NURSING DOCUMENTATION

NURSING

DOCUMENTATION

OBJECTIVES

1. The learner will be able to state 2 components of documentation that meet the ‘Standard of Care’

2. The learner will be able to identify 4 characteristics of a ‘complete skin assessment’

3. The learner will be able to identify 4 characteristics of a ‘complete wound assessment’

DOCUMENTATION IS…

Ø Something you learn in nursing school Ø Something you do everyday at work Ø How you record patient vitals, diet, meds…

THE permanent record of nursing

DOCUMENTATION

Ø ‘any written or electronically

generated information about a

patient that describes the care or

services provided to that patient’

SOME EXAMPLES…

‘

Skin intact, red, and broken’

‘

The skin was moist and dry’

‘

Pulses are probably in both

‘

Examination of

genitalia reveals that

he is circus-sized’

‘300cc PWISOTF’

(Plus what I spilled on the floor)

‘Patient found dead:

felt cold,

blanket added,

voiced no

‘

She has no rigors or

shaking chills, but her

husband states she

was very hot in bed

last night’

‘

Large brown stool

ambulating in the hall’

Documentation is the process of

recording the patient assessment

and the care provided

It MUST demonstrate that the

‘Standard of Care’ has been met

STANDARD OF CARE

What is it and who decides?

STANDARD OF CARE

Ø Guidelines used to determine what a nurse

should or should not do

Ø Model of established practice that is

commonly accepted as correct

Ø Basis for nursing care that draws on the

latest scientific data from nursing literature

Ø Based on the premise that the registered

nurse is responsible for and accountable to the individual patient for the quality of nursing care he or she receives

STANDARD OF CARE

The nurse has a professional responsibility, and is held accountable to document patient data that accurately reflects: Ø Nursing assessment

Ø Plan of care

Ø Appropriate interventions

Ø Evaluation of the patient’s condition

Standard of Care

ü Nursing Assess

ü Plan of Care

ü Interventions

STANDARD OF CARE

Developed and implemented to define the ‘quality of care provided’

Ø Federal / State laws, rules and regulations Ø Professional organizations establish norms for

the average practitioner

Ø The ANA and Joint Commission on Accreditation of Healthcare Organizations (JCAHO) have established nationally recognized ‘Standards of Care’

POLICY AND PROCEDURE

In addition-

Ø Nurses must understand and

follow the policies and procedural

guidelines of their individual

facilities

LEGAL CONSIDERATIONS

The healthcare industry can be a minefield of litigation when patients

Ø Don’t heal as expected

Ø Develop unexpected complications or infections which can lead to prolonged recovery or even death

Lawsuits often involve all those who cared for the patient, including the nurse

WOUND LITIGATION

ON THE RISE

Ø Increasing elderly population Ø Regulatory climate

Ø Misunderstanding by families as to the cause of wounds

Ø Perceived as ‘bad care’

Ø Public opinion that wound cases are an ‘easy target’

LEGAL CONSIDERATION

Ø Nursing documentation

Ø often starting point in malpractice cases Ø can either deter a plaintiff from filing a lawsuit or

provide the leverage that is required to initiate one

Jurors and attorneys view what is written in

the patient record as the best evidence of what really occurred

PRESSURE ULCERS

The incidence of Hospital acquired pressure ulcers (HAPUs) is considered a ‘quality indicator’ of patient care

Ø ‘Quality care should not result in a HAPU’ Ø A ‘Never Event’

Ø High public awareness

Ø Frequent involvement in litigation Ø Reimbursement issues

The reality is that not all pressure ulcers are preventable….

The nurse MUST be able to show that all appropriate assessments and interventions were done….

…That the ‘Standard of Care’ was met

DOCUMENTATION THAT MEETS

THE STANDARD OF CARE

Ø Timely

Ø Accurate

Ø Comprehensive

Ø Complete

Characteristics ü Timely ü Accurate ü Comprehensive ü Complete Standard of Care ü Nursing Assess ü Plan of Care ü Interventions ü Eval / Re-Eval

DOCUMENTATION THAT MEETS

THE STANDARD OF CARE

ASSESSMENT, ASSESSMENT, ASSESSMENT…..

ü SKIN ASSESSMENT ü WOUND ASSESSMENT ü RISK ASSESSMENT Standard of Care ü Nursing Assess ü Plan of Care ü Interventions ü Eval / Re-Eval Characteristics ü Timely ü Accurate ü Comprehensive üComplete

SKIN ASSESSMENT

1.  TIMELY

ü  ON ADMISSION ü  EVERY SHIFT OR VISIT ü  FOLLOW FACILITY POLICY

Characteristics ü Timely ü Accurate ü Comprehensive ü Complete Standard of Care ü Nursing Assess ü Plan of Care ü Interventions ü Eval / Re-Eval

SKIN ASSESSMENT

2.  ACCURATE / COMPREHENSIVE / COMPLETE

ü  INTEGRITY- Alteration in Epidermis or Dermis

ü  COLOR- Erythema, Pallor, Cyanosis…

ü  TURGOR- Dehydration …

ü  MOISTURE STATUS- ü  TEMPERATURE-

ü  HIGH RISK AREAS- _{Characteristics}

ü Timely ü Accurate ü Comprehensive ü Complete Standard of Care ü Nursing Assess ü Plan of Care ü Interventions ü Eval / Re-Eval

SKIN ASSESSMENT

DOCUMENT

AND REPORT ABNORMALITIES

Characteristics ü Timely ü Accurate ü Comprehensive ü Complete Standard of Care ü Nursing Assess ü Plan of Care ü Interventions ü Eval / Re-Eval

WOUND ASSESSMENT

1.  TIMELY

ü  ON ADMISSION ü  EVERY SHIFT OR VISIT

ü  UPON TRANSFER / DISCHARGE ü  PER FACILITY POLICY

Characteristics ü Timely ü Accurate ü Comprehensive ü Complete Standard of Care ü Nursing Assess ü Plan of Care ü Interventions ü Eval / Re-Eval

WOUND ASSESSMENT

2. ACCURATE / COMPREHENSIVE / COMPLETE ü  Wound Type ü  Location ü  Measurement ü  Undermining / Tunneling ü  Wound Bed Appearance ü  Drainage

ü  Odor

ü  Surrounding Skin Characteristics ü Timely

ü Accurate ü Comprehensive ü Complete Standard of Care ü Nursing Assess ü Plan of Care ü Interventions ü Eval / Re-Eval

WOUND DOCUMENTATION

Paints the picture & tells the story

SURROUNDING SKIN ODOR DRAINAGE APPEARANCE UNDERMINING TUNNELING MEASUREMENT LOCATION WOUND TYPE WOUND Characteristics ü Timely ü Accurate ü Comprehensive ü Complete

WOUND TYPE

FOR PRESSURE ULCERS:

Ø If you know how to stage it-Do it! Ø If you are uncertain-Describe it!

SACRAL AREA COCCYX

TROCHANTER ILIAC CREST

GLUTEAL FOLD ISCHUIM

LOCATION, LOCATION

Correctly identify wound location

Sacrum Coccyx

MEASUREMENT

LENGTH X WIDTH X DEPTH

Longest point

Head to toe direction Perpendicular to length Widest point 90 degree angle Deepest point

UNDERMINING /

TUNNELING

UNDERMINING TUNNELING

Document with measurement

APPEARANCE

GRANULATION TISSUE SLOUGH ESCHAR

Document tissue type or describe color

DRAINAGE

ODOR

Document presence of…

SURROUNDING SKIN

Document condition of skin surrounding wound

REALITY

Audits are enlightening…

Ø Wrong location Ø Wrong wound type

Ø Wrong pressure ulcer stage

Ø Ever changing pressure ulcer stage…

Ø Missing assessment data Ø Inconsistencies from shift to shift

Common Liability Issues

ü Lack of documentation ü No admission assessment

ü Discrepancy with prior / post facility assessment / staging

ü No measurements ü Lack of interventions

ü Specialty support surface ü Off-loading

ü Documentation of turning / repositioning

MORE Liability Issues

ü Failure to identify skin breakdown

ü Failure to notify doctor of changes in wound ü Failure to apply proper treatment

ü Failure to obtain wound care consult ü INCONSISTENCY IN DOCUMENTATION

AUDIT EXAMPLE

Date 2/28 2/ 28 2/ 29 2/ 29 3/1 3/ 1 3/2 3/2 3/3 3/3 3/4 3/4 3/ 5 3/5 3/6 3/6 3/7 3/7 Wound Consult Time 10Am Pm Am Pm AM Pm Am Pm Am PM Am Pm Am Pm Am PM Am Pm AM

PU Stage III III III III SDTI I III II Un- stageable

Measure 4X2 4x2 4x2 3 x 1.2 x .2 Undermining

Tunneling

Wound color Pink yellow White /

yellow White / yellow Red / yellow Pink / yellow Pink / yellow Green Pink UTA UTA White / yellow Incis edges approx separated Separated Separated Separated NA UTA UTA NA

Exudate amt Small None None None None None UTA UTA Small Exudate type Serous None None None None None UTA UTA Serous Odor Absent Absent Absent Absent Absent Absent Absent Absent Absent Absent Surrounding skin Intact Intact Intact Intact Intact Intact Intact Intact UTA UTA Intact Closure None None None None None None Liquid

tissue None None None None NA Dressing

assess/changed

Changed Changed Changed Changed WDP Changed No

Change WDP WDP Changed Wnd cleanser NS NS NS NS NS NS Dressing applied Gauze Gauze Hydrogel

Gauze Hydrogel Foam Gauze Hydrogel Foam Hydro- gel Hydro- colloid Hydrocolloid Hydrogel Foam Foam Hydrocolloid Secondary dressing

None None other None Foam None Other Secured with Paper

tape Paper tape

Paper tape Paper tape

Paper tape

Paper tape

Good News: Wound is noted on admission

Not So Good News:

No Charting: for the next 3 days

Staging: Inconsistent (IIIàSDTIàIàIIIàII)-actually Unstageable

Measurement: noted on day 3 / Stage III, no depth documented, ever

Incision edges: Documented consistently… (in a pressure ulcer?)

Closure: ‘liquid tissue’ ?

DOCUMENTATION TIPS

Documentation should include:

Ø Data from Nursing Assessment Ø Nursing actions / interventions taken Ø Individuals notified about concerns / issues

Ø Evaluation of actions _{Standard of Care}

ü Nursing Assess

ü Plan of Care

ü Interventions

ü Eval / Re-Eval

DOCUMENTATION TIPS

Ø Document within timeframe outlined per

facility policy

Ø Correctly identify LEFT and RIGHT Ø Correctly identify LOCATION, especially

Ø SACRAL Ø COCCYX

Ø Correctly stage all PRESSURE ULCERS Ø Do NOT stage wounds that are

NOT pressure ulcers

Characteristics ü Timely ü Accurate ü Comprehensive ü Complete

GENERAL CAUTION

Spell correctly:

Ø “Fecal heart tones heard”

Use appropriate words and grammar: Ø “The pelvic exam was done on the floor” Avoid inappropriate comments:

Ø “Patient received insufficient care today because nurse patient ratio was 1:7”

Don’t Forget

RISK ASSESSMENT

ü  Evidenced based tool: Braden / Norton ü  Follow facility policy for frequency ü  INTERPRET RESULTS

ü Implement appropriate interventions ü Use score to adjust the plan of care

Standard of Care ü Nursing Assess ü Plan of Care ü Interventions ü Eval / Re-Eval

IMPROVING COMPLIANCE

Ø Staff education and support related to wound ID, pressure ulcer staging, wound assessment..

Ø Tools and visuals to assist staff in wound identification and staging

WOUND DOCUMENTATION

FORMAT SUGGESTIONS

Ø Nurse ‘friendly’

Ø Contain all components necessary for ‘complete’ documentation

Ø Improves probability of comprehensive doc

EXAMPLE

1-INDICATE LOCATION OF WOUND (S) ON BODY DIAGRAM

2-DOCUMENTATION FOR: ALL WOUNDS EXCEPT INTACT SURGICAL WOUNDS

Wound # Location Wound Type / Pressure Ulcer

Stage Wound

Measurement Appearance Drainage Odor Cleansed with Dressing Applied

Click boxes for ‘smart text’ options 1 Left ILIAC PRESSURE ULCER STAGE II 2 X 2 X .2cm RED SCANT

SEROUS ABSENT NS Hydrocolloid

3-DOCUMENTATION FOR INTACT SURGICAL WOUNDS ONLY

A-Intact surgical incisions #___ through #___ (choose smart textà (1 / 2 / 3 / 4 / 5 / 6 / 7 / 8 / 9 / 10) B-Incision Appearance __________________________

(choose smart textà (clean / dry / well approximated / without erythema / without drainage / without odor) C-Closure ______________

(choose smart textà staple / sutures / glue / other / none)

‘SMART TEXT’ OPTIONS Wound# àchoose smart textà (1 / 2 / 3 / 4 / 5 / 6 / 7 / 8 / 9 / 10) Location àchoose smart textà (coccyx, ischial, scaral…) Wound Type / àchoose smart textà (arterial, diabetic, PU stage I, PU stage II, PU stage III…)

Measurement àchoose smart textà (length 1 / 2 / 3…) (Width 1 / 2 / 3…) (Depth 1 / 2 / 3...)

Appearance àchoose smart textà (red / pink / yellow / gray….)

Drainage àchoose smart textà (none, scant, small…) Odor àchoose smart textà (absent, present)

Cleansed with àchoose smart textà (NS, wound cleanser...)

Dressing àchoose smart textà (Calcium alginate, gauze, hydrocolloid…)

X #1

BOTTOM LINE

Every nurse is responsible for the patient care provided and the DOCUMENTATION

to support it

NURSING TOOLS

Ø Nurse ‘cheat sheet’

Ø Pressure ulcer staging analogy Ø PU staging algorithm

Ø Musical wound assessment

‘Cheat Sheet’

for Nurses Pressure Ulcer Analogy

Baker Pressure Ulcer Staging Tool Nursing Tools Musical Wound Assessment Standard of Care ü Nursing Assess ü Plan of Care ü Interventions ü Eval / Re-Eval Characteristics ü Timely ü Accurate ü Comprehensive ü Complete

Thank You