DOCUMENTINGREPORTING

NURSING INFORMATICS

Communication is Vital!Technology is your friend!

PRINCIPLES OF DATA ENTRY

Accurate:Observations onlyDo not use

subjective wordsCorrect spelling,

grammar & med terms

Complete:New or changed

informationS/S, clients

behaviorNursing

interventionsMeds givenPhysicians orders

carried outClient teaching and

response to therapy

PRINCIPLES OF DATA ENTRY Consistent

Concise and brief using approved abbreviations Objective

Important when documenting psychosocial and mental health issues

Legible Writing must be clear and easily read by others Line out errors: 100 cc clear yellow urine from foley

Organization Use nursing process

Timelines Document care, treatments, procedures and

medications as soon as possible

DOCUMENTATION Purpose of documentation:

CommunicationAssessmentCare planningQuality assuranceReimbursementLegal documentationResearchEducation

INFORMATICS Technology in healthcare is advancing Information will be managed

electronically Outcomes:

Safe patient carePatient centered care Improved outcomesEase of access to informationWorkflow

EHR- A STANDARD DOCUMENT THE BEDSIDE CHART HAS MOVED FROM A DESCRIPTIVE DOCUMENT TO A DATA DRIVEN DOCUMENT

Forms use a standardized language Radio buttons, drop-down boxes Data driven Mandatory fields Charting by exception Increases compliance Alerts to abnormal findings Able to document all aspects of nursing

care

TECHNOLOGY WILL YOU ENCOUNTER IN THE HOSPITAL AND CLINICS

EHR/EMR Monitoring Imaging Medication administration Pharmacy Clinical Decision Support

Systems ADT CPOE Central supply ordering systems

HEALTH IT SYSTEMS AND HUMAN ERRORElements that reduce human error: CPOE Bar Code High Alert Medication Documentation Point of Care Documentation Mandatory Fields Smart Pumps Communication Tool

COMMON DOCUMENTS USED BY NURSES

Admission History and Assessment

Discharge Form Nursing Care Plans Flow Sheets/graphic

sheets Kardex

Clinical Pathways Medication

Administration Records (MAR)

Nursing Progress Notes

Patient education form

Acuity charting Incident report

Does NOT go in pt chart!

VITAL SIGNS

MAR

ASSESSMENT FORM

PATIENT SUMMARY SCREEN

ORDERS SCREEN

MEDICATION ADMINISTRATION

OTHER TECHNOLOGY

REMEMBER:

HIPAA

CHANGE OF SHIFT REPORTPurpose TechniquesContent 

SBARSituation Pt name Age Physician’s name Diagnois Hospital day/POD

#

Background

What brought them to the hospital

Past medical history

SBARSituation BackgroundAssessment Recommendation/ Request Often a framework for communication-

calling MD, giving report, etc

SBARAssessment State what you think

is the problem Give review of

symptoms

Recommendation or Request

What needs to be done

What was done Plan for discharge

TYPES OF NURSING NOTES- NARRATIVE Information written in sentences or

phrases usually time sequenced

Must write a narrative note q2 hrs

Many combined with flow sheets

TYPES OF NURSING NOTES- CHARTING BY EXCEPTION Document only findings that fall outside

of “normal” Flow sheet with check boxes Assessment findings, routine care

activities Narrative notes only when there is an

exception or abnormal finding Eliminates redundancy