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

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.

Chapter 2

Nursing Documentation Overview

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2.5 Nursing diagnoses, NOC, and NIC

LO 2.1 Role of Documentation in

Nursing Practice

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

• 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

Nursing Practice

• Concerns with Use of EHRs

– Confidentiality/HIPAA– Power outages

– Computer “crashes”

– Computer viruses altering data

LO 2.2 Purposes of Documentation

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

• Three ‘Cs’ of Documentation

– Comprehensive– Concise

– Clear

LO 2.2.Purposes of Documentation

• Characteristics of Good Documentation

– Factual– Accurate– Complete– Current– Organized– Legible

– Secure

• Types of Documentation Errors

– Errors of omission– Inaccurate documentation– Incomplete documentation

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

LO 2.3 Documentation Methods

• PIE

– Problem– Intervention– Evaluation

• SOAP

– Subjective– Objective– Assessment– Plan

Subjective Data

Objective Data Assessment

Assessment Nursing Diagnosis Plan Nursing Outcomes Intervention Nursing Intervention Evaluation Evaluation

Revision Revision

LO 2.4 Electronic Medication Administration Record (eMAR)

• Medication Administration = Key nursing function

Administration Record (eMAR)

Rights of Medication Administration

• Right education

• Right evaluation

• Patient’s right to

• Right documentation

• Documenting Medication Administration

– Medication name– Medication dosage– Medication route– Medication frequency– Date and time of administration– Signature of nurse who administers

Administration Record (eMAR)

• Document when held

– Prevents appearance of error of omission– Indicates reason for withholding

• Follow facility policy

• Benefits of eMars

– Reduction in medication errors– Efficient tracking of medications– User-friendly

– Interface with bar code systems where available

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

2.5 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

• Nursing Outcome Classifications (NOC)

– Reflect desired outcomes of nursing care– Linked to nursing diagnoses

2.5 Nursing Diagnoses, NOC, and NIC

• Nursing Intervention Classifications (NIC)

– Reflect nursing actions designed to help meet nursing outcomes

– Linked to nursing diagnoses