Chapter 10 Study Guide:

Communication and patient care:

Absent inaccurate or delayed communication can subject the patient to serious risks or delayed
recovery.

Effective, ongoing communication among the healthcare team assures that patients receive
care that is timely, safe and responsive.

The Joint Commission identified critical communication failure as one of the most common root
causes responsible for sentinel (unanticipated events that results in death) events.

Documentation- handwritten, typed, or electronic communications.

Reporting- verbal communication when 2 or more people share information about patient care.
(ex: change of shift report, handoff, etc)

Patient health record:

The purpose of patient health or medical records is communication.

Contains info about reason for seeking care, medical diagnosis, medical and surgical hx, meds,
demographics, family hx, lifestyles habits (smoking, ETOH use, exercise)

Communication must be clear, accurate and up to date, patient documentation is a cornerstone

for safe care delivery providing flow of information between providers of care.

Patient records communicates the plan of care and patient progress to all healthcare team
members and conveys clear picture of patient through different viewpoints and at different
times. Patient records ensures continuity of care and provides data for evaluation and revision
or continuation of care.

*What is written and spoken about in patient care should be confidential and should reflect
consideration for each basic human dignity.

Purpose of the health record:

Assessment
o Allows comparison of objective and subjective assessment data gathered by all
team members to determine current health status and progress toward goals.
Care planning
o Availability of all assessment data allows nurses to more accurately develop
nursing diagnoses, patient goals, outcome criteria, interventions, and evaluation
criteria for the patient plan of care.
o Data collection allows for the development of a personalizes plan of care.
 o The care plan becomes a permanent part of the patient record.
Legal document
o Can be used in court to prove or disprove injuries a patient incurred
unintentionally or to implicate or absolve a healthcare professional with regard
to improper care.
o Because of this, accurate and complete documentation is crucial in patient
record.
o Legal cases have been argued with the principle that “if it was not documented it
was not done.”
Quality assurance
o Medical record audits can be performed to determine whether certain standards
of care were met and documented and often lead to changes in care provision.
o Ongoing quality assurance programs that include audits of patient records are a
part of accreditation requirements.
o This is better known as chart audits = review of records
Examples:
Did a pneumonia patient receive their antibiotic within a predetermined time frame per
protocol?

Was a heart failure teaching performed @ time of patient discharge?

Reimbursement
o Provides the basis for decisions regarding care and subsequent reimbursement
to the agency.
o Federal, state, and private payers usually require specific criteria to be met to
cover specific health-related expenses, including diagnostic-related group (DRG)
classification and appropriate related interventions.
o Electronic Health Record (EHR) provides a means to collect, store and share
patient date electronically so that it may be analyzed and used to improve
outcomes.
o To try to improve safety CMS stopped reimbursement for HACs (they were
deemed preventable through evidence-based guidelines).
Research
o Nursing and healthcare research is often carried out using patient records.
Accurate documentation helps assure that research outcomes are valid and
reliable.
o When obtaining info, strict guidelines must be followed to. Protect the privacy
and rights of patients.
Education
o Contains valuable educational information that allows students to relate patient
signs and symptoms, interventions, and outcomes.
o Helps to link info about patient condition together. (Ex: medical hx, labs, dx,
meds, treatments)
Principles of documentation and how should it be:
Documentation should be always:

Confidential
o Keeping information private is a legal and an ethical requirement.
o Applies to written and computerized medical records and any other information
pertaining to the patient’s health status or care.
o The Health Insurance Portability and Accountability Act (HIPAA) regulates all
areas of information management, including security of records.
o Students must de-identify any patient information in written assignments to be
HIPAA compliant.

Nurse should never discuss patient with or without names and their situations in public places,
such as elevators, hallways, or the cafeteria.

*Never share passwords and never leave computer with patient info unattended.
*Patient info should not be share in social media.

Accurate
o Nursing documentation should only contain observations that nurses have seen,
heard, smelled, or felt. Observations or statements by other healthcare
professionals need to be identified as such.
o All information that was charted remains in the patient record; erasure is not
permissible.
o Proofreading should be done to assure correct spelling and correct use of
medical terms.

*Always make sure that the name of the providers or other health professionals are spelled
correctly.
*When info is charted in error, it must be corrected if it is written or electronically documented.

Concise and complete

o Partial sentences and phrases should be used in narratives.
o The patient’s name and terms referring to the patient can be eliminated in
narrative charting.
o Only abbreviations that are commonly accepted and approved by the institution
should be used.
o Use checklist if appropriate.
o Use abbreviations as often as possible.
Objective
 o Using direct quotes of patient statements can help maintain objectivity,
especially when documenting psychosocial and mental health issues.
o Actual patient behavior should be described rather than making interpretations.
o Never use assumptions and be as objective as possible.
Organized and timely
o Information should be documented chronologically and include patient response
to interventions.
o Timely documentation decreases the chance of forgetting important
information.
o All medications and procedures should be documented upon completion and
never before.
o Out of sequence entries can cause confusion.
o DON’T DELAY CHARTING UNTIL LATER IN THE DAY

*Point of care (POC): documentation takes place as it occurs

*Waiting until the end of the day to chart is known as “batch” charting and may cause a nurse
to omit important data or enter inaccurate information.
*Each entry must clearly show a logical and systematic. Grouping of important information by
problem occurrence.

Universal Computer-Based Patient Record:

Federally initiated goal of having a single health-related electronic record for all individuals.

*This also allows for individuals to get medical info, find providers, make appts and
communicate with health care providers.

Would allow patients to share their complete health information with any practitioner,
regardless of institutional affiliation or location.

Supported by the 2009 Health Information Technology for Economic and Clinical Health
(HITECH) Act whose goal it is to increase patients’ access to their own medical records.

The use of EHR allows healthcare practitioners withing large and geographically dispersed
healthcare organizations to have uniform access to a single patient record, allowing greater
accuracy and improved care.

Clinical surveillance tools

o Automated surveillance tools that scan electronic health record data and
produce a real-time patient’s risk score for designated high-risk conditions.
o Scan data in real time in the patients’ health record to look for potential
problems (ex. sepsis)
Handheld devices
 o Smartphone and tablets allow bedside access to such supports as drug
information, assessment tools, conversion tables, immunization guidelines,
language translation, and access to evidence to support clinical decisions.
o Some allow for point of care documentation (POC).

Standardized vocabulary
o Important for use in the electronic health record, as consistency of terminology
makes retrieval of individual and aggregate data possible.
o Everyone “speaking the same language” when it comes to medicine and nursing.

Types of nursing entries:

1. Kardex
o Patient care summary.
o Demographics
o Code status
o Safety precautions
o Basic care needs
o Treatment and procedures
o IV therapy and blood transfusion
o Diagnostic and laboratory test

2. Admission Entries
o Nutrition
o Activity
o Sleep
o The patient medical history and the history relating to the reason for seeking
current care.

3. Narrative notes
o Timely may be repetitive.
o Is a method for recording relevant patient and nursing activities through a shift
or during a single visit.
o Documentation should occur immediately after the assessment or activities are
completed throughout the day.

4. Charting by Exception
o ONLY document findings that fall of standard of care and norms that have been
identify by the institution.
o CBE requires less time.

5. Progress Notes
 o Summarizes

6. SOAP and SOAPIER notes

o Relates to only one health problem.
o This format is used by all team members.
S: Subjective O: Objective A: Assessment P: Plan / I: Intervention E: Evaluation R: Revision

7. PIE and APIE notes

o Simplifies documentation by incorporating the plan of care into the progress
note.
o To designate new problems or abnormal assessment “A” this allows the nurse to
provide pertinent assessment data in the documentation.
o Documentation is enter for each nursing diagnosis during every shift, using
acronym “PIE” to structure their information according to:
P: Problem I: Intervention E: Evaluation / A: Assessment or abnormal assessment

8. FOCUS DAR notes

o Can be more broad and does not have to focus on a nursing dx.
o Entry on significant event, positive growth, or learning that occurs during
teaching session.
o Patient documentation can be focus on the patient strengths as well as problem
areas.
o Patient response to therapy can be also discuss in the response section.
D: Data A: Action R: Response

Types of nursing entries #2:

Flow sheets: Tables with vertical and horizontal columns allowing for documentation of routine
assessments and procedures.
Plan of care: Contains nursing diagnoses, goals, outcome criteria, interventions, and evaluation.
Standardized plans of care may be used, but must always be individualized.
o Generated on admission and is updated accordingly

Clinical pathways: Multidisciplinary tools that identify expected progression of patients toward
discharge. Often used for patients requiring complex care or for frequently encountered
situations.
o Based on scientific knowledge about best practice.
o Used on patients to guide care that generally have predictable outcomes.
o Provides a concise means for all members of healthcare team to view the patient
continuing needs and progress towards discharge.

Types of nursing entries #3:

Written Handoff Summary

o Transfer of care of the patient from one healthcare provider to the other.
o Occurs @ shift change and transfer between different care units at the hospital, or when
pt transferred to a different facility.
Nursing Discharge Summary
o Provides specific info about care after discharge.
Medication Administration Record (MAR)
o Document administration of meds promptly.
o This includes schedule and PRN meds.
o PRN meds requires a f/u with effectiveness.
Home Care Documentation
o (OASIS) Outcome and Assessment Information Set
o The OASIS tool accurately measures the patient’s status at various specified points
during an episode of care, thus providing the basis for measuring patient outcomes.
o OASIS data items include sociodemographic data, environmental information, support
system, health status, and functional status of all adult home care patient.
Long-Term Care Documentation
o (RAI) Resident Assessment Instrument
o The RAI tr acks goal achievement among long term care residents by:
A. Minimum data set
B. Triggers
C. Resident assessment protocols
D. Utilization management
The goal of the RAI is to coordinate the efforts of all members of the healthcare team to
optimize the resident’s quality of care and quality of life.

Incident Report
o Unusual happening: fall, medication error, malfunction in equipment or injury to a pt,
visitor or employee, that occurs during the performance of the healthcare activities.
(Includes patient response to full nursing assessment)
o DO NOT attach incident report in the patient chart, this should be used to evaluate
quality of care.
o Provider should be notified, even for additional orders and assessment.

Template for communication

SBAR
o Situation: What is happening at the present time?
o Background: What are the circumstances leading up to this situation?
o Assessment: What is the problem?
o Recommendations: What should be done to correct the problem?

Reporting to the Primary Healthcare Provider/Healthcare Team

Telephone communication
o Always document that call was made and CPOE for orders received.
Verbal Orders
o Should ONLY be given and taken in an emergency situation.
Consults
o For specialist based in nursing assessment a consult might be order.
Rounding
o Hourly rounding
o Repositioning
o Toileting
o Comfortable
o Any specific request?
o Scan room before leaving call light, personal belongings with reach.
Care Plan Conferences
o Used a lot in rehab.
o RN, PT, and social services
o Patient who benefits most have multiple complex problems.