mental Status D. Level of Comfort/Response E. Venous Access 1. Total amount infused (including blood and blood products) 2. Time discontinued 3. Condition of site F. Medications 1. Time administered 2. Dosage 3. Route 4. Administered by 5. Patient response Note: Usage of only acceptable medication names and dosage abbreviations. G. Oral Fluid Tolerance H. Report Given to Subsequent Caregiver I. Discharge Instructions Given by Given to Verbalizes or demonstrates understanding Signature of patient and/or accompanying adult Discharged according to criteria or by physician discharge order J. Disposition Destination Accompanied by (name of individual) Mode of transportation K. Time of Discharge L. Nursing Observation Notes Unusual events, interventions and outcomes M. Discharge Nurse Signature Discharge Instructions to Outpatients A. Type of Procedure Performed B. Activity 1. Normal 2. Restrictions (e.g., driving, operating machinery, working) C. Diet Normal Modifications a. Special diet instructions 64
b. Fluids Restrictions NPO (e.g., until anesthetic worn off) Avoidance of alcohol (state number of hours) D. Post-Procedure Complication Symptoms 1. List symptoms specifically (e.g., abdominal pain, fever, evidence of bleeding) 2. Instructions for notifying physician or obtaining emergency assistance (include physician office/answering service phone numbers) E. Instructions for Symptoms and Sensations Expected as Normal, and Remedies Sore throat - throat lozenges, gargle with warm water, etc. Redness at IV site - apply warm compress, etc. Gaseous discomfort - belching, passing flatus F. Medication Instructions 1. Continue 2. Discontinue 3. New medications prescribed 4. Interactions of medications with food and other drugs G. Specimen Results Method for obtaining results (e.g., call physician s office) H. Additional Pertinent Instructions Follow-up visit with physician Referrals, if appropriate I. Signatures 1. Patient and/or accompanying adult 2. Nurse discharging the patient A copy of the discharge instructions or written documentation is given to the patient and one is kept in the patient s chart. 65