Chapter 2 - Nursing documentation overview. After completing Chapter 2, the students will be able to: Describe the role of documentation in nursing practice; identify the purposes of documentation; identify and explain different types of documentation methods; explain documentation of medication administration using an electronic Medication Administration Record (eMAR); explain the importance and relevance of nursing diagnoses, NOC, and NIC in nursing documentation.
2-1 Chapter Nursing Documentation Overview McGrawHill © 2012 The McGrawHill Companies, Inc. All rights reserved 2-2 Chapter 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 2-3 LO 2.1 Role of Documentation in Nursing Practice 2-4 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 2-5 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 2-6 LO 2.1 Role of Documentation in Nursing Practice • Concerns with Use of EHRs – Confidentiality/HIPAA – Power outages – Computer “crashes” – Computer viruses altering data 2-7 LO 2.2 Purposes of Documentation 2-8 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 2-9 LO 2.2.Purposes of Documentation • Three ‘Cs’ of Documentation – Comprehensive – Concise – Clear 2-10 LO 2.2.Purposes of Documentation • Characteristics of Good Documentation – Factual – Accurate – Complete – Current – Organized – Legible – Secure 2-14 LO 2.3 Documentation Methods • PIE – Problem – Intervention – Evaluation 2-15 LO 2.3 Documentation Methods • SOAP – Subjective – Objective – Assessment – Plan 2-16 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 2-17 SOAPIER Nursing Process Subjective Data Objective Data Assessment Assessment Nursing Diagnosis Plan Nursing Outcomes Intervention Nursing Intervention Evaluation Evaluation Revision Revision 2-18 LO 2.4 Electronic Medication Administration Record (eMAR) 2-19 LO 2.4 Electronic Medication Administration Record (eMAR) • Medication Administration = Key nursing function 2-20 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 2-21 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 2-22 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 2-23 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 2-24 2.5 Nursing Diagnoses, NOC, and NIC 2-25 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 2-26 2.5 Nursing Diagnoses, NOC, and NIC • Nursing Diagnoses – North American Nursing Diagnosis Association-International (NANDA-I) – Nursing diagnosis classifications • • • • • Reflect nursing needs of individuals Guide nursing decisions Guide nursing plans of care Used in variety of settings Based on assessment data 2-27 2.5 Nursing Diagnoses, NOC, and NIC • Nursing Outcome Classifications (NOC) – Reflect desired outcomes of nursing care – Linked to nursing diagnoses 2-28 2.5 Nursing Diagnoses, NOC, and NIC • Nursing Intervention Classifications (NIC) – Reflect nursing actions designed to help meet nursing outcomes – Linked to nursing diagnoses ... Secure 2- 11 LO 2. 2.Purposes of Documentation • Types of Documentation Errors – Errors of omission – Inaccurate documentation – Incomplete documentation 2- 12 LO 2. 3 Documentation Methods 2- 13 LO 2. 3.. . 2- 2 Chapter 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... assessment data 2- 27 2. 5 Nursing Diagnoses, NOC, and NIC • Nursing Outcome Classifications (NOC) – Reflect desired outcomes of nursing care – Linked to nursing diagnoses 2- 28 2. 5 Nursing Diagnoses,