Lecture Nursing documentation using electronic health records: Chapter 2 - Byron R. Hamilton, Mary Harper, Paul Moore

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Chapter 2
Nursing Documentation Overview
McGraw­Hill

© 2012 The McGraw­Hill Companies, Inc. All rights reserved.


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Chapter 2 Content
2.1 Role of documentation in nursing
practice
2.2 Purposes of documentation
2.3 Documentation methods
2.4 Medication administration using an
electronic Medication Administration
Record (eMAR)
2.5 Nursing diagnoses, NOC, and NIC


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LO 2.1 Role of Documentation in
Nursing Practice


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LO 2.1 Role of Documentation in

Nursing Practice
• Communication
• Key to preventing medical errors
• Promoted by documentation by all disciplines
–
–
–
–

Assessments
Treatments
Diagnostic testing
Preparation for discharge

• Trend toward use of EHR to enhance
communication


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LO 2.1 Role of Documentation in
Nursing Practice
• Advantages of EHRs
– Enhanced quality of documentation
– Promotion of safe, effective patient care
– Readily accessible information
– Elimination of illegible handwriting
– Automatic alerts
– Decision support
– Reduction in duplication of diagnostic testing

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LO 2.1 Role of Documentation in
Nursing Practice
• Concerns with Use of EHRs
– Confidentiality/HIPAA
– Power outages
– Computer “crashes”
– Computer viruses altering data


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LO 2.2 Purposes of Documentation


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LO 2.2.Purposes of Documentation
• Prevention of medical errors
• Communication with other healthcare
providers
• Demonstrate the delivery of care
• Ensure appropriate reimbursement
• Demonstrate adherence to accreditation
standards
• Provide evidence in legal proceedings
• Promote knowledge development through

research


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LO 2.2.Purposes of Documentation
• Three ‘Cs’ of Documentation
– Comprehensive
– Concise
– Clear


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LO 2.2.Purposes of Documentation
• Characteristics of Good Documentation
– Factual
– Accurate
– Complete
– Current
– Organized
– Legible
– Secure


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LO 2.2.Purposes of Documentation
• Types of Documentation Errors
– Errors of omission

– Inaccurate documentation
– Incomplete documentation


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LO 2.3 Documentation Methods


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LO 2.3 Documentation Methods
• Documentation Methods
– Narrative
– Charting by exception (CBE)
– Source oriented
– Focus charting (DAR)
– Critical pathway / caremap
– Problem-oriented
• PIE
• SOAP
• SOAPIER


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LO 2.3 Documentation Methods
• PIE
– Problem
– Intervention

– Evaluation


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LO 2.3 Documentation Methods
• SOAP
– Subjective
– Objective
– Assessment
– Plan


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LO 2.3 Documentation Methods
• SOAPIER
– Subjective – patient verbalization
– Objective – measurable data
– Assessment – nursing diagnosis
– Plan – desired outcomes
– Intervention – nursing actions
– Evaluation – patient response
– Revision/resolution – modifications of plan


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SOAPIER

Nursing
Process

Subjective Data
Objective Data

Assessment

Assessment

Nursing Diagnosis

Plan

Nursing Outcomes

Intervention

Nursing Intervention

Evaluation

Evaluation

Revision

Revision


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LO 2.4 Electronic Medication
Administration Record (eMAR)


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LO 2.4 Electronic Medication
Administration Record (eMAR)
• Medication Administration = Key nursing
function


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LO 2.4 Electronic Medication
Administration Record (eMAR)
Rights of Medication Administration
• Right patient
• Right
assessment
• Right medication
• Right education
• Right time
• Right evaluation
• Right dose
• Patient’s right to
• Right route
• Right
documentation

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LO 2.4 Electronic Medication
Administration Record (eMAR)
• Documenting Medication Administration
– Medication name
– Medication dosage
– Medication route
– Medication frequency
– Date and time of administration
– Signature of nurse who administers


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LO 2.4 Electronic Medication
Administration Record (eMAR)
• Withholding Medications
– Reasons for withholding
•
•
•
•

Patient NPO
Patient nauseated/vomiting
Patient condition contraindicates
Patient refusal

• Document when held
– Prevents appearance of error of omission
– Indicates reason for withholding

• Follow facility policy


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LO 2.4 Electronic Medication
Administration Record (eMAR)
• Benefits of eMars
– Reduction in medication errors
– Efficient tracking of medications
– User-friendly
– Interface with bar code systems where
available


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2.5 Nursing Diagnoses, NOC,
and NIC


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2.5 Nursing Diagnoses, NOC, and NIC
• Standardized Nursing Language

– Unified language for documenting care
• Allows comparison of care across settings

– Communicates
• Quality
• Effectiveness
• Value of nursing care

– Purpose – accurate, legal, reimbursable
documentation