Y khoa, y dược - Chapter 2: Nursing documentation overview

Chapter 2Nursing Documentation Overview© 2012 The McGraw-Hill Companies, Inc. All rights reserved.McGraw-HillChapter 2 Content2.1 Role of documentation in nursing practice2.2 Purposes of documentation2.3 Documentation methods2.4 Medication administration using an electronic Medication Administration Record (eMAR)2.5 Nursing diagnoses, NOC, and NICLO 2.1 Role of Documentation in Nursing PracticeLO 2.1 Role of Documentation in Nursing PracticeCommunicationKey to preventing medical errorsPromoted by documentation by all disciplinesAssessmentsTreatmentsDiagnostic testingPreparation for dischargeTrend toward use of EHR to enhance communication LO 2.1 Role of Documentation in Nursing PracticeAdvantages of EHRsEnhanced quality of documentationPromotion of safe, effective patient careReadily accessible informationElimination of illegible handwritingAutomatic alertsDecision supportReduction in duplication of diagnostic testingLO 2.1 Role of Documentation in Nursing PracticeConcerns with Use of EHRsConfidentiality/HIPAAPower outagesComputer “crashes”Computer viruses altering dataLO 2.2 Purposes of DocumentationLO 2.2.Purposes of DocumentationPrevention of medical errorsCommunication with other healthcare providersDemonstrate the delivery of care Ensure appropriate reimbursementDemonstrate adherence to accreditation standardsProvide evidence in legal proceedingsPromote knowledge development through researchLO 2.2.Purposes of DocumentationThree ‘Cs’ of DocumentationComprehensiveConcise ClearLO 2.2.Purposes of DocumentationCharacteristics of Good DocumentationFactualAccurateCompleteCurrentOrganizedLegibleSecureLO 2.2.Purposes of DocumentationTypes of Documentation ErrorsErrors of omissionInaccurate documentationIncomplete documentationLO 2.3 Documentation MethodsLO 2.3 Documentation MethodsDocumentation MethodsNarrativeCharting by exception (CBE)Source orientedFocus charting (DAR)Critical pathway / caremapProblem-orientedPIESOAPSOAPIERLO 2.3 Documentation MethodsPIEProblemInterventionEvaluationLO 2.3 Documentation MethodsSOAPSubjectiveObjectiveAssessmentPlanLO 2.3 Documentation MethodsSOAPIERSubjective – patient verbalizationObjective – measurable dataAssessment – nursing diagnosis Plan – desired outcomes Intervention – nursing actionsEvaluation – patient responseRevision/resolution – modifications of planSOAPIERNursing ProcessSubjective DataObjective DataAssessmentAssessmentNursing DiagnosisPlanNursing OutcomesInterventionNursing InterventionEvaluationEvaluationRevisionRevisionLO 2.4 Electronic Medication Administration Record (eMAR)LO 2.4 Electronic Medication Administration Record (eMAR)Medication Administration = Key nursing functionLO 2.4 Electronic Medication Administration Record (eMAR)Rights of Medication AdministrationRight patientRight medicationRight timeRight doseRight routeRight assessmentRight educationRight evaluationPatient’s right to Right documentationLO 2.4 Electronic Medication Administration Record (eMAR)Documenting Medication AdministrationMedication nameMedication dosageMedication routeMedication frequencyDate and time of administrationSignature of nurse who administersLO 2.4 Electronic Medication Administration Record (eMAR)Withholding MedicationsReasons for withholdingPatient NPOPatient nauseated/vomitingPatient condition contraindicatesPatient refusalDocument when heldPrevents appearance of error of omissionIndicates reason for withholdingFollow facility policyLO 2.4 Electronic Medication Administration Record (eMAR)Benefits of eMarsReduction in medication errorsEfficient tracking of medicationsUser-friendlyInterface with bar code systems where available2.5 Nursing Diagnoses, NOC, and NIC2.5 Nursing Diagnoses, NOC, and NICStandardized Nursing LanguageUnified language for documenting careAllows comparison of care across settingsCommunicatesQuality EffectivenessValue of nursing carePurpose – accurate, legal, reimbursable documentation2.5 Nursing Diagnoses, NOC, and NICNursing DiagnosesNorth American Nursing Diagnosis Association-International (NANDA-I)Nursing diagnosis classificationsReflect nursing needs of individualsGuide nursing decisionsGuide nursing plans of careUsed in variety of settingsBased on assessment data2.5 Nursing Diagnoses, NOC, and NICNursing Outcome Classifications (NOC)Reflect desired outcomes of nursing careLinked to nursing diagnoses2.5 Nursing Diagnoses, NOC, and NICNursing Intervention Classifications (NIC)Reflect nursing actions designed to help meet nursing outcomesLinked to nursing diagnoses