COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION - Nursing Care POLICY NUMBER: 316 Effective Date: August 31, 2006 SUBJECT: NURSING PROGRESS NOTES 1. PURPOSE: The Individual depends on the WRP Team to communicate with one another to ensure that the best quality of care is delivered. All of the team members must have the same information about the Individual to ensure an organized and comprehensive plan of care. The clinical record is designed to facilitate care, enhance continuity of care, and help coordinate the treatment and evaluation of the Individual. Progress Notes are used to: a) effectively communicate specific information about the Individual s care, b) avoid fragmentation of care, c) avert unnecessary repetition of tasks, d) prevent therapies from being delayed or omitted, e) insure the interventions are directed toward the Individual s maximum recovery, f) reflect the Individual s status in relation to the desired outcomes, and g) compare the Individual s response with the desired outcomes as defined by the plan of care. 2. POLICY: 1. Nursing notes shall substantiate implementation, interventions, and response to the nursing care and the response to the integrated treatment intervention plan of the WRP team reflecting: a. Changes in the Individual s condition b. The clinical course of treatment, including the outcome and progress or lack of response to care and treatment 2. Psychiatric Technician/Licensed Vocational Nurse Weekly Progress Notes shall be used to document weekly notes. Registered Nurse Progress Note shall be used to document monthly notes (and Weekly note if done by RN on an Acute unit). NOC Shift Notes are written in the IDN s. 2. The PT/LVN Progress and RN Progress notes shall address all opened psychiatric and physical conditions consistent with the Nursing Care Plans including Individual s response to the plan of care. Make reference to the status of health maintenance problems, temporary conditions (TC s), response to prescribed treatment, and prn s. Identify pertinent issues, and appointments. 3. Nursing Progress Notes are to be written: - 1 -
Type of Note Unit acceptance note for admission to hospital or transfer from another unit When Shall Note Be Written Upon arrival Who Shall Write Note RN and/or PT/LVN Transfer note Prior to transfer RN and/or PT/LVN Daily progress note for Individual s new to the hospital Every shift for 7 days Daily progress note for Individual s transferred to another unit Weekly progress note (starting 7 days after admission) Monthly progress summary As often as the Individual s behavior warrants Acute: each shift 30 days then weekly thereafter. ICF: Weekly for the duration of hospitalization (Begins upon transfer to ICF from Acute) Within the first month of hospitalization and monthly thereafter. NOC Shift Monthly Starting with first month PRN Changes in Individuals condition/special observation orders Antibiotic Therapy Treatment Plan Modifications Weekly and on conclusion of therapy Whenever Treatment Plan changed or Discontinued PT, LVN or RN PT or LVN RN RN RN or LVN - 2 -
Discharge Note Day of discharge RN monthly progress note: SECTION I: BEHAVIORAL SUBSYSTEMS 1. Registered Nurse Progress Note for RN monthly progress recording (and Weekly Note by RN on an Acute unit). Progress note From: To: (documented in IDN). NOC Shift RN use an IDN. 2. Determine the appropriate medical conditions by assessing the Individual, reviewing the current focus of treatment from the team conference, psychiatric technician weekly progress notes, and other WRP team progress notes, and other WRP team progress notes as appropriate. 3. Rate all open problems and medical conditions that have a major impact on treatment. 4. Indicate problem number and describe the behavioral changes or medical conditions in the narrative. SECTION II: OVERALL RATING 1. Indicate previous and current overall behavior and medical conditions. 2. Review and update RAND and acuity to assure consistency with progress note. SECTON III: CARE NEEDS REQUIRED 1. Review care needs required for psychological, emotional, social, spiritual, recreational, skin problems, dietary problems, sleep problems, physical limitations, and elimination problems. 2. Address narrative all care needs required 3. Address in narrative all open temporary conditions, PRN usage, medication changes and any critical lab/consults/evaluations. Address in narrative all other physical problems.make reference to the status of any health maintenance problems of TC s (Temporary Conditions). 4. The RN/Case Manager should also address the Individual s response to the nursing care plan interventions and progress toward the established WRP team goals. ADL SKILLS: Address in IDN 5. PT/LVN weekly progress note: 1. Psychiatric Technician/Licensed Vocational Nurse Weekly Progress Note) for weekly progress reporting. Indicate the time frame for this progress note Weekly note from to (use IDN). NOC Shift PT/LVN use the IDN. 2. Address in narrative Individual s physical and behavioral responses to the Nursing Care Plan Interventions for all open problems. Make - 3 -
reference to the status of any health maintenance problems and Temporary Conditions (TC s) 3. Record the status of all open temporary conditions. Make reference to the status of any health maintenance problems. SECTION II: ADL SKILLS address in IDN Recommendation for writing progress notes: The following information is provided to help nursing services staff with writing the PT Weekly IDN and RN Monthly notes for assigned Individuals. Prior to writing the Weekly Note or RN Monthly progress note, nursing services staff attempt to discern the Individual s perception of their care by discussing with the Individual their current status of the open problems. Include the Individual s input in those areas and the Individual s reaction to the care given, along with staff observations. Use quotes for Individual s verbalizations. Be brief, concise, pertinent, and non-judgmental. Record changes and new observations. Only chart on pertinent behavioral level changes in the Individual s behavior, relationships, and type of interactions with peers, staff, WRP Team, effectiveness of medication, and progress or regression of the Individual observed on a particular shift. The RN will evaluate and document the Individual s progress towards meeting the goals or outcome criteria of the established plan of care. Entries are to be based on objective, measurable information (e.g. Individual punched wall twice this week. This is a reduction of 5 times from the previous week). One of the most important professional functions of the registered nurse is evaluation of the Individual s responses to nursing care as an ongoing part of the nursing process. Documentation needs to reflect that decision-making ability involved with making complex, sophisticated decisions concerning Individual care. Documentation must clearly communicate the nurse s judgments and evaluations. The ability to make a difference in the Individual outcomes must be demonstrated in practice and in charting. The monthly summary should provide an overview of the Individual s behavior and physical problems as they relate to the Individual s current treatment plan. - 4 -
The RN and the PT/LVN should keep each other appraised of the behavioral and medical issues and interventions, how the Individual care plans are working and/or discuss revision of the plan as needed. Both should be working together on the planning and designing of the Individual care plan. The Individual needs to be included in this planning and evaluation off the effectiveness of the plans whenever possible. LATE ENTRIES: Identify late entries correctly. Late entries result when: Important information should be added to the medical record after progress notes have been completed The medical record is not available for charting at the time the nursing staff needs it The nursing staff forgets to write progress notes on a particular chart. Late entries should not be squeezed into an existing note or placed in the margins. The late entry should not be added in such a way as to appear suspicious. When writing late entries note the reason why the entry is being added to the record. The following approach is recommended: 1. Add the entry to the first line available 2. Label the entry Late Entry to indicate it is out of sequence 3. Record the time and date of the entry 4. In the body of the entry, record the time and date it should have been made. - 5 -