Efnisyfirlit

• Cover
• Title Page
• Copyright
• Dedication
• Contributors
• Previous Contributors
• Foreword
• 1 Understanding documentation
• A look at documentation
• You reach a wide audience
• A short history of documentation
• Role of documentation
• Communication
• A growing team
• Evaluation of actions
• Legal protection
• The evidence speaks for itself
• Research and education
• A reciprocal relationship
• Accreditation and licensure
• Quality is key
• Getting what they deserve
• Track with a tracer
• Charting clinical competence
• Is that safe?
• Quality and consistency
• Reimbursement
• It’s payback time . . . or is it?
• Examinations aren’t just for patients
• Keeping the proper care going
• Performance improvement
• Up to snuff?
• Nurse practice acts
• Accountability
• Types of medical records
• A comprehensive record
• Source-oriented narrative method
• Missing the complete picture?
• Get on the same page
• Problem-oriented method
• Focusing on each problem
• Other medical record formats
• Designer documentation
• Electronic health record
• They even have good bedside manners
• Suggested references
• 2 The nursing process
• A look at the nursing process
• Going through the steps
• Assessment
• Getting the whole picture
• First impressions
• Health history
• Getting started
• Making the most of your time
• Physical examination
• It’s in the details
• The Joint Commission standards
• Family matters
• Is the patient well-equipped?
• No yes-or-no answers, please
• Learning obstacles
• Prioritize, prioritize, prioritize
• Nursing diagnosis
• Diagnosing a diagnosis
• One patient, two types of treatment
• Emergencies get top billing
• Planning care/outcomes
• Take three giant steps
• Outcome identification
• Keeping it real
• Four-part format
• Writing outcome statements
• Implementation
• Divine intervention
• Writing interventions
• Documenting interventions
• Tailor your style (and format) to policy
• Evaluation
• Charting changes
• A tough transition
• The value of evaluation
• Whenever within sight
• Evaluating expected outcomes
• Not resolved? Revise . . .
• Documenting evaluation
• Get specific
• Suggested references
• 3 Care plans
• A look at the nursing care plan
• Now a part of the permanent record
• A word about words
• Style of care plans
• Traditional care plans
• Looking toward an outcome
• Personal, visual, clear
• Time isn’t on its side
• Standardized care plans
• Insist on individuality
• Computers make combos less cumbersome
• These advantages come standard
• Is it individualized?
• Interdisciplinary contributions to the care plans
• Patient-teaching plan
• Pointers for the perfect plan
• Parts of the teaching plan
• Which evaluation techniques are most valuable?
• Start simple
• Taking different paths to learning
• Tracking down teaching tools
• Break down language barriers
• Documenting the patient-teaching plan
• Give it time . . . and thought
• Forms, forms, and more forms
• Just your type
• Care pathways
• Practical when predictable
• Accomplished a goal? Check it off!
• A collaborative effort
• Determining the path
• A bundle of benefits
• Here’s where it gets complicated . . .
• Choosing the right path
• Priorities in the pathway
• Suggested references
• 4 Documentation systems
• A look at documentation systems
• To write or not to write?
• Narrative documentation
• Using narrative documentation
• Documentation mania!
• Observe and take note
• One thought leads to another
• A narrative with a happy story
• The narrative takes a turn for the worse . . .
• Problem-oriented medical record
• A multidiscipline approach
• Four-part format
• A four-star knowledge
• Dividing the diagnoses
• It’s as easy as 1, 2, 3, 4, 5 . . .
• Plan on patient participation
• A clean SOAP or SOAPIE component
• POMR pros . . .
• . . . and cons
• PIE system
• Using the PIE system
• Pieces of PIE
• Got a problem with that?
• Keeping track
• Reevaluate and review
• Reasons to give PIE a try
• Problems with PIE
• FOCUS (F-DAR) system
• Coming into FOCUS (F-DAR)
• Writing FOCUS (F-DAR) progress notes
• Lights, camera, data, action, response!
• DAR-e to succeed?
• FOCUS (F-DAR) downers
• Charting by exception
• CBE guidelines
• Document deviations
• Defining normal parameters
• Get your guidelines here
• CBE format
• Making progress?
• Fill in the blanks
• Checks, asterisks, and arrows
• Note normalcy
• Make more marks
• Care-ful combinations
• More checks and asterisks
• It’s exception-all
• CBE shortcomings
• Electronic health record
• Information station
• Multitasker
• The upside
• The downside
• Using an EHR
• Mum’s the word
• Starting the record
• Individual access
• Practitioner’s use
• Help for managing meds
• Ready, set, document
• Fast and functional
• Follow protocol
• Types of EHR systems
• Talk, touch, or click
• Adding your personal touch
• What’s your type?
• Nursing information system
• From passive to interactive
• Nursing minimum data set
• Consistent and coded
• Nurse’s little helper
• But it’s always about the patient
• Nursing outcomes classification system
• Voice-activated systems
• Look ma, no hands!
• Report support and more
• Hanging on every word
• Additional system features
• Patient schedules
• Bar code technology
• Medication administration
• To be discontinued . . .
• Sorry, wrong number
• Streamlined service
• Blood administration
• Support provided
• When computers fail
• Choosing a documentation system
• Getting better and better
• Does your documentation measure up?
• Are you committed? Serve on a committee . . .
• Suggested references
• 5 Enhancing your documentation
• A look at expert documentation
• Documenting completely, concisely, and accurately
• Say what?
• Don’t be wishy-washy
• Maintaining objectivity
• Don’t put words in other people’s mouths
• Secondhand data
• Ensuring timeliness
• Document ASAP
• Give them the time of day
• Put your documentation in order
• Better late than never
• Ensuring legibility
• No pencils, please
• Spelling counts
• Using abbreviations appropriately
• Correcting errors properly
• Signing documents
• To be continued . . .
• What you didn’t see can hurt you
• Practitioner’s orders
• Written or electronic orders
• Heading off mistakes
• Preprinted orders
• Verbal orders
• From words to paper
• Telephone orders
• From phone to paper
• Questioning practitioner’s orders
• Chart authority
• Stop, question, and document
• Suggested references
• 6 Avoiding legal pitfalls
• A look at legal pitfalls in documentation
• The aim is communication
• Legal standards
• In a confused state? Read on . . .
• Accreditation organizations/federal regulations
• The more things change, the more they stay the same
• Every relationship brings with it responsibility
• The ties that bind
• Documenting defensively
• How to chart
• Rule #1: Stick to the facts
• Rule #2: Avoid labeling
• Rule #3: Be specific
• Rule #4: Use neutral language
• Rule #5: Eliminate bias
• Rule #6: Keep the record intact
• Rule #7: Know your EHR
• What to document
• Rule #1: Document significant situations or unusual events
• Rule #2: Document complete assessment data
• Rule #3: Document discharge instructions
• When to document
• Don’t get ahead of yourself
• Who should document
• Finish what you started
• Risk management and documentation
• Mining the records for potential risk
• Preventing adverse events
• Reporting the out of the ordinary
• Let’s review
• Making sure everyone is on the same page
• Managing incidents
• The claim chain reaction
• Eight legal hazards
• Hazard #1: Incident reports
• The form’s function
• It’s an eyewitness report
• Hazard #2: Informed consent
• Waive it good-bye
• Hazard #3: Advance directives
• A change may be in order
• Who else can give a DNR order?
• A patient’s right
• State-ments
• Hazard #4: Patients who refuse treatment
• The patient who says “no”
• Get to them early
• Hazard #5: Documenting for unlicensed personnel
• Countersign-language
• Hazard #6: Using restraints
• The laws, they are a-changing . . .
• Putting restraints on abusing restraints
• The earlier, the better
• One day at a time—no more
• Getting into training
• Hazard #7: Patients who request to see their charts
• Don’t just hand it over
• Hazard #8: Patients who leave AMA
• Taking aim at the AMA form
• Relate the patient’s state
• The case of the missing patient
• Suggested references
• 7 Documenting procedures
• Guidelines for documenting procedures
• Medication administration
• You document MARvelously
• No room for exceptions
• Paging the practitioner . . .
• Double team
• I.V. therapy
• Basic documentation
• Getting complicated
• Don’t forget the family
• We interrupt this service . . .
• Accounting for autotransfusions
• Reacting to a suspected transfusion reaction
• Surgical incision care
• Records that get around
• Who’s up first?
• Detailed care and discharge data
• Pacemaker care
• Peritoneal dialysis
• Peritoneal lavage
• Chest tube
• The documentation goes on and on
• Cardiac monitoring
• Keep on chartin’
• Chest physiotherapy
• Mechanical ventilation
• Take a deep breath—then document!
• Nasogastric tube insertion, use, and removal
• Using the NG tube
• The tube is removed—so document some more!
• Seizure occurrence and management
• Suture and staple removal
• Tube feedings
• Obtaining an arterial blood sample
• Need an ABG analysis? That’s another form!
• Documenting assisted procedures
• Procedures may change, but the documentation remains the same
• Bone marrow aspiration
• Esophageal tube insertion and removal
• Arterial line insertion and removal
• The arterial line’s work may be done, but not yours . . .
• CVAD insertion and removal
• Out with the access device, in with the documenting . . .
• Lumbar puncture
• Paracentesis
• With responsibility comes more documentation
• Thoracentesis
• Documenting miscellaneous procedures
• Diagnostic tests
• Document your first impressions
• Pain control
• Translating body language
• Hourly rounding
• I&O
• Taking the intake documentation challenge
• Don’t forget these types of intake
• Transferring a patient to a specialty unit
• Withdrawal of life support
• Advanced warning
• Match the patient’s wishes to the situation
• Before withdrawal of life support
• Codes
• Getting up to code
• A helpful critique
• Suggested references
• 8 Documenting special situations
• A look at special situations
• Situations related to patient rights and safety
• Photographing a patient
• Get the old John Hancock
• What is my role with photographs?
• No signature required
• Permanent fixture
• Releasing information to the media
• Permission policy
• One-word is enough
• In the spotlight
• Documenting duties
• For the (public) record
• Dealing with death
• Searching for contraband
• Probable cause?
• Request denied
• Can I have a witness?
• Search basics
• Take note
• Equipment tampering
• Write on
• Situations related to personal safety
• Hostile advances
• Take action
• The write stuff
• Harassment, bullying, and sexual harassment
• To be harassment free
• Focus on the facts
• Suggested references
• 9 Acute care documentation
• A look at acute care
• Barriers to documentation
• Is this ALWAYS the case?
• Computerized documentation: The electronic health record
• Forms, forms, and more forms
• Admission database form
• The clock is ticking
• Finding form
• Get it together!
• Documentation with style
• Form and function
• How to use the admission database form
• Ready, willing, and able?
• Turning to friends and family
• Too many cooks . . . er, health care workers . . . can spoil the chart
• Medication reconciliation
• Care plans and care pathways
• Care plans
• Care pathways
• Watch your step on the pathway
• Patient care Kardex
• It’s all in the Kardex
• The Kardex can be all aces
• A key Kardex kriticism
• Getting the most out of your medication Kardex
• How are things progressing? Need more space?
• Graphic form
• Advantages—in graphic terms
• Disadvantages—in graphic terms
• Progress notes and flow sheets
• Making good progress
• Progress or pitfalls?
• Don’t repeat yourself
• Flow sheets
• Symbolic significance
• Completing the picture
• A ban on blanks
• Go flow sheets!
• Flow sheet faults
• Discharge summaries
• In sum, discharge summaries are all good
• How to use discharge summaries
• Taking note of narrative discharge notes
• Medication reconciliation
• Suggested references
• 10 Home health care documentation
• A look at home health care
• An emerging health care powerhouse
• Quicker has equaled sicker
• Not your traditional patient
• Documentation requirements
• Creating opportunities for care
• Legal risks and responsibilities
• Meeting standards
• Risks of poor documentation
• Let’s admit it: Admission assessment is crucial
• No record, no proof
• A bad business practice
• Documentation guidelines
• Be sure to begin at the beginning
• The information you provide gets around
• Documentation details
• Home health care forms
• Agency assessment and OASIS documentation
• Care plan
• Family counsel
• Don’t go astray—without documenting it, at least
• Collating care
• Progress notes
• Work in progress
• Patient teaching
• Keeping continuity
• Being there
• Setting the terms (on the packages)
• Signing off
• Nursing and discharge summaries
• Summing it all up
• Medicare-mandated forms
• Practitioner calls
• Fill out and sign, please . . .
• Future developments
• One predicted outcome: More reliance on outcomes
• Computers at work
• Keeping it confidential
• Suggested references
• 11 Long-term care documentation
• A look at documenting in long-term care
• Documentation distinctions
• Categories of care
• Care may be complex . . .
• . . . or not so complex
• Regulatory agencies
• Medicare
• Making reimbursement a reality
• Medicaid
• Reimbursement for intermediate care
• CMS and Resident Assessment Instrument
• OBRA
• The Joint Commission
• Forms used in long-term care
• MDS
• CAA
• PASARR
• Initial nursing assessment
• Nursing summaries
• Summing it up
• ADL checklists and flow sheets
• Care plans
• Discharge and transfer forms
• Documentation guidelines
• Suggested references
• Appendices
• Glossary
• Index