Communication is Vital!
Technology is your friend!
 Accurate:
 Observations
only
 Do not use subjective
words
 Correct spelling,
grammar & med terms
 Complete:
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New or changed
information
S/S, clients behavior
Nursing interventions
Meds given
Physicians orders
carried out
Client teaching and
response to therapy

Consistent


Objective
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Concise and brief using approved abbreviations
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
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
Organization


Use nursing process
Timelines

Document care, treatments, procedures and medications
as soon as possible
 Purpose
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of documentation:
Communication
Assessment
Care planning
Quality assurance
Reimbursement
Legal documentation
Research
Education
 Technology
in healthcare is advancing
 Information will be managed electronically
 Outcomes:
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Safe patient care
Patient centered care
Improved outcomes
Ease of access to information
Workflow
 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
 EHR/EMR
 Monitoring
 Imaging
 Medication
administration
 Pharmacy
 Clinical
Decision Support Systems
 ADT
 CPOE
 Central
supply ordering systems
Elements that reduce human error:
 CPOE
 Bar Code
 High Alert Medication Documentation
 Point of Care Documentation
 Mandatory Fields
 Smart Pumps
 Communication Tool
 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!
HIPAA
Purpose
Techniques
Content
Situation
Background
 Pt
 What
name
 Age
 Physician’s name
 Diagnois
 Hospital day/POD #
brought them
to the hospital
 Past medical
history
Situation
Background
Assessment
Recommendation/ Request
 Often a framework for communicationcalling MD, giving report, etc
Assessment
 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
 Information
written in sentences or phrases
usually time sequenced
 Must
 Many
write a narrative note q2 hrs
combined with flow sheets
 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