Efnisyfirlit

• Cover
• Title Page
• Copyright
• Dedication
• Contributors
• Previous Contributors
• Foreword
• 1 Understanding documentation
  • A look at documentation
  • You reach a wide audience
  • A short history of documentation
  • Role of documentation
  • Communication
  • A growing team
  • Evaluation of actions
  • Legal protection
  • The evidence speaks for itself
  • Research and education
  • A reciprocal relationship
  • Accreditation and licensure
  • Quality is key
  • Getting what they deserve
  • Track with a tracer
  • Charting clinical competence
  • Is that safe?
  • Quality and consistency
  • Reimbursement
  • It’s payback time . . . or is it?
  • Examinations aren’t just for patients
  • Keeping the proper care going
  • Performance improvement
  • Up to snuff?
  • Nurse practice acts
  • Accountability
  • Types of medical records
  • A comprehensive record
  • Source-oriented narrative method
  • Missing the complete picture?
  • Get on the same page
  • Problem-oriented method
  • Focusing on each problem
  • Other medical record formats
  • Designer documentation
  • Electronic health record
  • They even have good bedside manners
  • Suggested references
• 2 The nursing process
  • A look at the nursing process
  • Going through the steps
  • Assessment
  • Getting the whole picture
  • First impressions
  • Health history
  • Getting started
  • Making the most of your time
  • Physical examination
  • It’s in the details
  • The Joint Commission standards
  • Family matters
  • Is the patient well-equipped?
  • No yes-or-no answers, please
  • Learning obstacles
  • Prioritize, prioritize, prioritize
  • Nursing diagnosis
  • Diagnosing a diagnosis
  • One patient, two types of treatment
  • Emergencies get top billing
  • Planning care/outcomes
  • Take three giant steps
  • Outcome identification
  • Keeping it real
  • Four-part format
  • Writing outcome statements
  • Implementation
  • Divine intervention
  • Writing interventions
  • Documenting interventions
  • Tailor your style (and format) to policy
  • Evaluation
  • Charting changes
  • A tough transition
  • The value of evaluation
  • Whenever within sight
  • Evaluating expected outcomes
  • Not resolved? Revise . . .
  • Documenting evaluation
  • Get specific
  • Suggested references
• 3 Care plans
  • A look at the nursing care plan
  • Now a part of the permanent record
  • A word about words
  • Style of care plans
  • Traditional care plans
  • Looking toward an outcome
  • Personal, visual, clear
  • Time isn’t on its side
  • Standardized care plans
  • Insist on individuality
  • Computers make combos less cumbersome
  • These advantages come standard
  • Is it individualized?
  • Interdisciplinary contributions to the care plans
  • Patient-teaching plan
  • Pointers for the perfect plan
  • Parts of the teaching plan
  • Which evaluation techniques are most valuable?
  • Start simple
  • Taking different paths to learning
  • Tracking down teaching tools
  • Break down language barriers
  • Documenting the patient-teaching plan
  • Give it time . . . and thought
  • Forms, forms, and more forms
  • Just your type
  • Care pathways
  • Practical when predictable
  • Accomplished a goal? Check it off!
  • A collaborative effort
  • Determining the path
  • A bundle of benefits
  • Here’s where it gets complicated . . .
  • Choosing the right path
  • Priorities in the pathway
  • Suggested references
• 4 Documentation systems
  • A look at documentation systems
  • To write or not to write?
  • Narrative documentation
  • Using narrative documentation
  • Documentation mania!
  • Observe and take note
  • One thought leads to another
  • A narrative with a happy story
  • The narrative takes a turn for the worse . . .
  • Problem-oriented medical record
  • A multidiscipline approach
  • Four-part format
  • A four-star knowledge
  • Dividing the diagnoses
  • It’s as easy as 1, 2, 3, 4, 5 . . .
  • Plan on patient participation
  • A clean SOAP or SOAPIE component
  • POMR pros . . .
  • . . . and cons
  • PIE system
  • Using the PIE system
  • Pieces of PIE
  • Got a problem with that?
  • Keeping track
  • Reevaluate and review
  • Reasons to give PIE a try
  • Problems with PIE
  • FOCUS (F-DAR) system
  • Coming into FOCUS (F-DAR)
  • Writing FOCUS (F-DAR) progress notes
  • Lights, camera, data, action, response!
  • DAR-e to succeed?
  • FOCUS (F-DAR) downers
  • Charting by exception
  • CBE guidelines
  • Document deviations
  • Defining normal parameters
  • Get your guidelines here
  • CBE format
  • Making progress?
  • Fill in the blanks
  • Checks, asterisks, and arrows
  • Note normalcy
  • Make more marks
  • Care-ful combinations
  • More checks and asterisks
  • It’s exception-all
  • CBE shortcomings
  • Electronic health record
  • Information station
  • Multitasker
  • The upside
  • The downside
  • Using an EHR
  • Mum’s the word
  • Starting the record
  • Individual access
  • Practitioner’s use
  • Help for managing meds
  • Ready, set, document
  • Fast and functional
  • Follow protocol
  • Types of EHR systems
  • Talk, touch, or click
  • Adding your personal touch
  • What’s your type?
  • Nursing information system
  • From passive to interactive
  • Nursing minimum data set
  • Consistent and coded
  • Nurse’s little helper
  • But it’s always about the patient
  • Nursing outcomes classification system
  • Voice-activated systems
  • Look ma, no hands!
  • Report support and more
  • Hanging on every word
  • Additional system features
  • Patient schedules
  • Bar code technology
  • Medication administration
  • To be discontinued . . .
  • Sorry, wrong number
  • Streamlined service
  • Blood administration
  • Support provided
  • When computers fail
  • Choosing a documentation system
  • Getting better and better
  • Does your documentation measure up?
  • Are you committed? Serve on a committee . . .
  • Suggested references
• 5 Enhancing your documentation
  • A look at expert documentation
  • Documenting completely, concisely, and accurately
  • Say what?
  • Don’t be wishy-washy
  • Maintaining objectivity
  • Don’t put words in other people’s mouths
  • Secondhand data
  • Ensuring timeliness
  • Document ASAP
  • Give them the time of day
  • Put your documentation in order
  • Better late than never
  • Ensuring legibility
  • No pencils, please
  • Spelling counts
  • Using abbreviations appropriately
  • Correcting errors properly
  • Signing documents
  • To be continued . . .
  • What you didn’t see can hurt you
  • Practitioner’s orders
  • Written or electronic orders
  • Heading off mistakes
  • Preprinted orders
  • Verbal orders
  • From words to paper
  • Telephone orders
  • From phone to paper
  • Questioning practitioner’s orders
  • Chart authority
  • Stop, question, and document
  • Suggested references
• 6 Avoiding legal pitfalls
  • A look at legal pitfalls in documentation
  • The aim is communication
  • Legal standards
  • In a confused state? Read on . . .
  • Accreditation organizations/federal regulations
  • The more things change, the more they stay the same
  • Every relationship brings with it responsibility
  • The ties that bind
  • Documenting defensively
  • How to chart
  • Rule #1: Stick to the facts
  • Rule #2: Avoid labeling
  • Rule #3: Be specific
  • Rule #4: Use neutral language
  • Rule #5: Eliminate bias
  • Rule #6: Keep the record intact
  • Rule #7: Know your EHR
  • What to document
  • Rule #1: Document significant situations or unusual events
  • Rule #2: Document complete assessment data
  • Rule #3: Document discharge instructions
  • When to document
  • Don’t get ahead of yourself
  • Who should document
  • Finish what you started
  • Risk management and documentation
  • Mining the records for potential risk
  • Preventing adverse events
  • Reporting the out of the ordinary
  • Let’s review
  • Making sure everyone is on the same page
  • Managing incidents
  • The claim chain reaction
  • Eight legal hazards
  • Hazard #1: Incident reports
  • The form’s function
  • It’s an eyewitness report
  • Hazard #2: Informed consent
  • Waive it good-bye
  • Hazard #3: Advance directives
  • A change may be in order
  • Who else can give a DNR order?
  • A patient’s right
  • State-ments
  • Hazard #4: Patients who refuse treatment
  • The patient who says “no”
  • Get to them early
  • Hazard #5: Documenting for unlicensed personnel
  • Countersign-language
  • Hazard #6: Using restraints
  • The laws, they are a-changing . . .
  • Putting restraints on abusing restraints
  • The earlier, the better
  • One day at a time—no more
  • Getting into training
  • Hazard #7: Patients who request to see their charts
  • Don’t just hand it over
  • Hazard #8: Patients who leave AMA
  • Taking aim at the AMA form
  • Relate the patient’s state
  • The case of the missing patient
  • Suggested references
• 7 Documenting procedures
  • Guidelines for documenting procedures
  • Medication administration
  • You document MARvelously
  • No room for exceptions
  • Paging the practitioner . . .
  • Double team
  • I.V. therapy
  • Basic documentation
  • Getting complicated
  • Don’t forget the family
  • We interrupt this service . . .
  • Accounting for autotransfusions
  • Reacting to a suspected transfusion reaction
  • Surgical incision care
  • Records that get around
  • Who’s up first?
  • Detailed care and discharge data
  • Pacemaker care
  • Peritoneal dialysis
  • Peritoneal lavage
  • Chest tube
  • The documentation goes on and on
  • Cardiac monitoring
  • Keep on chartin’
  • Chest physiotherapy
  • Mechanical ventilation
  • Take a deep breath—then document!
  • Nasogastric tube insertion, use, and removal
  • Using the NG tube
  • The tube is removed—so document some more!
  • Seizure occurrence and management
  • Suture and staple removal
  • Tube feedings
  • Obtaining an arterial blood sample
  • Need an ABG analysis? That’s another form!
  • Documenting assisted procedures
  • Procedures may change, but the documentation remains the same
  • Bone marrow aspiration
  • Esophageal tube insertion and removal
  • Arterial line insertion and removal
  • The arterial line’s work may be done, but not yours . . .
  • CVAD insertion and removal
  • Out with the access device, in with the documenting . . .
  • Lumbar puncture
  • Paracentesis
  • With responsibility comes more documentation
  • Thoracentesis
  • Documenting miscellaneous procedures
  • Diagnostic tests
  • Document your first impressions
  • Pain control
  • Translating body language
  • Hourly rounding
  • I&O
  • Taking the intake documentation challenge
  • Don’t forget these types of intake
  • Transferring a patient to a specialty unit
  • Withdrawal of life support
  • Advanced warning
  • Match the patient’s wishes to the situation
  • Before withdrawal of life support
  • Codes
  • Getting up to code
  • A helpful critique
  • Suggested references
• 8 Documenting special situations
  • A look at special situations
  • Situations related to patient rights and safety
  • Photographing a patient
  • Get the old John Hancock
  • What is my role with photographs?
  • No signature required
  • Permanent fixture
  • Releasing information to the media
  • Permission policy
  • One-word is enough
  • In the spotlight
  • Documenting duties
  • For the (public) record
  • Dealing with death
  • Searching for contraband
  • Probable cause?
  • Request denied
  • Can I have a witness?
  • Search basics
  • Take note
  • Equipment tampering
  • Write on
  • Situations related to personal safety
  • Hostile advances
  • Take action
  • The write stuff
  • Harassment, bullying, and sexual harassment
  • To be harassment free
  • Focus on the facts
  • Suggested references
• 9 Acute care documentation
  • A look at acute care
  • Barriers to documentation
  • Is this ALWAYS the case?
  • Computerized documentation: The electronic health record
  • Forms, forms, and more forms
  • Admission database form
  • The clock is ticking
  • Finding form
  • Get it together!
  • Documentation with style
  • Form and function
  • How to use the admission database form
  • Ready, willing, and able?
  • Turning to friends and family
  • Too many cooks . . . er, health care workers . . . can spoil the chart
  • Medication reconciliation
  • Care plans and care pathways
  • Care plans
  • Care pathways
  • Watch your step on the pathway
  • Patient care Kardex
  • It’s all in the Kardex
  • The Kardex can be all aces
  • A key Kardex kriticism
  • Getting the most out of your medication Kardex
  • How are things progressing? Need more space?
  • Graphic form
  • Advantages—in graphic terms
  • Disadvantages—in graphic terms
  • Progress notes and flow sheets
  • Making good progress
  • Progress or pitfalls?
  • Don’t repeat yourself
  • Flow sheets
  • Symbolic significance
  • Completing the picture
  • A ban on blanks
  • Go flow sheets!
  • Flow sheet faults
  • Discharge summaries
  • In sum, discharge summaries are all good
  • How to use discharge summaries
  • Taking note of narrative discharge notes
  • Medication reconciliation
  • Suggested references
• 10 Home health care documentation
  • A look at home health care
  • An emerging health care powerhouse
  • Quicker has equaled sicker
  • Not your traditional patient
  • Documentation requirements
  • Creating opportunities for care
  • Legal risks and responsibilities
  • Meeting standards
  • Risks of poor documentation
  • Let’s admit it: Admission assessment is crucial
  • No record, no proof
  • A bad business practice
  • Documentation guidelines
  • Be sure to begin at the beginning
  • The information you provide gets around
  • Documentation details
  • Home health care forms
  • Agency assessment and OASIS documentation
  • Care plan
  • Family counsel
  • Don’t go astray—without documenting it, at least
  • Collating care
  • Progress notes
  • Work in progress
  • Patient teaching
  • Keeping continuity
  • Being there
  • Setting the terms (on the packages)
  • Signing off
  • Nursing and discharge summaries
  • Summing it all up
  • Medicare-mandated forms
  • Practitioner calls
  • Fill out and sign, please . . .
  • Future developments
  • One predicted outcome: More reliance on outcomes
  • Computers at work
  • Keeping it confidential
  • Suggested references
• 11 Long-term care documentation
  • A look at documenting in long-term care
  • Documentation distinctions
  • Categories of care
  • Care may be complex . . .
  • . . . or not so complex
  • Regulatory agencies
  • Medicare
  • Making reimbursement a reality
  • Medicaid
  • Reimbursement for intermediate care
  • CMS and Resident Assessment Instrument
  • OBRA
  • The Joint Commission
  • Forms used in long-term care
  • MDS
  • CAA
  • PASARR
  • Initial nursing assessment
  • Nursing summaries
  • Summing it up
  • ADL checklists and flow sheets
  • Care plans
  • Discharge and transfer forms
  • Documentation guidelines
  • Suggested references
• Appendices
• Glossary
• Index

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