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Documentation vs patient cares
Nursingmatters Newspaper,
September 2008
Working in an acute Behavioral Health
and Addiction setting has many
challenges. As nurses we're stretched to get our meds out on time,
make contact with our patients, provide the 1:1 time needed, and
hold therapeutic groups. We worry about maintaining safety,
preventing outbursts and having the time to de-escalate a situation
versus utilizing chemical restraint. We dread the thought of a fall
or having to place someone in mechanical restraints. The medical
acuity of our patients has increased over the years. We have IV's,
foley's, wound care and PIC lines. We have more geriatric patients
than ever before. Our patients' suicide attempts are more severe and
the consumption of alcohol and overdose is at an all time high. We
make every attempt to meet the needs of our patients but what do we
do when we're pressed for time and documentation is also a priority?
If documentation is not done, how will the psychiatrists and
physicians know what was effective? They utilize what we have
recorded to help plan their next course of treatment. We often find
ourselves in a dilemma of not having the time to register the
measures we've taken for periods of anxiety, agitation, increased
hallucinations, detox and withdrawal symptoms. Those periods of
documentation are generally reserved for the patient that we weren't
able to de-escalate or stabilize medically.
Joint Commission
requires us to document why we administered a prn. They want to know
what non-pharmacologic interventions we've attempted and what our
next steps were. They want to see what medications were given and
were they effective. I've seen more often than not, that although
one attempts to be diligent in documenting, for whatever the reason,
the reassessment is left out.
In dealing with
these challenges on a day to day basis, I took the opportunity to
develop a unit specific flowsheet for the Behavioral Health and
Addictions setting. By utilizing this form, the nurses now have
easier access to document the initial behavior, non-pharmacologic
interventions, medication provided and the effectiveness of all
therapies used at the time of application. No longer does the
psychiatrist or physician need to hunt through the progress notes to
see which prn medication was administered and determine if it was
effective.
The purpose of this flowsheet is to have a more
consistent way of documenting assessment and
reassessment of symptom levels using our universal 0/10 scale. On
this form one is able to chart initial assessment levels, the
non-pharmacologic interventions exercised and the effectiveness of
both or either, all on the same line.
By implementing
this form, nursing, medical and utilization review are able to track
the effectiveness of our prn medications as well as the alternative
interventions used in a more cost effective and well-organized
approach. Medical is able to, at a glance, assess whether the prn
medications prescribed are effective and to what degree, in treating
each individual. Because the psychiatrists and physicians are more
informed, they are better equipped to make the needed adjustments in
medication management for each individual. This can ultimately
result in improved medication compliance for the patient.
Joint Commission
is able to clearly and quickly ascertain that the documentation of
assessment and re-assessment is being done in a consistent and
efficient manner.
There is no
further need to chart prn's administered in the progress notes. This
type of charting is not only redundant but time consuming, pulling
the nurse away from time that could have been spent doing patient
cares. Now, the only time a progress note would be warranted for a
prn medication, would be that of "exception". For example, something
that would obligate further explanation such as the administration
of an IM injection and the behaviors leading up to this that could
not be explained in your comment box.
Behaviors most
frequently employed on this form are anxiety, agitation,
hallucinations and delusions. The "other" section is for additional
prn's administered for things such as insomnia, nausea, elevated
detox scores, etc. Non-Pharmacologic interventions are also
documented on this flowsheet as well as the date, time and initials
of each nurse completing the assessment and re-assessment. The
entire documented entry is completed on one line.
Shift to shift documentation for reassessments is no longer an
issue. The flowsheet is kept in the medication administration
record, and due to the easy read, each new shift coming on can easily
see when reassessment is due.
Not only has
implementing this form proven to be a productive way in
documentation, but there is also improved compliance with Joint
Commission regarding reassessments. Nursing is able to be utilized
more efficiently, and as a result it has the magnitude of placing
one's institution in a status for improved financial capacity.
Cynthia Kadziulis RN, BC, ALNC, CLNC |
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