SkillMasters: Better Documentation

217 Pages·2003·22.612 MB·English

by  Springhouse

SkillMasters
Better Documentation
1st Edition
2003
LippincottWilliams&Wilkins
Philadelphia
323NorristownRoad,Suite200,Ambler,PA19002-2756
978-1-58255-177-7
1-58255-177-4
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LibraryofCongressCataloging-in-PublicationData
Skillmasters:betterdocumentation.
p.;cm.
Includesindex.
Nursingrecords—Handbooks,manuals,etc.
[DNLM: 1. Nursing Records. 2. Documentation — methods. 3. Forms and Records Control. WY 100.5 S628b 2003] I. Title: Better
documentation.II.LippincottWilliams&Wilkins.
RT50.S5572003
651.5′04261—dc21
ISBN13978-1-58255-177-7
ISBN101-58255-177-4(phb.:alk.paper) 2002004446
Contributors and consultants
DebraAucoin-RatcliffRN,MN
NursingProgramDirector
WesternCareerCollege,Sacramento,Calif.
AthenaA.ForemanRN,MSN
NursingCoordinator
StanleyCommunityCollege,Albemarle,N.C.
LisaA.SalamonRN,C,MSN
ClinicalNurseSpecialist
ClevelandClinicFoundation
Lourdes“Cindy”Santoni-ReddyRN,MSN,MEd,CPP,FAAPM,NP-C
PainManagementPractitioner
Researcher;CRNPAssociates,P.C.,Yardley,Pa.
PamelaB.SimmonsRN,PhD
AssistantHospitalAdministratorforPatientCareServices
LouisianaStateUniversityHealthSciencesCenter,Shreveport
MarilynSmith-StonerRN,PhD
AdjunctFaculty
UniversityofPhoenix(Ariz.),HomeCareConsultant,Ontario,Calif.
CatherineUltrinoRN,MSN,OCN
NurseManager
BostonMedicalCenter
MarilynJ.VontzRN,PhD
NurseEducator
BryanHospitalSchoolofNursing,Lincoln,Nebr.
SuzanneP.WeaverRN,RHIT,CPHQ
DirectorofNursing
NeshaminyManor,Warrington,Pa.
Foreword
Now as never before, with consumer and market-driven forces playing a greater role in health care delivery, it's crucial for nurses to have
theskillsrequiredtoproduceaccurate,effective,andefficientdocumentation.
To that end, it's essential that nurses have a reference guide on documentation that's easy to use and that covers fundamentals, legal
aspects, special situations, and a variety of documentation systems for a variety of settings (acute care, long-term care, and home care).
SkillMasters:BetterDocumentationisthatreferenceguide.
Not only is documentation the main communication tool among professional health care team members, it's used to justify medical
treatment and reimbursement and to satisfy regulatory, licensing, and accreditation requirements. Students, faculty and researchers,
lawyers and judges, Medicare, Medicaid, and insurance companies as well as peer reviewers, and even an institution's own performance
improvement team rely on documentation to fulfill the multiple demands of today's health care management. The more documentation is
reviewedandused,themorecriticalthatitbeaccurateandofthehighestquality.
SkillMasters: Better Documentation provides guidelines for essentially every patient care setting in a variety of health care delivery
systems. It also demonstrates efficient and effective documentation by giving the nurse sample forms that show exactly how to document
nursing assessments, interventions, evaluations, and outcomes. Included are guidelines for using computerized documentation systems,
traditional narrative docu- menting, problem-oriented medical records, the FOCUS system, the problem- intervention-evaluation system,
charting by exception, and the FACT documentation system. Additionally, this fact-filled book discusses the advantages and disadvantages
ofeachdocumentationsystemalongwithadviceonhowtochooseanappropriatedocumentationsystem.
Highlighted throughout SkillMasters: Better Documentation are several timesaving techniques that can provide a more concise written
record without sacrificing accuracy or legal protections. This valuable guidebook also gives pointers on how to identify legal hazards and
avoid the possibility of a lawsuit. Legal standards of documentation, such as nurse practice acts, standards of the Joint Commission on
AccreditationofHealthcareOrganizations,andmalpractice litigation,arediscussedwithtipsonhowtoutilizeriskmanagementtechniques.
Critical pathways, care plans, progress notes, activities of daily living checklists, flow sheets – all are discussed and demonstrated in
SkillMasters: Better Documentation. Also shown in examples are the standardized and required documents used in long-term care and the
Medicare-mandatedformsneededinhomecare.
Another outstanding feature in SkillMasters: Better Documentation is the SkillCheck at the end of each chapter. This self-quiz is designed
tohelpnursesornursingstudentspracticeandusewhatthechapterhasdiscussed.
All in all, SkillMasters: Better Documentation offers a wealth of information, useful sample documentation forms, and self-help skills
evaluation in every chapter. SkillMasters: Better Documentation leads the way to superior documentation and helps nurses demonstrate
thequalityandvalueoftheirnursingcare.
JacquelineWalus-WigleRN,JD,CPHQ
ManagerofCompliance,Regulatory,andExternalAffairs,UniversityofCalifornia,SanDiegoHealthcare
Contents
Contributorsandconsultants
Foreword
Contents
1 Fundamentalsofdocumentation
2 Legalaspectsofdocumentation
3 Documentationsystems
4 Documentinginacutecare
5 Documentinginlong-termcare
6 Documentinginhomecare
7 Documentinginspecialsituations
AppendixA:Commonlyacceptedabbreviations
AppendixB:Commonlyacceptedsymbols
AppendixC:NANDATaxonomyIIcodes
Selected References
Index
P.1
1
Fundamentals of documentation
Documentation — or charting — is the process of preparing a complete record of a patient's care. Accurate, detailed documentation shows
theextentandqualityofthecareyou'veprovided,theoutcomeofthatcare,andthetreatmentandeducationthatthepatientstillneeds.
Documentation isavitaltoolforcommunication among health care teammembers. Frequently,decisions, actions, and revisionsrelated to
the patient's care are based on documentation from various team members. A well-prepared medical record shows the high degree of
collaborationamonghealthcareteammembers.
The information that's documented by team members must be easily retrievable and readable because a patient's medical record may be
readbyawideaudience,including:
 othermembersofthehealthcareteam
 reviewersfromaccrediting,certifying,andlicensingorganizations
 performance-improvementmonitors
 peerreviewers
 Medicareandinsurancecompanyreviewers
 researchersandteachers
 attorneysandjudges.
Properdocumentationisimportantforotherreasons.Oneofthemostcompellingreasonsforyoutodevelopgooddocumentationpractices
istoestablishyourprofessionalresponsibilityandaccountability.
In the past, documentation consisted of cursory observations, such as patient ate well or patient slept well. The chief purpose of these
documents was to show that the physician′s orders and the facility's policies had been followed and that the patient had received the
propercare.
In the 19th century, British nurse Florence Nightingale paved the way for modern nursing documentation. In her book, Notes on Nursing,
she stressed the importance of training nurses to gather patient information in a clear, concise, organized manner. As her theories gained
acceptance, nurses'perceptionsand observationsabout patient care gained credenceand respect.More than acentury later, inthe 1970s,
nursesbegancreatingtheirownvocabularyfordocumentationbasedonnursingdiagnoses.
Purposes of documentation
Accuratenursingdocumentationisimportantformanyreasons,includingthesenine:
 It'samodeofcommunicationamonghealthcareprofessionals.
P.2
 It'scheckedinhealthcareevaluations.
 It'slegalevidencethatprotectsyou.
 It'susedtoaidresearchandeducation.
 Ithelpsfacilitiesobtainaccreditationandlicenses.
 It'susedtojustifyreimbursementrequests.
 It'susedtodevelopimprovementsinthequalityofcare.
 Itindicatescompliancewithyournursepracticeact.
 Itestablishesprofessionalaccountability.
Communication
Patients receive care from many people who work different shifts, and these various caregivers may speak with each other infrequently.
Themedicalrecordisthemainsourceofinformationandcommunicationamongnurses,physicians,physicaltherapists,socialworkers,and
other caregivers. Today, nurses are often considered managers of care as well as practitioners, and nurses usually document the most
information.Everyone'snotesareimportant,however,becausetogethertheypresentacompletepictureofthepatient'scare.
As health care facilities continue to streamline and redesign care delivery systems, tasks that were historically performed by nurses are
now being assigned tomultiskilled workers. Todeliverhighly specialized care, each caregivermust provide accurate,thorough information
andbeabletointerpretwhatothershavewrittenaboutapatient.Theneachcanusethisinformationtoplanfuturepatientcare.
Health care evaluation
When health care is evaluated by other members of the health care team — reviewers, insurance companies, Medicare representatives,
attorneys, or judges — accurate documentation is one way to prove that you're providing high-quality care. Complete documentation is
both a record of what you dofor your patient and written evidence that this care is necessary. It's also a record of your patient's response
toyourcareandanychangesyoumakeinhiscareplan.
Legal protection
On the legal side, accurate documentation shows that the care you provide meets the patient's needs and expressed wishes. It also proves
thatyou'refollowingtheacceptedstandardsofnursingcaremandatedbythelaw,yourprofession,andyourhealthcarefacility.
Properdocumentationcommunicatescrucialclinicalinformationtocaregiverssotheymakefewererrors.Howandwhatyoudocumentcan
determine whether you or your employer wins or loses a legal dispute. Medical records are used as evidence in cases involving disability,
personalinjury,andmentalcompetency.Poordocumentationisthepivotalissueinmanymalpracticecases.
Research and education
Documentation alsoprovidesdataforresearch and continuing education. Forexample, researchersand nurse educatorsmay study medical
recordstodeterminetheeffectivenessofnursingcare.Medicalrecordsmayalsobeusedtogaugehowpatientteachingaffectscompliance;
thepatient'seducationallevelandbarrierstolearningarenoted,
P.3
asisanassessmentofhowwellhefollowedthetreatmentregimen.
Just as documentation is used in research, research studies can be used to improve documentation practices. For example, studies may
uncovererrorsinthemedicalrecord,therebypointingouttheneedforcontinuingeducationprogramsforhealthcareproviders.
Accrediting and licensing
For a facility to remain accredited, caregivers must document care that reflects the standards set by national organizations, such as the
American Nurses Association and the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). Some states also require
facilitiestobelicensed;licensinglaws,inturn,requireeachfacilitytoestablishpoliciesandproceduresforoperation.
A facility's accreditation and licensure may be jeopardized by substandard documentation. When a facility is cited for having poor
documentation or not meeting set standards, it receives awarning, and atarget date isset for the facility to make necessary changes and
corrections.Afacilitymayloseitslicenseifitdoesn'tcarryouttheseactions.
In effect, accreditation is evidence that a facility provides quality care and is qualified to receive federal funds. The federal government
works with state accrediting organizations to make sure facilities are eligible to receive Medicare reimbursement. Accreditation and
reimbursement eligibility require documentation that accurately reflects the care provided to patients. Good documentation demonstrates
thatfacilityandstatenursingpolicieswerefollowed.
Officials of accrediting organizations look at a facility's structure and function to decide if the facility should be accredited. They also
conductsurveysandauditsofpatientandmedicalrecordstoseeifcaremeetstherequiredstandards.
Officialsreviewchartsandfilestoensuregooddocumentation.Forexample,inacaseinwhichphysicalrestraintswereused,officialsmay
ask,“Isthereaformfordocumentingtheneedforrestraintsandtheircorrectuse?”and,“Doesthedocumentationin thechartsshowthat
restraintswereusedcorrectly?”Properdocumentationreflectsthequalityofcareprovidedandthefacility'saccountability.
Accrediting organizations also regularly survey and audit records to make sure the standard of care is consistent throughout a facility. For
example, a woman recovering from anesthesia after a cesarean birth should expect to receive the same monitoring in the labor and
deliverysuiteasshewouldinthepostanesthesiacareunit.JCAHOinspectorsreviewthedocumentationofbothdepartmentstoensurethat
a uniform standard of care is given and documented. Most accrediting organizations have similar standards for documentation. (See
Componentsoftheclinicalrecord,page4.)
Reimbursement
Reimbursement from Medicare and insurance companies depends heavily on accurate nursing documentation. For example, many facilities
today use elaborate electronic dispensing carts to keep track of supplies. To be reimbursed for these supplies, nursing documentation has
tojustifytheiruse.
Checklist
Components of the clinical record
Accreditingorganizationsrequiremanyofthesamestandardsfordocumentation.Forexample,eachpatient'smedicalrecordmustcontain:
□ identification data
□ the medical history, which includes the patient's reason for seeking care; details of his present illness; relevant past, social, and
familyhistories;andabodysystemassessment
□ a summary of the patient's psychosocial needs as appropriate for his age
□ a report of relevant physical examination findings
□ a statement of the impressions drawn from the admission history and physical examination
□ the care plan
□ diagnostic and therapeutic orders
□ evidence of informed consent
□ clinical observations, including the effects of treatment
□ progress notes
□ consultation reports, if applicable
□ reports of operative and other invasive procedures, tests, and their results, if appropriate
□ reports of diagnostic and therapeutic procedures, such as radiology and nuclear medicine examinations
□ records of donation and receipt of transplants or implants, if applicable
□ a final diagnosis
□ discharge summaries and instructions
□ results of autopsy, when performed.
Meeting requirements
Some organizations spell out the information each of these forms must contain. In these cases, the nurse-manager must write and
implementguidelinesthatmeettheserequirements.
P.4
Documentation is also used to determine the amount of reimbursement a facility receives. The federal government, for example, uses a
prospective payment system based on diagnosis- related groups (DRGs) to determine Medicare reimbursements. In other words, it pays a
fixed amount for a particular diagnosis. For a facility to receive payment, the patient's medical record at discharge must contain the
correctDRGcodesandshowthathereceivedthepropercare,includingappropriatepatientteachinganddischargeplanning.
Most insurance companies also base reimbursements on a prospective payment system, and they usually don't reimburse for unskilled
nursing care. They pay for skilled medical and nursing care only. For example, they compensate nurse practitioners and home health care
nursesforskilledcare,whichincludesassessingapatient'scondition,creatingacareplan,andfollowingastricttreatmentregimen.
Before reimbursing, an examiner studies the patient's medical record to decide whether he needed and received skilled nursing care. The
examiner may request copies of the patient's monthly bills and look at documented progress notes, especially if the intensity, frequency,
andcostofthecareincreased.
Examinersalsocheckforinconsistenciesindocumentation,suchasadiscrepancy