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Documentation Module Documentation Module 1 | Page Documentation May 2017 “If it wasn’t documented, it wasn’t done” Table of Contents About this Module/Overview/Objectives………………………………………Page 3 Pre-Test…………………………………………………………………………Page 4-5 Chapter 1………………………………………………………………………..Page 6- 7 Abbreviations Appropriate Use of Abbreviations Approved JCAHO “Do Not Use” List Chapter 2……………………………………………………………………….Page 7-8 Good Documentation Components Who, What, When, Where, How, Outcome, Follow-up, Accuracy, Objective Data vs. Subjective Data Chapter 3……………………………………………………………………..Page 9-11 Basic Rules of Documentation Documenting when it happens or as soon as possible Legal Implications: If it wasn’t documented, it wasn’t done State Regulations Related to Documentation Federal Regulations Related to Documentation Chapter 4…………………………………………………………………….Page 11-13 Best Practices 24 hour Communication Tool SBAR Report Chapter 5…………………………………………………………………….Page 13 Walking Rounds Ways to do them without overtime Seeing conditions of residents Chapter 6…………………………………………………………………….Page 14-21 Resources Documentation in-service Case Studies / Examples of documentation (or lack thereof) that lead to bad outcomes Electronic Health Records and Use of Electronic Signatures Sample Nurses Notes (Proper/Poor Documentation) 2 | Page Documentation May 2017 SBAR example About this Module: Documentation is a process of reporting and recording information used by health-care practitioners to aid in the directing of resident care based on decision making and continuity of care. Documentation is written evidence of: The interactions between and among health professional, clients, their families, and health care organizations. The administration of tests, procedures, treatments, and resident/family education. The result of, or resident response to diagnostic tests and interventions Documentation is a professional responsibility of all health-care practitioners; documentation provides written evidence of the practitioner’s accountability to the resident, institution, profession, and society. Additional reasons for documentation include communication, education, and research, satisfaction of legal and practice standards and reimbursement. Overview: Documentation in the resident’s medical record is a communication method that confirms the care provided to the resident and clearly outlines all important information regarding the resident. This documentation in the medical record is used to share resident information between health care professionals, to provide education to students from all types of health care professions, for research purposes, and may be used as evidence in a malpractice lawsuit. Objectives: The objectives for this module include: a. Identify abbreviations on the Joint Commissions “do not use” abbreviation list b. Discuss the importance of nursing documentation c. Describe the components of proper documentation d. Discuss state and federal requirements concerning nursing documentation 3 | Page Documentation May 2017 Pretest: Mark each statement either T (True) or F (False). 1. The medical record is a legal document. True False 2. You can document care given by a friend if that person is trustworthy. True False 3. Documentation is a communication tool. True False 4. The two primary reasons for healthcare documentation are accountability and research. True False 5. When documenting resident care, abbreviations and symbols may not be used. True False 6. Words such as “good” or “normal” are excellent words to use when documenting a resident’s assessment findings. True False 7. White out should not be used to correct documentation errors. True False 8. Subjective data is information that the client tells you about. True False 9. To save time, it is acceptable to document administration of a medication before it has been completed. True False 10. It is important for healthcare providers to document their opinions of the care provided by other healthcare providers. 4 | Page Documentation May 2017 True False Answer Key Answers: 1. T 2. F 3. T 4. F 5. F 6. T 7. T 8. T 9. F 10.F 5 | Page Documentation May 2017 Chapter 1: Abbreviations: There are abbreviations that are often used when documenting the care that is provided to a resident; however, the Licensed Vocational Nurse (LVN) should ensure that he/she is only using abbreviations that are approved for use within the facility. The LVN must also understand that when abbreviations are used, there may be confusion if other staff members are not familiar with the abbreviations used. 1. Appropriate use of Abbreviations1: The use of abbreviations, symbols, or acronyms can be an efficient form of documentation if their meanings are well understood by everyone and standard abbreviations, symbols, and acronyms are used by everyone. Abbreviations and symbols that are ambiguous, obsolete, poorly defined or have multiple meanings can lead to errors which can cause harm to the residents, cause confusion, and waste time. It is important for health-care practitioners to follow the facilities approved abbreviations list and The Joint Commission’s “Do Not Use” list. 2. Approved Abbreviations: Approved abbreviations are a list of abbreviations that the medical staff has reviewed and approved for use in the facility. Most are standard abbreviations that are used in most healthcare facilities; however; the LVN should make sure to check the facility’s policy and procedures on abbreviations. 3. JCAHO (The Joint Commission) “Do Not Use List”:2 Because of the increase in medication errors related to the misuse of abbreviations; the Joint Commission mandated an implementation of its “do not use” list in those facilities that seek Joint Commission Accreditation. This list prohibited the use of certain abbreviations. Listed below are some of the abbreviations on the Joint Commission’s “do not use list” Do Not Use Potential Problem Use Instead U (Unit) Mistaken for “0” (zero), the Write “Unit” number “4” (four), or “cc” IU (International Unit) Mistake for IV (intravenous) Write “International Unit” or the number 10 (ten) Q.D., QD, q.d., (daily) Mistaken for each other Write “daily” Q.O.D., QOD, q.o.d., qod, Write “every other day” 1 Kuhn, Ivy; Abbreviations and Acronyms in Healthcare: When shorter isn’t Sweeter: http://www.medscape.com/viewarticle/566966-print 2 Joint Comission. (2017). Retrieved May 6, 2017, from Joint Comission: https://www.jointcommission.org/facts_about_do_not_use_list/ 6 | Page Documentation May 2017 (every other day) Period after the Q mistaken for “I” and the “O” mistaken for “I” Trailing zero (x.0 mg) Decimal point is missed Write X mg Lack of leading zero (.X mg) Write 0.X mg MS Can mean morphine sulfate Write “morphine sulfate” MS04 and MgSo4 or magnesium sulfate Write “magnesium sulfate” Confused with one another The Institute for Safe Medication Practices has also developed an Error Prone Abbreviations, Symbols, and Dose Designations List which includes the Joint Commission’s short list. To review the ISMP’s lists go to: www.ismp.org/Tools/Errorproneabbreviations.pdf It is important that the LVN knows and understands the different abbreviations that may result in issues to the care of the residents. Chapter 2: Components of Good Documentation: Good documentation is a clear, concise, complete, and accurate description of the care that the LVN has given. The LVN must understand that good documentation includes observations, any actions taken by the LVN, the resident’s response, any unusual incidents, omitted treatments; safety precautions the LVN took to protect the residents, and communication with the interdisciplinary team. It tells a story that anyone reading will be able to follow. 1. Guidelines for Good Documentation3: a. Report objectively, be specific and describe each complaint or situation. It is recommended to use phrases instead of complete sentences. b. Write clearly and legibly, with a black ink pen only. c. Start all writing with the complete date (Month, day, and year) and the time (most facilities require military time use). Finish all entries with full signature and title. d. Do not use words that are open to interpretation, such as “good” or “normal” and do not leave spaces. e. Chart at least every two hours in sequence and only for your actions. f. Use quotation marks when documenting the resident’s statements and use only abbreviations that are accepted by the facility. 3 Hartman’s In-Service Education Sourcebook Series, The Importance of Observation and Documentation. 7 | Page Documentation May 2017 g. Record all attempts to notify your supervisor or the resident’s physician and/or family. If you have to leave a message document with whom, the time and the date the message was left. h. Do not erase errors. Do not use white out and cover errors. Do not obliterate error. Typically it is acceptable to correct errors in this way: i. Draw a line through the wrong entry; and ii. Write “Error” and initial and date the correction. i. For a late entry on the medical record: the definition of a late entry should be determined by the facility’s policies. i. Start the late entry with current date and time. ii. Then document “late entry for_________________.” iii. Complete your documentation. iv. Sign and date the entry. j. Never chart a procedure until it has been completed. To document a procedure: i. Document date and time procedure was done. ii. Who completed the procedure. iii. What the procedure was and any specifics required (i.e. 14 F catheter). iv. How the resident tolerated the procedure. v. Any follow-up care given k. Make sure words are spelled correctly. l. Make sure that everything that goes on with the resident is documented; good and bad. 2. Components of Good Documentation: a. Who i. The resident is who you are documenting about. There is no need to document ‘the resident” The whole medical record is about the resident. b. What i. What were the assessment findings? ii. What was the resident’s complaint? iii. What resident care did you provide? c. When i. The time when you provided care to the resident. d. Where i. In what place did the event happen? ii.
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