NURSING DOCUMENTATION

 

TERMINAL LEARNING OBJECTIVE  Identify the procedures for proper nursing documentation

INTRODUCTION  Accurate documentation of patient symptoms and observations is critical to proper treatment and recovery.  Entries written on a patient's medical record are a written, legal, permanent document.  If documentation is poorly or inaccurately entered into a medical record, patient may receive improper or potentially harmful care.  What you document as fact in a medical record, is directly used by physicians, nurses, and physician assistants to plan, implement, and evaluate their patient's course of treatment.

 

Medical Record Purposes and Confidentiality

a.   Purposes

 

   (1)  Primary - Insures that AMEDD personnel have a concise and complete medical history l

 

   (2)  Assists AMEDD officers in advising commanders on personnel use and retention

 

   (3)  Appraises Army-wide physical fitness and readiness

 

   (4)  Communication - a means of communicating and sharing information on the patient's status throughout the hospitalization with health care team members

 

   (5)  Legal documentation - a legal document and admissible in court as evidence

 

   (6)  Patient care planning - each professional working with the patient has access to the patient's baseline and ongoing data.  Patient responds to the treatment plan from day-to-day is documented.  Modifications of the plan of care are then based on this data.

 

   (7)  Audit - patient records may be reviewed to evaluate the quality of care received and to improve the quality of care as indicated

 

   (8)  Research - patient records may be studied by researchers to learn how best to recognize or treat health problems

 

   (9)  Education - clinical manifestations of particular health problems, effective treatment methods, and factors affecting client goal achievement are documented

 

(10) Historic document - past information may be pertinent concerning a patient's healthcare

 

(11) Reimbursement record - insurance companies, Medicare, and Medicaid require written record of treatments, equipment, and diagnostic procedures before they pay the agency

  

b.   Confidentiality of medical information

 

   (1)  Medical confidentiality of all patients will be protected as fully as possible.

 

   (2)  Access given to

 

      (a) The patient

 

      (b) Patient care personnel

 

      (c) Medical researchers

 

      (d) Medical educators

 

CAUTION:  DO NOT discuss patient information within hearing range of the patient or with unauthorized personnel.

 

   (3)  Personnel not involved in a patient's care or in medical research will not have access to patient information unless the following situations apply

 

      (a) Access required by law (court order)

 

      (b) Access needed for hospital accreditation

 

      (c) Access authorized by patient

 

WARNING:  Unauthorized disclosure of medical information is grounds for Uniform Code of Military Justice (UCMJ) action against the informant.

 

   (4)  Disclosure of medical information

 

      (a) All requests done in writing except in emergency situations

 

      (b) Handled by patient administrator

 

      (c) Not provided by the 91W

 

Medical Record Documentation Procedures

 

a.   Required procedures for making entries

 

   (1)  Legibly typed or handwritten

 

   (2)  In black or blue black ink

 

   (3)  Signed by the individual who made the entry

 

      (a) Military personnel - Sign with full payroll signature, rank, MOS, branch of service

 

      (b) Civilians - Sign with full payroll signature, title, GS (pay grade)

 

   (4)  Date in day-month-year sequence

 

   (5)  Capitalized at the beginning

 

   (6)  Written with present or past tense verbs

 

   (7)  Recorded ASAP

 

   (8)  Abbreviated IAW AR 40-60 - Only use authorized abbreviations

 

   (9)  Must be clear, concise, and objective

 

(10) Include patient identification on patient identification block.  Use addressograph or write information legibly.

 

      (a) Name

      (b) Rank

 

      (c) Social security number

 

      (d) Ward/clinic

 

      (e) Admission date/date of visit

 

      (f)  Hospital register number (inpatient only)

b.   Correction procedures for an entry error

 

   (1)  DO

 

      (a) Draw a single line through information

 

      (b) Write your initials above the line

 

   (2)  DO NOT

 

      (a) Erase or use correction fluid

 

      (b) Skip lines

 

      (c) Write between lines

 

      (d) Chart for someone else

 

      (e) Leave blank lines above signature

 

c.   Information needed on the DD Form 689 (individual sick slip)

 

   (1)  MTF personnel are responsible for making sure DD Form 689 blocks 1 through 9 are correctly filled out by a soldier prior to being evaluated by a screener

 

   (2)  MTF personnel may fill out a sick slip for a soldier if he is unable to due injury, illness, or reporting directly to the MTF in the event of an emergency

 

   (3)  All military forms will be filled out in black ink

 

   (4)  Block 1 - box checked by individual that best fits remarks section (block 8)

 

      (a) Illness--acute or chronic, (e.g. common cold symptoms, athletes foot, nausea, vomiting, etc.)

 

      (b) Injury--acute (e.g. direct/indirect trauma within 24 to 48 hours)

 

   (5)  Block 2 - date

 

   (6)  Block 3 - name (e.g. complete last, first, middle initial, Doe, Johnny E.)

 

   (7)  Block 4 - service number. SSN (e.g. complete 9 digits, 000-11-0000)

 

   (8)  Block 5 - grade/rank (e.g. pay grade, E-1, etc.)

 

   (9)  Block 6 - organization and Station (e.g. C Co. 232D Medical Battalion, Ft. Sam Houston, TX 78234)

 

NOTE:     If soldier is on training status, command may require soldier to indicate what platoon and/or squad for accountability purposes.

 

(10) Block 7 - in line of duty (e.g. yes/no depending on circumstances)

 

      (a) Company or unit commander ONLY fills out this block when injury occurs

 

      (b) Often left blank unless negligence is suspected (e.g. soldier was intoxicated at time of injury, or was not at his/her appointed place of duty at time of injury etc.)

 

(11) Block 8 - remarks (e.g. sore throat and cough x4 days; right ankle pain, difficulty walking due to injury x24 hrs.)

 

      (a) Filled out by individual

 

      (b) Includes chief complaint (c/o). (e.g. sore throat; right ankle pain)

 

      (c) How long?  problem(s) have existed or when injury occurred. (e.g. x4 days; x24 Hrs)

 

NOTE:  Soldier may not have medical knowledge, therefore, confirm injury or illness with individual before being screened.

 

(12) Block 9 - signature of unit commander

 

      (a) First line supervisor or person who is in charge of quarters (CQ) may sign for unit commander (per unit SOP)

 

      (b) Individual signing the sick call slip must be in individual's immediate chain of command

 

NOTE:  Blocks 10 through 13 are to be filled out by MTF personnel ONLY.

 

(13) Block 10 - in line of duty (e.g. yes/no or left blank)

 

NOTE:     Screening physician may agree with commander or come up with own conclusion based on examination.

 

(14) Block 11 - disposition of patient.

 

(15) Block 12 - remarks (e.g. Quarters x24 Hrs, return in A.M. for follow up or Profiling e.g. no running or marching x 5 days)

 

      (a) Remarks reflect box checked in block 11

 

      (b) Also indicates

 

         1)  Soldier's arrival time at MTF

 

         2)  Soldier's disposition

 

         3)  Time of release back to unit

 

(16) Block 13--signature of medical officer ONLY

 

(17) Disposition of DD Form 689

 

      (a) DD Form 689 is returned to individual after medical evaluation has been completed

      (b) Soldier returns original sick slip to first line supervisor or per unit SOP

 

      (c) Soldier keeps copy of sick slip if quarters or profile given

 

 

Perform a Patient History

   a.      Medical history - Gives you an idea of the patientís problem before you start physical exam

 

   (1)  Chief complaint

 

      (a) This is the reason for the patients visit

 

      (b) Use direct quotes from patient

 

     (c) Avoid diagnostic terms

 

   (2)  Observation - begins as soon as the patient walks through the door

 

   (3)  Listening - listen carefully. This will help you get an accurate diagnosis of the problem

 

   (4)  Open ended questions - help you to get more complete and accurate information

 

   (5)  Provider obstacles - your attitude or predetermination may prevent you from making an accurate judgment

 

   (6)  Patient obstacles - the patient has many obstacles to overcome. Patients must have confidence in you

 

b.   History of present illness/injury (HPI)

 

   (1)  Duration - when the illness/injury started

 

   (2)  Character - use the patientís words to note character of pain

 

   (3)  Location - have the patient explain, then have them point it out

 

   (4)  Exacerbation or remission - what makes it better or worse and is it constant or does it vary in intensity

 

   (5)  Positional pain - does the pain vary with the change of the patientís position.

 

   (6)  Medications/allergies - note any medications whether over the counter or not. Do the medications relate to the problem? Take note of the patientís allergies. Do not rely on the patientís health record or SF 600.

 

   (7)  Pertinent facts - facts that lead you to your diagnosis. Usually consist of classical signs and/or symptoms.

 

c.   Another method to take a medical history is by using the key phrase "SAMPLE PQRST"

 

     S - Symptoms

 

     A - Allergies

 

     M - Medicine taken

     P - Past history of similar events

 

     L - Last meal

 

     E - Events leading up to illness or injury

 

     P - Provocation/Position - what brought symptoms on, where is pain located

 

     Q - Quality - sharp, dull, crushing etc.

 

     R - Radiation - does pain travel

 

     S - Severity/Symptoms Associated with - on scale of 1 to 10, what other symptoms occur

 

     T - Timing/Triggers - occasional, constant, intermittent, only when I do this (Activities, food)

 

EXAMPLE:  S) 21 y/o male c/o sore throat. No known allergies. Taking no meds.  Has approx. (2) Sore throats per year.  Eating and drinking normally.  Was fine until yesterday morning when woke up with sore throat.  Denies fevers, chills, sweats, shortness of breath, & headache.

 

d.   Past History (PH)

 

   (1)  Medical history

  

   (2)  Surgical history

 

e.   Social History (SH)

 

   (1)  Drugs, recreational

 

   (2)  Alcohol

 

   (3)  Tobacco

 

   (4)  Over the counter medications

 

Medical Record Documentation

a. SOAP documentation

 

b.   SOAP acronym and descriptions

 

   (1)  S - Subjective Data

 

      (a) What the patient tells you about his problem

 

      (b) Usually expressed in the patientís own words.  For example,  "My throat hurtsď, or  "I am in pain from my broken leg.ď  Patient may have many complaints.

 

      (c) Important to record exactly what the patient states is the problem

 

   (2)  O - Objective Data

 

      (a) Observations made by the 91W that support or are related to the subjective data

      (b) Record what you observe about the patient.  For example, the patient in pain may speak with a loud, agitated voice, or his facial expressions (grimace) might indicate pain.  He may be guarding the painful area.  Or he may be very quiet and not moving much which would aggravate the pain.  Vital signs may indicate increased pain such as pulse is elevated or blood pressure is elevated.

 

      (c) Important to record all observations made of the patient to include any physical finding

 

      (d) Physical examination findings are recorded here

 

   (3)  A - Assessment

 

      (a) This is your interpretation of the patientís problem/condition 

 

      (b) Subjective and objective data is carefully analyzed to reach conclusions regarding the patientís complaint or problem

 

   (4)  P - Plan

 

      (a) The plan for dealing with the problem/compliant or situation is recorded here

 

      (b) This may include comfort measures, pharmacological interventions, notifying the physician, patient education, etc.

 

      (c) Your plan should be concise and should reflect all the information gathered to this point

 

Medical Record Forms

 

a.   SF 600 - Chronological record of medical care

 

b.   SF 558 - Used instead of SF 600 in emergency rooms

 

Screen Immunization Records for accuracy and completeness

 

a.   Screen immunization records

 

   (1)  Validate identification of soldier

 

   (2)  Ensure all immunizations are current on PHS 731 (Shot Record)

 

      (a) Refer to medical record if shot record is not available

 

      (b) Inquire regarding allergic reactions

 

      (c) Check for Medical Warning Tags

 

      (d) Refer to immunization site if immunizations are required

 

   (3)  Return immunization record to soldier

 

   (4)  Secure medical record

 

b.   Immunization administration

   (1)  Persons who administer vaccinations must be trained in:

 

      (a) Management of anaphylaxis

 

      (b) Immunization procedures

 

      (c) Proper use and maintenance of equipment

 

      (d) Indications and contraindications for each vaccine

 

      (e) Storage requirements

 

      (f)  Management and reporting of adverse reactions

 

      (g) Immunization record maintenance

 

   (2)  Patients who report to immunizations should be

 

      (a) Screened for chronic/acute illness

 

      (b) Screened for pregnancy

 

      (c) Screened for medications that might interact with immunizations

 

      (d) Screened for allergies

 

      (e) Offer Tylenol to minimize local and systemic shot reactions

 

      (f)  Observed for at least 20 minutes after administration for symptoms of anaphylaxis

 

Introduction to Composite Health Care System (CHCS)

 

a.   The Composite Health Care System (CHCS) provides worldwide automated medical information system support to all MTFs in providing comprehensive, high quality health care to uniformed service personnel, retirees and dependents

 

b.   Functions performed by CHCS

 

   (1)  CHCS serves more than 9 million beneficiaries of the U.S. military health care worldwide

 

   (2)  CHCS is installed in more than 700 DoD hospitals and clinics providing health care to the men and women of the armed services and their dependents, veterans, and the retired military community

 

   (3)  CHCS

 

      (a) Shorter waits for patients

 

      (b) Faster reporting of diagnostic test results

 

      (c) Improved use of the medical and professional resources

 

      (d) Significant improvements in the quality of patient care

 

   (4)  CHCS functions

 

      (a) Patient registration, admission, disposition, and transfer

 

      (b) Inpatient and outpatient activity documentation

 

      (c) Appointment scheduling

 

      (d) Laboratory, radiology, pharmacy services

 

c.   Benefits to medical professionals

 

(1)   CHCS saves staff time

 

   (2)  CHCS offers medical professionals

 

      (a) Immediate notification of test results

 

      (b) Reduced paperwork

 

      (c) Easy access to complete patient care information and administrative data

 

      (d) Improved documentation and accountability for patientsí medication orders

 

d.   Benefits to patients

 

   (1)  On the patient level, CHCS increases quality of care by providing complete, accurate, and secure information about patients and their care

 

   (2)  CHCS means

 

      (a) Authorized users can immediately access medical records, thus facilitating appropriate patient care

 

      (b) Improved access to health care services due to better scheduling and resource utilization

 

      (c) Fewer repeated tests and examinations thanks to improved reporting and data management

 

SUMMARY  The medical record is a legal document. Through accurate documentation the record serves as a description of exactly what happened.  The purpose of the documentation is to provide information for communcation, education, assessment, research and legal accountability. "Care not documented is care not done."