Working draft to inform revisions to:
Policy Title/#: Clinical Documentation: Inpatient Electronic- CL 30-05.16
PURPOSE:
This policy outlines the minimum standards for nursing documentation for all Inpatient and Observation status Patients. Documentation reflects the nursing process and should protect the patient, the nurse, and the medical center by reflecting and communicating to the health care team a concise, accurate and meaningful record of care and patient response.
POLICY:
For this policy, documentation requirements are defined as follows:
Documentation…
- BASELINE: A comprehensive patient assessment will be documented within 24h of admission (or significant change in patient level of care) to establish patient physiological, functional, psychosocial baseline to inform the plan for care.
- SHIFT: Standard inpatient assessments (displayed in caps) and those related to the individuals’ problem or risk of problems list shall be documented every shift followed by timely focused re-assessments of significant problems.
- PLAN: The plan of care shall reflect prioritized problems, interventions, significant care team communications, plan changes, goals, patient response to care and discharge readiness.
- DISCHARGE: A current shift assessment should be completed prior to discharge, problems needing follow-up should be identified and documented with a plan to address…
SPECIFIC INFORMATION:
Patients are monitored in the inpatient setting according to the level of care required. Assessments, hands on care, teaching, counseling, and team communication may or may not be documented in the medical record depending on need for that information. This guideline is to ensure the nursing staff spends more time caring for the patient than documenting universal care standards.
The extent, frequency and timeliness of documentation depends on the importance of this information to inform team care decisions and support regulatory reporting. There are three levels of timeliness: (1) Real-time, (2) Near-time, and (3) Summative data. Real-time data captured by machine (e.g. Ventilator data , Barcoded meds, Glucometer) and is available immediately in the record. Manually transcribed machine data should be entered directly into record (VS). Near-time data (e.g. Neuro assessment, Restraint check) is documented as soon as reasonable, but no greater than 2 hours in ICU and 4 hours in acute care. The date/time should be adjusted to reflect the time the assessment or intervention was done (resulting in time stamps for time done and time entered). Summative data reflects non- time sensitive information and can be done at any time to reflect previous assessments and interventions done this shift. Nurses make copy their own assessment documentation up to 72 hrs
DEFINITIONS:
· Goals – One to two short term measureable goals are set for priority problems early in the shift. Outcomes of these goals are described in the patient Response to Care narrative summary.
· Care Categories - Physiological (Cardiac, Neuro), Functional (Activity, Nutrition), and Psychosocial (Coping, Safety) groupings that organize the assessments & interventions that reflect nursing practice. (Exhibit [A])
· Standards of Care - “Every patient every time. “Reflect standards of practice and provide a guide to the knowledge, skills, judgment and attitudes that are needed to practice safely. They are (1) considered as the baseline for quality nursing care; (2) developed in relation to the law governing nursing practice; (3) applicable to the registered nurse practicing in any setting at all levels of practice. http://www.hg.org/article.asp?id=6237
· Nursing Process - The common thread uniting different types of nurses who work in varied areas is the nursing process—the essential core of practice for the registered nurse to deliver holistic, patient-focused care. It includes: Assessment, Nursing Diagnosis (Problems) , Outcomes/Planning, Implementation & Evaluation. http://www.nursingworld.org/especiallyforyou/studentnurses/thenursingprocess.aspx
· Response to Care – Patient response to interventions, progress against goals and plan changes.
· Modified Charting by Exception – To reduce repetitive charting of normal assessment detail , nurses chart within normal/expected limits (WNL, WEL) for each care category omitting normal findings except for normal values needed for decision support (Braden, Morse, RASS). Findings that are outside expected limits (OEL) require supporting documentation (eg tachycardia).
o WNL – Within normal limits. Meets standard criteria for developmental age
o WEL – Within expected limits. Does not meet all the standard criteria for development age, but is expected for patients in this clinical phase (post-op) or normal for patient and does not require measures beyond the standard of care.
o OEL – Outside expected limits - Does not meet criteria for WNL or WEL (eg. agitated), but has not risen to the level of a problem. No additional, special care except include in next focused assessment. Some notation of what parameter is OEL in a key data field (eg RASS = 1) or associated comment (pt c/o dizziness). Temporary foley catheter.
o Problems (Nursing diagnoses) require targeted interventions and should be a significant focus of the plan of care (eg. Incision)
o Priority problems Priority problems are flagged in red and represent the most important shift focus based on patient (eg pain), team (eg oxygenation) and nurse’s assessment of risk (eg skin integrity) . They require measureable goals and outcomes are described in the Response to Care narrative statement.
· Interventions – Reflect implementation of the plan of care (Assess, Care, Teach, Notify) based on provider orders, VUMC Policy & Procedure, and published Nursing standards of care (ie Mosby).
DOCUMENTATION PROCEDURES
All care categories require documentation on admission. Assessments shown in all capital letters are required documentation every shift. Focused re-assessment is done if the initial assessment for that category was outside expected limits or if the patient unstable, is at risk for, or has an existing problem for that care category.
Assessments are problem focused, meaning that the nurse will assess whether the patient presents as Within Normal limits (WNL), Within Expected Limits (WEL), Outside Expected Limits (OEL), or has a Nursing diagnosis (problem or problem risk) needing focused monitoring and/or care
Table 1 - Required assessments (X)
CARE CATEGORY / ADM / QSHIFT + / FOCUSED REASSESSMENT- PAIN / X / X / if problem/risk
- NEURO / X / X / if problem/risk
- CARDIAC / X / X / if problem/risk
- Vascular/Perfusion / X / if problem/risk
- RESPIRATORY / X / X / if problem/risk
- GASTROINTESTINAL / X / X / if problem/risk
- SAFETY/FALL RISK / X / X / if problem/risk
- SKIN/WOUND / X / X / if problem/risk
- URINARY/RENAL / X / X / if problem/risk
- Activity/Musculoskeletal / X / if problem/risk
- Fluid/Nutrition / X / if problem/risk
- Medication / X / if problem/risk
- Infectious/Metabolic / X / if problem/risk
- Psychosocial / X / if problem/risk
- Reproductive / OB / if problem/risk
- Self-care (ADL) / X / if problem/risk
Admission History & Baseline Assessment
Document a baseline against which to evaluate changes in patient physiological, functional, developmental and behavioral health status within 24 hr. This includes pertinent medical, procedural and medication history as well as home medical equipment, therapies and duration of therapy. Initiate high risk screening as warranted/ required (influenza, sleep apnea, nutrition, abuse, pregnancy risk, lactation). Special populations require additional screening (e.g. OB, neonate, psych). Note significant conditions and devices present on admission (e.g. pressure ulcer, CVC) not already noted. Any cultural or religious considerations should be noted if relevant. Initiate individualized plan of care based on findings. This builds on the Adm Hx assessment completed in StarPanel (Exhibit [B]
Shift assessment
Assessments (including devices) shall be documented every shift AND with change in level of care. If instability or risk exists, additional assessments may be required. In addition, the nurse will document data required for approved population based decision support[C] (Braden PU Risk, Glascow Coma Scale) or data to meet current regulatory requirements[D].
Abnormal Signs & Symptoms: Patients assessed as outside expected limits or with problems (skin integrity impairment) should have supporting signs & symptoms (coccyx red, heel blister) recorded. Normal values (skin dry & intact) should not be charted as they are documented at the care category level (Skin WNL or OEL).
Focused Re-assessment
Once the initial shift assessment is done, focused reassessments are documented as warranted based on orders and/or patient condition. If the patient is stable in some or all categories (except Pain), the nurse documents ONLY that the reassessment was either Unchanged, or Unchanged except, noting only the exception. See example below:
Figure 1 - Reassessment (HED) example
etc..
Abnormal, unexpected findings or patients with significant risk of problems may merit further assessment and intervention. Interventions include monitoring, treatment as ordered and those within scope of practice, patient and family education referrals/ escalation as warranted. Findings of risk will dictate the frequency of the focused assessment.
INTERVENTION DOCUMENTATION
Interventions include four action types: (1) Monitoring, (2) Direct care, (3) Patient & family education and (4) Care Team communication.
Interventions are performed (1) as prescribed in the current plan of care, (2) according to VUMC policy if applicable, and/or (3) published nursing care standards (Mosby) within the TN Nursing Scope of Practice.
Documentation of interventions detail is not required unless it is needed to inform future care decisions such as conveying special techniques or frequency of documentation. This can be done through annotations.
Example:
§ Respiratory intervention: Tracheostomy care; ties & dsg changed
§ Neuro intervention: Seizure precautions ; room darkened, side rails padded
A list of common interventions, expected timeliness, and references are available in Appendix [E].
Intervention documentation timeliness (example)
Action / Intervention / Document / Guideline (if not prescribed)Monitoring / Vital Signs / Real-time / Mosby Skill
Direct Care / Trach care / Q Shift / Mosby Skill
Direct care / Med administration / Real-time / CL 30-06.01
Direct care / Pressure ulcer prevention / Near-time / CL 30-09.01
Direct care / Seizure precautions / Near-time / Mosby Skill
Education / Pacemaker education / Q Shift / Krames – Adult
Communication / Notify HO if temp > / Near-time / -
Monitoring & Direct Care
Monitoring and direct care will be implemented at a level and/or intensity appropriate to the patient (Peds, OB, Elderly, etc.) and follow prescribed care, VUMC Policy, or an evidence based standard (Mosby
Care team communication
Significant discussion with members of the healthcare team should be reflected in the Communication/Event Note . The note should include who was notified and why, as well as the outcome of the discussion.
SCREEN LAYOUT (ROWS & TABS)
The organization layout of the documentation screens in HED generally reflects workflows (VS , Med Admin) in the tabs across the top, and Care Categories (which change according to tab) rows in the left hand navigation panel. The Plan of Care is the landing page when documentation begins in order to review current patient status (problems, goals, outcomes).
CARE CATEGORIES (ROWS)
WORKFLOWS (TABS)
Protocol tab
The protocol tab supports complex decisions that rely on data from multiple care categories for special, at risk populations such as substance abuse withdrawl. See CIWA Appendix[F]
Documentation tabs
The organization of the documentation screens in HED generally reflects workflows (VS , Med Admin) in the tabs across the top, and Care Categories (which change according to tab) rows in the left hand navigation panel. The Plan of Care is the landing page when documentation begins in order to review current patient status (problems, goals, outcomes).
PLAN / VS/IO+ / PARTNER / ASSESS / INTERVE / ADMINRX / PAIN/CDR / TEACH / DEVICE / ALL DOC- / RISK- PAIN / APHERESIS
- NEURO / ASSIGN
- CARDIAC / DIALYSIS
- Vascular/Perfusion / ECMO/CRRT
- RESPIRATORY / POCT
- GASTROINTESTINAL / TRANSFUSE
- SAFETY/FALL RISK / ETC
- SKIN/WOUND
- URINARY/RENAL
- Activity/Musculoskeletal
- Fluid/Nutrition
- Medication
- Infectious/Metabolic
- Psychosocial
- Reproductive
- Self-care (ADL)
- PAIN
Seq / TAB – NAME / view / FULL NAME/ PURPOSE
1 / PLAN / 12h / PLAN OF CARE - Consolidated view of problems, goals, interventions, patient response to care and readiness for discharge. Also significant events and/or care team communications.
2 / VS/IO+
VS/IO_4h / 1h,
4h / VITAL SIGNS_INTAKE & OUTPUT + MONITORED DATA (DAS), PEWS, MEWS (future)
+ INTERVENTIONS?
3 / PARTNER / 4h / CARE PARTNER – One tab for all data entry by care partners
4 / ASSESS1
ASSESS4 / 1h,4h / ASSESSMENTS/PROBLEMS - Less scrolling with interventions removed
5 / INTERVENTION / 1h / INTERVENTIONS/PROCEDURES - includes complex procedure w/ significant charting that also have its own tab (ECMO, CRRT…)
6 / ADMINRX / 1h / MEDICATIONS - Medications, immunizations… Related drug teaching
7 / PAIN/CDR / 1h / PAIN + CONTROLLED DRUG RECORD
8 / TEACHEDUCATION / 24h / PATIENT EDUCATION & ENGAGEMENT
Support System (Care Contacts), language, understanding, willingness and ability to participate in therapeutic plan related to condition or procedure. Includes Discharge readiness related to knowledge deficit and non-adherence.
9 / DEVICE / 1h / COMPLEX MECHANICAL DEVICE requiring extensive documentation
Ie IABP, CRRT, DIALYSIS
9 / A/D/T / 24h / ADMISSION/DISCHARGE/TRANSFER
Establishes baseline. Contains all the elements required on admission, internal transfer, and/or discharge to home or other facility. Includes post-mortem data
10 / ALL DOC- / 12h / ALL DOCUMENTATION – Assessments, Interventions, Education, Plan
11 / RISKPROTOCOL / 1h / RISK SCORING – Infrequently done risk scoring whose many elements fall across care categories. - NAS, WATS, CIWA, PEWS, MEWS?
ALPHA / SORT
APHERESIS / 1h / APHERESIS
ASSIGN / PATIENT ASSIGNMENT
DIALYSIS / 1h / HEMODIALYSIS & PERITONEAL DIALYSIS
ECMO/CRRT / 1h / ECMO, CRRT
POCT / 4h / POINT OF CARE TESTING
TRANSFUSE / 15m / BLOOD & BLOOD PRODUCT TRANSFUSION
ETC / ETC
View is the default timescale with which to view trended data.
Patient & Family education
Patient & Family education is an ongoing process and part of our care standards. Documentation is focused on the outcomes of education, rather than the individual components of a teaching session.
reflects the the data elements noted in the table below: