provider ò B=background: date of admission, diagnosis & current condition including test results ò A=Assessment: summary of recent events/changes in condition or treatment and any anticipated changes in condition or treatment. ò R=Recommendations: state your nursing recommendations with any new treatment in the plan of care by the medical provider. Abandonment ò Termination of patient care without assuring the continuation of care at the same or higher level. ò In various medical venues (office/clinic practice; walking off the job; leaving pt without transferring pt to another nurse; refusing overtime) (6) Sexual Misconduct Controlled Substances ò Self-prescribing controlled medication for one’s own use or for family members. ò Diversion Social Media ò Facebook ò Twitter ò Texts ò E-mails Info about & from patients Telephone calls ò Office scenario ò Date and time of call ò Advice you gave ò Who you spoke with and if other caregivers notified Hospital scenario Date and time of call Provider name Client’s chief complaint Information you provided Orders received/not received ò Nurses who disagree with a provider’s order should not carry out an obviously erroneous error. Pitfalls for Staff Red Flag Complaints Documentation Documentation ò Written evidence of interaction between and among health professionals, patients, and their families; the administration of procedures, treatments, and diagnostic tests; the patient’s response to them and education of the family support unit. ò Major purpose of medical record is to document the care given to the patient. ò Nurse Practice Act states the general duty is to “record pertinent information including the response to interventions”. ò Also a legal document. Courts have issued a warning to nurses & medical personnel that the availability of accurate medical records is NOT a technicality but IS a legal requirement. ò Chart is a persuasive witness because it’s a description of the facts at the time. ò Should be no unanswered questions to the patients chart that the plaintiff attorneys can use to construct their version of what happened. ò Documentation reflects: character, competency, and the care delivered by the nurse Documentation Do’s ò Nursing procedures (procedure name; when performed; who performed; how performed; client tolerated; adverse reactions) ò Phone calls ò Health care team visits ò Don’t wait to chart ò Client refusals ò Client’s subjective data ò Medication omission ò Late entry ò Not applicable Required to document ò Sudden decline in patient’s condition, actions, outcome ò Patient injuries/medication errors ò Equipment failure/incorrect use ò Failure of provider to respond ò The “red flag” patient or family ò Client/family education/instructions Documentation Don’ts ò Complaints ò Opinions ò Altering the record ò Chart ahead ò Staffing problems ò Staff conflicts ò Leave empty lines/spaces ò Make reference to incident reports Documentation ò The following can lead to state licensing board suspending or revoking nurse license: ò Failure to document entries in patient record ò Falsification of patient record ò Making incorrect entries ò Each health care provider is responsible for the ABC’s of recording: Accuracy, brief, complete Documentation ò The old adage, “If it wasn’t charted it wasn’t done….” is clarified in CBE (charting by exception) as “If interventions, expected outcomes, and patient responses weren't charted using symbols to reflect predefined norms-and variances weren't charted in detail-then it wasn’t done.” ò CBE is a shorthand of documenting normal findings, based on clearly defined normal, standards of practice, and predetermined criteria for assessments and interventions. Significant findings or exceptions to the predefined norms are documented in detail. ò Computerized charting: Protect password security & don’t forget to log off Common Charting mistakes ò Failing to record pertinent health or drug info ò Failing to record nursing actions ò Failing to record that medications have been given ò Recording on the wrong