Nursing Know-How: Charting Patient Care PDF
Preview Nursing Know-How: Charting Patient Care
1944 FM.qxd 8/21/08 7:09 PM Page i Nursing Know-How Charting Patient Care 1944 FM.qxd 8/21/08 7:09 PM Page ii STAFF The clinical treatments described and recom- mended in this publication are based on re- Executive Publisher search and consultation with nursing, medical, Judith A. Schilling McCann, RN, MSN and legal authorities. To the best of our knowl- edge, these procedures reflect currently accept- Editorial Director ed practice. Nevertheless, they can’t be consid- H. Nancy Holmes ered absolute and universal recommendations. For individual applications, all recommenda- Clinical Director tions must be considered in light of the pa- Joan M. Robinson, RN, MSN tient’s clinical condition and, before adminis- tration of new or infrequently used drugs, in Art Director light of the latest package-insert information. Mary Ludwicki The authors and publisher disclaim any re- sponsibility for any adverse effects resulting Editorial Project Manager from the suggested procedures, from any unde- Ann E. Houska tected errors, or from the reader’s misunder- standing of the text. Clinical Project Manager © 2009 by Lippincott Williams & Wilkins. All Kate Stout, RN, MSN, CCRN rights reserved. This book is protected by copy- right. No part of it may be reproduced, stored Editor in a retrieval system, or transmitted, in any Patricia Nale form or by any means—electronic, mechanical, photocopy, recording, or otherwise—without Copy Editors prior written permission of the publisher, ex- Kimberly Bilotta (supervisor), cept for brief quotations embodied in critical JeannineFielding, Pamela Wingrod articles and reviews and testing and evaluation materials provided by the publisher to instruc- Designer tors whose schools have adopted its accompa- Donna S. Morris (project manager), Joseph nying textbook. Printed in China. For informa- John Clark (cover design) tion, write Lippincott Williams & Wilkins, 323 Norristown Road, Suite 200, Ambler, PA 19002- Digital Composition Services 2756. Diane Paluba (manager), Joyce Rossi Biletz NKHCPC010508 Associate Manufacturing Manager Library of Congress Beth J. Welsh Cataloging-in-Publication Data Editorial Assistants Nursing know-how. Charting patient care. p. ; cm. Karen J. Kirk, Jeri O’Shea, Linda K. Ruhf Includes bibliographical references and index. 1. Nursing records—Handbooks, manuals, etc. Indexer [DNLM: 1. Nursing Records—Handbooks. 2. Docu- Dianne L. Schneider mentation—methods—Handbooks. 3. Nursing Assessment—methods—Handbooks. 4. Patient Care Planning—Handbooks. WY 49 N9749 2009] RT50.N875 2009 651.5'04261—dc22 ISBN-13: 978-0-7817-9194-6 (alk. paper) ISBN-10: 0-7817-9194-4 (alk. paper) 2008004152 1944 FM.qxd 8/21/08 7:09 PM Page iii Contents Contributors and consultants v Part one Documentation and legal issues 1 1 Documenting from admission to discharge 2 2 Legal and ethical implications of documentation 67 3 Legally perilous documentation 90 4 Electronic patient records 107 5 Documentation in acute care 120 Part two Charting examples (in alphabetical order) 173 NANDA-I nursing diagnoses by domain 378 Selected references 382 Index 383 iii 1944 FM.qxd 8/21/08 7:09 PM Page iv 1944 FM.qxd 8/21/08 7:09 PM Page v Contributors and consultants Jeanette M. Anderson, RN, MSN Nurse Consultant Fort Worth, Tex. Helen Christina Ballestas, RN, MS, CRRN Faculty Nursing New York Institute of Technology Old Westbury Rita Bates, RN, BS, MSN Assistant Professor University of Arkansas—Fort Smith Julie Calvery, RN, MS Instructor University of Arkansas—Fort Smith Cindy Cook, RN Quality Outcomes Coordinator Blue Ridge HealthCare, Inc. Morganton, N.C. MaryAnn Edelman, RN, MS, CNS Assistant Professor—Nursing Kingsborough Community College Brooklyn, N.Y. v 1944 FM.qxd 8/21/08 7:09 PM Page vi vi Contributors and consultants Christine Greenidge, APRN,BC, DHA Director of Nursing Professional Practice Montefiore Medical Center Bronx, N.Y. Timothy L. Hudson, BSN, MED, MS, CCRN, FACHE Evening/Night Nursing Supervisor U.S. Army, Martin Army Community Hospital Fort Benning, Ga. Merita Konstantacos, RN, MSN Clinical Consultant Clinton, Ohio Kimberly Such-Smith, RN, BSN, LNC Legal Nurse Consultant/Long-term Care Consultant Nursing Analysis & Review Byron, Minn. Chris Thompson, RN, BSN Quality Coordinator Texoma Medical Center Denison, Tex. Rita Wick, RN, BSN Education Specialist Berkshire Health Systems Pittsfield, Mass. 194401.qxd 8/21/08 7:34 PM Page 1 Part one Documentation and legal issues 1 194401.qxd 8/21/08 7:34 PM Page 2 1 Documenting from admission to discharge Documentation must reflect the nursing process, which is based on theories of nursing and other disciplines and follows the scientific method. This problem-solving process: (cid:2) systematically organizes nursing activities to ensure the highest quality of care (cid:2) allows you to determine problems you can help alleviate and poten- tial problems you can help prevent (cid:2) helps you identify what kind and how much assistance a patient re- quires (cid:2) helps you identify the person who can best provide assistance to the patient and the desired and actual treatment outcomes. Six-step nursing process This flowchart shows the six steps of the nursing process and lists the forms you should use to document them. Step 1 Step 2 Step 3 Assessment Nursing diagnosis Outcome Gather data from the patient’s Make judgments based on as- identification health history, physical exami- sessment data. Set realistic, measurable nation, medical record, and Documentation tools goals with outcome criteria diagnostic test results. Nursing care plan, patient and target dates. Documentation tools care guidelines, clinical Documentation tools Initial assessment form, flow pathway, progress notes, Nursing care plan, clinical sheets problem list pathway, progress notes 2 194401.qxd 8/21/08 7:34 PM Page 3 Fundamentals of nursing documentation 3 To get a complete picture of the patient’s situation, you’ll need to systematically follow and document the six steps of the nursing process—assessment, nursing diagnosis, outcome identification, plan- ning, implementation, and evaluation. (See Six-step nursing process.) F undamentals of nursing documentation To ensure clear communication and complete, accurate documentation of nursing care, you must keep in mind the fundamentals of documen- tation. Write neatly and legibly Documentation allows you to communicate with other members of the health care team. Clean, legible documentation eases the communica- tion process. Sloppy or illegible handwriting: (cid:2) confuses other members of the health care team and wastes time (cid:2) causes a patient potential injury if other caregivers can’t understand crucial information. If you don’t have room to document something legibly: (cid:2) leave that section blank, put a bracket around it, and write, “see progress notes” (cid:2) document the information fully and legibly in the progress notes (cid:2) indicate the date and time when cross-referencing a progress note. Step 4 Step 5 Step 6 Planning Implementation Evaluation Establish care priorities, se- Carry out planned inter- Use objective data to lect interventions to accom- ventions. assess outcome. plish expected outcomes, Documentation tools Documentation and describe interventions. Progress notes, flow tools Documentation tools sheets Progress notes Nursing care plan, patient care guidelines, clinical pathway 194401.qxd 8/21/08 7:34 PM Page 4 4 Documenting from admission to discharge Write in ink Complete documentation in ink, not in pencil, which is susceptible to erasure and tampering. Also follow these guidelines: (cid:2) Use black or blue ink because other colors may not photocopy well. (cid:2) Don’t use felt-tipped or gel ink pens on charts containing carbon pa- per; the pens may not produce sufficient pressure for copies. Use correct spelling and grammar Documentation filled with misspelled words and incorrect grammar creates the same negative impression as illegible handwriting. To avoid spelling and grammatical errors: (cid:2) keep a general and medical dictionary in documentation areas (cid:2) post a list of commonly misspelled words, especially terms and medications regularly used on the unit. Use standard abbreviations The Joint Commission standards and many state regulations require health care facilities to use an approved abbreviation list to prevent confusion. To make sure that your documentation meets applicable standards: (cid:2) Know and use your facility’s approved abbreviations. (cid:2) Place a list of approved abbreviations in documentation areas. (cid:2) Avoid using unapproved abbreviations because they may result in ambiguity, which may endanger the patient’s health. (See Abbrevia- tions to avoid.) Write clear, concise sentences (cid:2) Avoid using a long word when a short word will do. (cid:2) Clearly identify the subject of the sentence. (cid:2) Use “I,” as in “I contacted the patient’s family at 1300 hours, and I explained the change in his condition.” Doing so differentiates your actions from those of the patient, physician, or another staff member. Say what you mean (cid:2) Be precise. Don’t use inexact qualifiers such as “appears” or “appar- ently” because other caregivers reading the patient’s chart may con- clude that you weren’t sure what you were describing or doing. (cid:2) State clearly and succinctly what you see, hear, and do. (cid:2) Don’t sound tentative.
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