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Nursing Orientation: DOCUMENTATION

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by

Linda Jennings

on 26 January 2016

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Transcript of Nursing Orientation: DOCUMENTATION

References
Basic Information that is required when Documenting
Documentation for the court: value of good nursing records and the difficulties for nurses when their reports are poor
Objectives:
EMR: Computerized Charting
DOCUMENTATION
Dr. Linda Jennings
Research and Electronic Nursing Documentation
1. Study by Kelly, Brandon and Docherty in 2011
2. The study question was to examine the relationship between electronic documentation and the quality of care provided to hospitalized patients.
3. Results:
a. nurse felt that it aided in their memory by placing care options
b. with drop-down boxes, nurse did not have to remember, what data elements to chart
c. made it easy for nurses to not "think"about the nursing process
d. limit the full description of the patient's health status
e. does not completely meet their needs in day-to-day practice



1. Explain the importance of documentation as a health care provider.
2. Identify the legal aspects of nursing documentation.
3. Identify the basic information that is required when documenting.
4. Discuss computerized documentation concerns.
5. Discuss Do's and Dont's of documentation.
6. Discuss the consequences of poor documentation.
The Importance of Nursing Documentation
Comparison between Paper-based and Electronic Medical Records
What is EMR's ?
Waving Red Flags for Attorneys
Notes that are sloppy, incomplete, inconsistent, have gaps
Entries that are timed or dated or appear out of sequence
Entries that show delays or failures in initiating treatment orders
Entries that show the care provided was substandard or inappropriate
Entries that show care rendered was not supported by the healthcare provider's prescription
The statement "
Completed an Event Report
"
Value of high quality nursing records in court
Used as evidence to create an accurate sequence of events, patient health status and care being provided
Sanction justice and the right outcomes to transpire in civil and criminal cases
Additional information in coronial inquests that gives closure to families of the deceased about a cause of death and additional actions in regards to health practitioners involved if necessary
It can be assessed by only one facility
It can be created, gathered, manged and consulted by authorized clinicians and staff within the VA organization
Track data over time
Identify patients who are due for preventive visits and screenings
Monitor how patients measure up to certain parameters (B/P readings, A1c)
Improve overall quality of care in a practice
Kelly, T. F., Brandon, D. H. & Docherty, S. L. (2011). Electronic documentation as a strategy to improve quality of patient care. Journal of Nursing Care, 43(2).
1. Good charting means better care
2. Proper documentation provides future readers the tools they will need to ensure timely continuity of care
3. Substantiating the health condition, illness or presenting concern of a patient.
4.Recording the patient's response to care.
5.Can provide data for research studies
6.Maybe the basis for planning and implementing quality improvement measures
7. Teaching health care professionals about caring for patients.
Why is it important as a nurse???
Documentation- Legal
All health care professionals have a duty of care to adhere to and are accountable for the care they provide
Nursing Competency Standards and Code of Professional Conduct outline that nurses must practice in accordance with the standards of the profession, such as those relating to accurate health documentation. Breach of this, may constitute either unprofessional conduct or professional misconduct.
Documentation may be required for legal proceedings, such as civil or criminal proceedings.
Accurate and factual accounts of good patient care, can provide valuable assistance in the court of law
ANA principles for Nursing Documentation
The Principles suggests that documentation systems must:
designed in consultation with nursing staff so that the nurses concerns are addressed
promote a "record once, read many times" approach to avoid duplicate recording by different providers.
use ANA recognized data set (examples: patient falls, pressure ulcers, staff mixing
be readily accessible by nurses and support data analysis
encourage nurse to critically evaluate the system of documentation and patient outcomes.
Brusco, J. M. (2011). Electronic health records: what nurses need to know.
Association of

PeriOperative Nursing, 93
(3).
Austin, S. (2011). Stay our of court with proper documentation.
Nursing201136
(1). retrieved from www.Nursing2011.com
Austin, S. (2006). "Ladies of the jury, I present... the nursing documentation" & gentlemen.
Nursing2006
. retrieved from www.nursing2006.com
Benefits of EHRs (2014). Retrieved from www.healthi.gov
Eisenberg, S. (2010). electronic medical records. life in the paperless world.
Yocum, R. (2002). Documenting for quality patient care.
Nursing2002, 32
(8)
Monarch, K. Documentation, part 1: Principles for self-protection. Preserve the medical record--and define yourself.
American Journal of Nursing, 107
(7).
Dimick, C. (2008). Documentation bad habits: Shortcuts in electronic records post risk.
Journal Health Information Management Association, 79
(6)
Failing to record pertinent health or drug information
Failing to record nursing actions
Failing to record that medications have been given
Recording on the wrong chart
Failing to document a discontinued medication
Failing to record drug reactions or changes in the patient's condition
Transcribing orders improperly or transcribing improper orders
Writing illegible or incomplete records
What you need to document to prevent Fraud:
document medication when they are
actually
given
document assessments, dressing changes, and other treatments as completed when they were done
only one component of care can be documented before it happens--the plan of care
the Do's and Don't's of Charting:

DO
THINK before you abbreviate
DO
follow the same rules with flow sheets
Do
write legibly
Do
follow professional standards for nursing practice
Do
name anyone who becomes involved in the patient's care
Don't
use abbreviates that are not approved by your institution or Joint Commission
Don't
fall into the temptation of shortcuts, using copying and pasting
Saving our Trees
Case Studies
Full transcript