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 assessment and care provided…
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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 feet’
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‘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 complaints’
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‘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
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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 ü Eval / Re-Eval
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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 additionØ 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
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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
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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
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
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
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SKIN ASSESSMENT 1. TIMELY ü ON ADMISSION ü EVERY SHIFT OR VISIT ü FOLLOW FACILITY POLICY
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 2. ACCURATE / COMPREHENSIVE / COMPLETE ü ü ü ü ü ü
INTEGRITY- Alteration in Epidermis or Dermis COLOR- Erythema, Pallor, Cyanosis… TURGOR- Dehydration … Standard of Care ü Nursing Assess MOISTURE STATUSü Plan of Care ü Interventions TEMPERATUREü Eval / Re-Eval HIGH RISK AREASCharacteristics ü Timely ü Accurate ü Comprehensive ü Complete
SKIN ASSESSMENT
DOCUMENT AND REPORT ABNORMALITIES 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
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WOUND ASSESSMENT 1. TIMELY ü ü ü ü
ON ADMISSION EVERY SHIFT OR VISIT UPON TRANSFER / DISCHARGE Standard of Care PER FACILITY POLICY ü Nursing Assess ü Plan of Care ü Interventions ü Eval / Re-Eval Characteristics ü Timely ü Accurate ü Comprehensive ü Complete
WOUND ASSESSMENT 2. ACCURATE / COMPREHENSIVE / COMPLETE ü ü ü ü ü ü ü ü
Wound Type Location Measurement Undermining / Tunneling Wound Bed Appearance Drainage Odor Surrounding Skin
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
WOUND DOCUMENTATION Paints the picture & tells the story WOUND TYPE SURROUNDING SKIN
ODOR
LOCATION
WOUND
MEASUREMENT
UNDERMINING TUNNELING
DRAINAGE APPEARANCE
Characteristics ü Timely ü Accurate ü Comprehensive ü Complete
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WOUND TYPE FOR PRESSURE ULCERS: Ø If you know how to stage it-Do it! Ø If you are uncertain-Describe it!
LOCATION, LOCATION
SACRAL AREA COCCYX TROCHANTER
Sacrum
ILIAC CREST
GLUTEAL FOLD
Coccyx
ISCHUIM
Correctly identify wound location
MEASUREMENT LENGTH
Longest point Head to toe direction
X
WIDTH
Perpendicular to length Widest point
X
DEPTH
90 degree angle Deepest point
Document on Admission and per facility policy
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UNDERMINING / TUNNELING
UNDERMINING
TUNNELING
Document with measurement
APPEARANCE
GRANULATION TISSUE
SLOUGH
ESCHAR
Document tissue type or describe color
DRAINAGE
How much and what does it look like?
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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 and day to day
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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
Time PU Stage
10Am
2/ 28 Pm
2/ 29 Am
2/ 29 Pm
3/3
3/3
3/4
3/4
Am
PM
Am
Pm
III
III
III
III
4X2
3/1
4x2
4x2
AM
3/ 1 Pm
3/2
3/2
Am
Pm
Pink
yellow
Incis edges Exudate amt Exudate type Odor Surrounding skin Closure
approx Small Serous Absent Intact None
separated None None Absent Intact None
White / yellow Separated None None Absent Intact None
White / yellow Separated None None Absent Intact None
Absent Intact None
Absent Intact None
Dressing assess/changed Wnd cleanser Dressing applied
Changed
Changed
Changed
Changed
WDP
Changed
NS Gauze
NS Gauze
NS Hydrogel Gauze
NS
NS Hydrogel Gauze Foam
Hydrogel Foam
None
None
other
None
Foam
None
Paper tape
Paper tape
Paper tape
Paper tape
Paper tape
Paper tape
Secondary dressing Secured with
Red / yellow
Intact
3/ 5 Am
3/5
3/6
3/6
3/7
3/7
Pm
Am
PM
Am
Pm
I
III
II
SDTI
Measure Undermining Tunneling Wound color
Wound Consult AM
Unstageable 3 x 1.2 x .2
Pink / yellow
Pink / yellow
Liquid tissue No Change Hydrogel Hydrocolloid Other
Green
Pink
UTA
UTA
Separated None None
NA None None Absent Intact None
UTA UTA UTA Absent UTA None
UTA UTA UTA Absent UTA None
WDP
WDP
Changed
Foam
NS Hydrocolloid
None
Hydrocolloid Hydrogel Foam
White / yellow NA Small Serous Absent Intact NA
Good News: Wound is noted on admission Not So Good News: No Charting: for the next 3 days Staging: Inconsistent (IIIàSDTIàIàIIIàII)-actually Unstageable Measurement: noted on day 3 / Stage III, no depth documented, ever Incision edges: Documented consistently… (in a pressure ulcer?) Closure: ‘liquid tissue’ ? Dressing: Not assessed consistently-dressing type changes shift to shift
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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 Characteristics ü Timely NOT pressure ulcers 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”
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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
Ø Visual
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EXAMPLE 1-INDICATE LOCATION OF WOUND (S) ON BODY DIAGRAM
#1
X
2-DOCUMENTATION FOR: ALL WOUNDS EXCEPT INTACT SURGICAL WOUNDS Wound Location Wound Type / Wound Appearance Drainage Odor # Pressure Ulcer Measurement Stage
Cleansed with
Dressing Applied
Click boxes for ‘smart text’ options
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Left ILIAC
PRESSURE ULCER STAGE II
2 X 2 X .2cm
RED
SCANT SEROUS
ABSENT
NS
Hydrocolloid
‘SMART TEXT’ OPTIONS Wound# àchoose smart textà (1 / 2 / 3 / 4 / 5 / 6 / 7 / 8 / 9 / 10) Location àchoose smart textà (coccyx, ischial, scaral…) Wound Type / àchoose smart textà (arterial, diabetic, PU stage I, PU stage II, PU stage III…) Measurement àchoose smart textà (length 1 / 2 / 3…) (Width 1 / 2 / 3…) (Depth 1 / 2 / 3...) Appearance àchoose smart textà (red / pink / yellow / gray….) Drainage àchoose smart textà (none, scant, small…) Odor àchoose smart textà (absent, present) Cleansed with àchoose smart textà (NS, wound cleanser...) Dressing àchoose smart textà (Calcium alginate, gauze, 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)
BOTTOM LINE
Every nurse is responsible for the patient care provided and the DOCUMENTATION to support it
SOME OPTIONS…
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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
Nursing Tools
Baker Pressure Ulcer Staging Tool
Standard of Care ü Nursing Assess ü Plan of Care ü Interventions ü Eval / Re-Eval
Musical Wound Assessment
Characteristics ü Timely ü Accurate ü Comprehensive ü Complete
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Thank You
Wound Care Nursing
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