DOCUMENTATION BASIC PRINCIPLES FOR LONG TERM CARE

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Walter Cannon
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1 DOCUMENTATION BASIC PRINCIPLES FOR LONG TERM CARE

2 Speakers for this conference have disclosed that they do not have significant relationships or affiliations with any commercial organization that could bias or impose a conflict of interest related to the educational content of this program. AFMC operates under contract with Arkansas Medicaid and the Centers for Medicare & Medicaid Services to accomplish quality improvement and provide education and support to Arkansas providers. Successful completion of the activity for continuing education credit is defined as attending the entire program. Individuals who want CE credit must fill out an Attendance Information Sheet. After the program, please make sure you are signed in to ensure you receive your Certificate of Attendance. We would appreciate the completion of the evaluation form included in your packet. 6/17/2016 Copyright 2015 AFMC, Inc. All Rights Reserved. 2

3 Know your policy Each facility has the opportunity to establish their own policy, procedure and/or protocols for documentation. It is your responsibility to know what your facility s requirements are. 6/17/2016 Copyright 2015 AFMC, Inc. All Rights Reserved. 3

4 Why do we do it? Documentation is a critical piece of patient care. The written record is essential to ongoing evaluation and treatment and providing safe and effective care. Failing to accurately or intelligibly report or document is also a violation of the Nurse Practice Act. 6/17/2016 Copyright 2015 AFMC, Inc. All Rights Reserved. 4

5 Why do we do it? Boards of nursing are state regulatory agencies with a mission to "protect and promote the welfare of the people by ensuring that each person holding a license as a nurse in the state is competent to practice safely." Within board of nursing regulations, nurses can find information about licensure, practice, and disciplinary processes and seek clarification of gray areas through position statements. Nurses are required to adhere to the nursing practice acts and board of nursing rules that hold the force of the law, as well as practice to the level of their knowledge and skill and intervene/advocate on behalf of patients at all times as set forth by the standards of professional nursing. Part of this duty to the patient is to provide for complete and accurate reporting and documentation. 6/17/2016 Copyright 2015 AFMC, Inc. All Rights Reserved. 5

6 Why do we do it? Documentation is the basic tool health-care providers have to demonstrate the delivery of consistent, effective quality care to the resident. Increased consumer awareness Increased acuity Increased emphasis on outcomes 6/17/2016 Copyright 2015 AFMC, Inc. All Rights Reserved. 6

7 One medical record/many purposes A record of communication among health care team members A record of care given, patient s response to care A record for reimbursement A record for research A record for guiding quality improvement A record for evidence in legal proceedings 6/17/2016 Copyright 2015 AFMC, Inc. All Rights Reserved. 7

8 Who is our Audience? The Healthcare Team Doctors, Nurses, Social Services, Activities, Therapists The Scribe -The nurse is also documenting for his/her own purposes. Documentation that's complete and accurate can also serve as a memory refresher when details are unclear or forgotten Residents & their family Lawyers and Experts The nurse's documentation is read by lawyers and experts when a lawsuit ensues. The Judge and Jury -may also be read by nonnursing or nonmedical jurors deciding a case. 6/17/2016 Copyright 2015 AFMC, Inc. All Rights Reserved. 8

10 What am I responsible for? Gathering data Recording data Reporting pertinent information Obtaining orders for interventions Providing interventions Recording outcomes 6/17/2016 Copyright 2015 AFMC, Inc. All Rights Reserved. 10

12 Clinical Assessments Nurses Notes should tell the story of the residents care while in your facility Clinical Assessment is essential Prior to change of condition; start of new treatments; transfer to hospital; new lab order and start of hot rack charting. A goal of documentation is to document the presence and/or absence of s/s of infection as defined by the McGeer s list. 6/17/2016 Copyright 2015 AFMC, Inc. All Rights Reserved. 12

14 Resident cont on Cipro 500mg po BID for UTI. Resident denies dizziness, nausea, vomiting, diarrhea and no rash noted. Vital signs are T98.4, B/P 140/72, P 88, R 19. Residents cont with bilat flank pain and dysuria and foul odor during urination. MD aware of continuing symptoms. Administered PRN pain med as ordered for reported pain level of 7/10. Will reassess in 1Hour. 6/17/2016 Copyright 2015 AFMC, Inc. All Rights Reserved. 14

15 will cont to monitor Try not to use the words will cont to monitor as the word monitor indicates a monitoring tool is being used with specific times of assessment, like with neuro checks or behavior monitoring. 6/17/2016 Copyright 2015 AFMC, Inc. All Rights Reserved. 15

16 Skilled Charting Needs to give a picture of resident s care over all shifts Needs to give a picture of resident s care over all disciplines Needs to give a picture of resident s care from admission to discharge 6/17/2016 Copyright 2015 AFMC, Inc. All Rights Reserved. 16

18 COMPONENTS OF A TELEPHONE ORDER Resident s first and last name Resident s location/ room number Provider s name Date and time order received Medication Dose Frequency Route Duration Diagnosis Nurse s signature 6/17/2016 Copyright 2015 AFMC, Inc. All Rights Reserved. 18

20 Do s and don ts of documentation pitfalls Never use medical terminology unless the meaning of the word is known. When in doubt, spell it out. Be familiar with your institution's policies and procedures related to acceptable abbreviations. Never document an acute abnormality found during assessment without documenting the intervention initiated. 6/17/2016 Copyright 2015 AFMC, Inc. All Rights Reserved. 20

21 Do s and don ts of documentation pitfalls Never document the intervention initiated without documenting the evaluation/response of the resident Don't become complacent with check-off assessments. Every facility has some sort of check box system for documenting the patient assessment. It's vital that documentation be reflected as accurately as possible. 6/17/2016 Copyright 2015 AFMC, Inc. All Rights Reserved. 21

22 Do s and don ts of documentation pitfalls Always write legibly. There's no single factor regarding documentation that bears more importance than the ability of the audience to read what's written. Ensure that late entries should follow your facility's policy. Don t write imprecise descriptions such as a large amount 6/17/2016 Copyright 2015 AFMC, Inc. All Rights Reserved. 22

23 More do s and don ts Do not openly criticize the care that was rendered by a coworker. Don t document personal opinion Whenever possible, do not document subjective descriptions. Do not mention short-staffing in the medical record. 6/17/2016 Copyright 2015 AFMC, Inc. All Rights Reserved. 23

25 More do s and don ts Never document nursing care before it is provided. Nursing staff should never chart assessments, medication administration or treatments prior to actually completing the tasks Do not routinely document care rendered by others. Do not record another patient's name in the medical record. 6/17/2016 Copyright 2015 AFMC, Inc. All Rights Reserved. 25

27 Red flags in the medical record Lack of treatment Delayed/substandard/inappropriate treatment Lack of patient teaching/discharge instructions Charting inconsistencies/time lapses Late entries Lack of informed consent Fraudulent entries/destroying records/missing entries No match back: order intervention response 6/17/2016 Copyright 2015 AFMC, Inc. All Rights Reserved. 27

28 Reporting Pertinent Information Change of conditions Abnormal lab values Incidents Changes in behavior Complaints Changes in mental status Adverse reactions to medications 6/17/2016 Copyright 2015 AFMC, Inc. All Rights Reserved. 28

29 Providing Interventions Know the medication, its actions & side effects Understand the order Explain to the resident Provide the intervention Follow up 6/17/2016 Copyright 2015 AFMC, Inc. All Rights Reserved. 29

30 Recording Outcomes PRN medications New treatments Changes in treatments Changes in safety precautions Dietary supplements & Diet changes Medication therapy Strength training & physical therapy Changes in behavior 6/17/2016 Copyright 2015 AFMC, Inc. All Rights Reserved. 30

32 Most common allegations of professional negligence Failure to accurately assess and monitor the patient s condition. Failure to notify the health care provider of problems. Failure to follow orders. Contributing to medication errors. Failure to convey discharge instructions. Failure to ensure patient safety. Failure to follow policies and procedures. Failure to properly delegate and supervise. 6/17/2016 Copyright 2015 AFMC, Inc. All Rights Reserved. 32

EXAMPLES OF PROFESSIONAL NEGLIGENCE 6/17/2016

34 Failure to accurately assess and monitor the residents condition To avoid this: Complete comprehensive nursing assessment. Document all findings consistent with facility policy. Document complete date/time/your name and credentials. 6/17/2016 Copyright 2015 AFMC, Inc. All Rights Reserved. 34

35 Failure to ensure resident safety To avoid this: Know what residents are at risk for falls. Know your facility s fall-prevention policy. Document all fall precautions you took. Document instructions you gave to resident. Document resident falls appropriately, stating your observations, not assumptions. Include resident s condition, resident s complaints/denials of pain, physical assessment findings, safety measures taken to prevent further harm, contact to health care provider, time health care provider responded, diagnostics performed, and contact to resident s family. 6/17/2016 Copyright 2015 AFMC, Inc. All Rights Reserved. 35

36 Failure to notify health care provider of problems To avoid this: Document your communication, whether by phone, in person, or through documentation i.e. fax. Document date/time/who you spoke with/what you communicate/response. 6/17/2016 Copyright 2015 AFMC, Inc. All Rights Reserved. 36

37 OOPS!! *Patient able to giggle toes bilaterally. *She was unresponsive but still bleeding spontaneously. *Foley draining fowl smelling urine *MD order: Walk in hell *Pulses are probably in both feet *Admitting diagnosis gang green *The patient fell while sitting down on a chair that wasn t there. 6/17/2016 Copyright 2015 AFMC, Inc. All Rights Reserved. 37

38 Oops, I made a mistake, now what? Never use white out, or black out an error in documentation Never document in the margins or squeeze information in-between the lines. DO follow your facilities Policy & Procedures for error reporting & follow up 6/17/2016 Copyright 2015 AFMC, Inc. All Rights Reserved. 38

39 Complete and Accurate is Key Nurses must know state law and the policies and professional standards related to the specialty in which they practice. When in doubt, a mentor, supervisor, or expert should be consulted to clarify any points of confusion. Most importantly, nurses should document based on evidencebased practice and the standards of care of a reasonable and prudent nurse. 6/17/2016 Copyright 2015 AFMC, Inc. All Rights Reserved. 39

40 OOPS!! *Patient had rectal breathing. *MD order: May shower with nurse *The patient was able to remove his neck but it does cause some discomfort. *Patient found dead: felt cold, blanket added, voiced no complaints. *She states she has been constipated most of her life until 1987, when she got a divorce. 6/17/2016 Copyright 2015 AFMC, Inc. All Rights Reserved. 40

41 Summary Status of the resident Nursing care rendered to the resident Medications and treatments and the response/evaluation of the resident when an intervention has been made. 6/17/2016 Copyright 2015 AFMC, Inc. All Rights Reserved. 41

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NOTE: The first appearance of terms in bold in the body of this document (except titles) are defined terms please refer to the Definitions section.

NOTE: The first appearance of terms in bold in the body of this document (except titles) are defined terms please refer to the Definitions section. TITLE MEDICATION ORDERS SCOPE Provincial APPROVAL AUTHORITY Clinical Operations Executive Committee SPONSOR Provincial Medication Management Committee PARENT DOCUMENT TITLE, TYPE AND NUMBER Not applicable