Chapter 5: Documentation and Interprofessional Communication

Chapter 5: Documentation and Interprofessional Communication Patient Health Record · The patient health record serves multiple purposes. In addition to being a legal document of patient care and nursing practice, the patient health record is used for communication among health team members, care planning, quality assurance, education, and research · Legal Document: ↳ the health record serves as a legal document regarding the patient's health status and interventions received ↳ can be used in civil or criminal law to reserve questions about accountability · Communication and Planning Care: ↳ Assessment data provides the basis for the plan of care (POC) that identifies conditions, outcomes, and interventions for the patient. The POC helps caregivers coordinate and individualize care until discharge · Quality Assurance: ↳ an audit occurs when an agency or outside group reviews the records of a health care facility to determine whether that facility is providing and documenting certain standards of care ↳ an internal audit's goal is to improve care ↳ Accrediting agencies establish standards and audit patient heath records to evaluate the quality of care provided · Education ↳ students in various health care professions can review patient health records to enhance clinical learning and to better understand complex clinical situations and to perform informed individualized care · Research ↳ health care professionals use patient health records to obtain data for nursing and medical research. Researchers must gain approval from Ethic's Review Board before any research study Principles Governing Documentation · Confidentiality: nurses are legally and ethically required to keep all information in the patient health record confidential and private ↳ information should be discussed only with other health care professionals directly involved in the patients care · Accurate and Complete: Assessment information that nurses enter into the patient's record must accurately reflect what was observed, heard, auscultated, palpated, percussed, or smelled ↳ use a patients exact words for subjective data, and use correct clinical terminologies · Organized: organized assessment data demonstrates a systematic grouping of information ↳ it is important to document entries of assessment chronologically · Timely: enter assessment data into the record in a timely manner. ↳ batch/block charting all at once is bad! You will likely forget key information! ↳ point-of-care documentation occurs when assessment information is documented as it is gathered · Concise: Charting is complete, yet concise. Unnecessary elaboration causes confusion. eg. document BP as "BP (right arm, sitting) 124/78" Nursing Admission Assessment · sometimes referred to as the nursing history and physical examination · obtain patient history and baseline data to gather information and plan individualized care · the admission assessment provides future care providers with comprehensive information about the patients physical, psychological, functional, social, and spiritual abilities and forms the basis for an individualized POC · Flow sheets: an efficient method used to document routine, scheduled assessments. They standardize the collected information, which permits easy comparison among assessments to detect a sudden change in status ↳ include vital signs, intake and output, routine assessments, and diabetic record · Plan of Care (POC): is part of the permanent patient record and is updated as the patient's condition changes. It individualizes goals, outcomes, and interventions · Clinical Pathway: a multidisciplinary tool that identifies a standard plan for a specific patient population (eg. hip replacement patients) ↳ includes patient conditions, expected outcomes, and interventions within a specified time frame · Progress Notes: documentation from multiple health team members that summarize how the patient is doing eg. SOAPIE, focus notes, PIE, etc. Reporting Documentation Formats: · Handoff: occurs anytime one provider transfers the · Narrative responsibility for the care of a patient to another, and · SOAPIE (subjective, objective, analysis, easily leads to more risks for errors plan, intervention, evaluation) ↳ Verbal vs. Written hand off · PIE (problem, intervention, evaluation) · reporting: reporting occurs at handoffs, during patient · Focus DAR (data, action, response) rounds, during patient and family care conferences, and · Charting by exception when calling/texting a provider to report a change in status or provide requested information ↳ Communication must be organized, complete, Types of Documentation (in more depth) accurate, concise, and respectful · Narrative: record information in an unstructured ↳ verbal and nonverbal cues paragraph, including relevant assessments and nursing activities during a shift or visit. Usually organized by time SBAR · SOAP(IE): subjective and objective data findings, A for · S: situation → state concisely why you are analyzing the condition and seeing if its improving or communicating worsening, P for plan of treating or improving the . B: background → describe the circumstances condition, I for interventions, and E to evaluate the leading up to the current situation patients condition · A: assessment → give objective and subjective · PIE: Problem, Interventions, and Evaluation. May include data pertinent to the situation A for assessment. Goal is to incorporate POC into a . R: recommendation → make suggestions for progress note what needs to be done · Focus: Data, Action, Response. Focuses on areas of strengths or health issues, family concerns, or nursing diagnoses. Data includes subjective and objective, Action represents interventions and treatments, and Response reviews how the patient responded or met outcomes · Charting by Exception (CBE): uses predetermined standards and norms, only document any unexpected assessment findings · Discharge note: Assessment should indicate patient is stable with completed teaching regarding medicines and follow up care and is noted in the chart