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Documentation Self Study
Please read and complete the following Documentation Self-Study packet. These materials areto be used as a refresher not to address all documentation issues, but to address issues commonlyfaced while evaluating staff documentation. As always please feel free to contact the EducationDepartment during normal business hours with any questions or concerns. Thank you forsubmitting all education materials timely. Please submit the feedback exercise one week fromtoday by next Monday’s payday. Keep the literature for your reference or to refer back to at alate date. Thank you.
Community Care Nursing Services, Inc.
Topics Discussed:General Information: LPN and RNGeneral Information: CNATime SheetsNursing DocumentationTranscribing Orders
1. General Information: LPN and RN
As a skilled nurse you have contracted with Community Care Nursing Services to
provide nursing services according the Scope of Work for Nursing.
You are required to use the Plan of Care, the Medication Record and the Treatment
Record to direct your nursing activities.
Also, you are required to document the nursing activities every two hours noting
assessments, interventions, and outcomes. Another way of describing your activities is:document what you see, document what you did and document what was the end result.
Your documentation of nursing activities ensures you are carrying out the Plan of Care.
Thus, IF it is NOT documented it was not done.
If you do not document at least EVERY TWO HOURS you are not following the rules
and regulations of Community Care Nursing Services.
Incomplete documentation can be seen as poor nursing care that puts the client at risk for
poor outcomes and the nurse at risk for termination of services.
Your documentation must be legible and written in black ink. Documentation that cannot
be read is considered improper documentation and can lead to remediation (re-training),suspension and termination, as you are not performing according to Community CareNursing Service standards of nursing care.
Medication Administration records are due in the office at the beginning of the new
month. If your MAR records are not delivered within 5 days of the new month you are atrisk for failing to perform according to Community Care Nursing Service policy. Theprimary nurse is responsible for the delivery of the “outdated” MAR. If there is no oneprimary nurse, please discuss among the team of nurses that work with the client whowill deliver the MAR to the office. The Nurse Supervisor will be notified of who will bedelivering the “outdated” MAR to the office. 2. General Information: CNA
Each shift you work you must document care on an Aide Service Sheet with all the
activities that you performed that coincide with the Nurse Assistant Service Plan. The activities on your Service Plan are obtained from the 485 Heath Certification and Plan of Care.
If there are any changes in your Client’s status please contact you Nurse Supervisor and
write in the name, date and time in the space provided on the Aide Service Sheet.
If your client is written for a treatment of Vital Signs the vital signs you are required to
obtain are the Temperature, Pulse, Respiration and Blood Pressure. 3. Time Sheets:
Fill out all sections legibly and with black ink. If your name is not legible on the
Employee Name line your check can be delayed. If you do not fill in each entry asrequested your check could be delayed. Date should be filled out: month/day/year in this format 00/00/00 Start and Finish Time: am or pm must be written on time sheet Hours Worked must be filled in daily Client’s Initials must be filled in daily Total Hours must be added and documented in the appropriate place. Your Signature and the Authorized Client Signature must be entered. 4. Nursing Documentation:
Physical Assessments are required each shift. The areas that require the most thorough
assessment are those areas requiring the most care. Usually your client is on somebreathing assistance and nutritional feeding.
If your client is written for a treatment of Vital Signs the vital signs you are required to
obtain are the Temperature, Pulse, Respirations and Blood Pressure.
When charting please include what you did, what you saw, and what the outcome was.
Example: 2:00 pm Diaper change. Small loose brown stool.
After each entry if there is extra space, place a line to the end of the page and write your
If you need to make additions to a particular note DO NOT change anything you already
wrote. Instead add another note as follows:
2:10 pm Addendum: 2:00 pm diaper changed also with moderate urine. Peri-care given.
If your client has an Insulin Order, transcribe the order and transcribe the Insulin Sliding
Scale below the insulin order on the MAR. If your client is on a sliding scale for insulinlist the blood glucose number obtained on the MAR order at the time taken line and listthe amount of insulin given on the line below it.
Example: Insulin Administration after Blood Sugar taken
6. Transcribing Orders: When transcribing orders be sure to use the following format:
Example: Reglan syrup, (1mg/1ml) give 1ml (1mg) daily per g tube.
Verbal Orders must be written on a blank medication sheet. The order should begin with
‘VO MD________________________” Date and time the entry. Transcribe the order astold to you by the medical practitioner. Read the order back to the medical practitionerfor clarification. Sign your name at the end of the order.
The verbal order should be sent to the office within 7 days after the order was taken. An
even safer way to ensure the verbal order is received at the office in a timely manner is tocall the in the order to the office and mail or deliver the verbal order you received within7 days.
When your client has a medical appointment bring medical order sheets with you (or
have the parent bring the order sheets with them if you are not attending the visit.) IF themedical provider does prescribe new orders please get the doctor to write the orders on aCommunity Care Nursing Service Order sheet. Transcribe the orders on the MAR andsend the new orders to the office.
Please mark all medications and treatments with a P when the parent gives the meds or
treatment. In the bottom left section of the MAR place a P for the initial and write Parent for the signature.
When your client is in the hospital, please mark all medications and treatments on the
MAR with the letter H. In the bottom left section of the MAR place an H for the initial and write Hospital for the signature.
Notify Community Care Nursing Service that your client is in the hospital.
When you client returns from the hospital, please alert the office that the client is back
home. Transcribe any discharge orders and send the orders to the office.
CNAs cannot take a verbal order or transcribe physicians orders.
**RNs, LPNs, and CNAs--- Please take blank physician’s order sheets on all MD visits
so new orders can be obtained at the time of the visit.**
Documentation Self Study Feedback Exercise
a. Remediation (retraining)b. Terminationc. Poor patient outcomesd. All the above
2. If the plan of care has an order for vital signs for every shift and there are two shift, who
a. The day nurse or aideb. The night nurse or aidec. Both the day and night nurse or aided. The family
3. It is important for nurses and aides to complete their notes during the shift and leave them
in the chart in the home for the next shift or family to read because it:
a. May be interestingb. Gives a report of your assessments, care and interventionsc. Help the nurse or family member figure out what to write in her notes
4. When completing your time sheet it is important to know that if your shift is for 8 hours
and you arrive 15 minutes late you should stay 15 minutes later so you patient can receivecare as it was ordered. However, if you arrive 15 minutes late (at 7:15am) and leave at the regular time (3:00pm)your time sheet should read:
5. You should compare the Plan of Care (physicians order) to the Medication
Administration Record (MAR) during each shift to ensure that all ordered medicationsand treatments are transcribed. Call the office if discrepancies are found. Accurate Plansof Care and Medication Administration Records are vital to ensure medically fragilepatients receive care as ordered by a physician. A home care nurse who receives a verbalorder you should:
a. Transcribe the order on the MARb. Write V.O. MD, the physician’s name, and also sign your name and date itc. Write the medication name, dose, strength, route, formulation, concentration, and
d. Forward it to the office as soon as possible within 7 days. e. All the above
6. Nurses notes must be written legibly. A note that cannot be read is useless. It cannot
help the medical team diagnose, prescribe, make predictions, etc. To help your patientand protect your nursing status, nurses notes must:
a. Contain entries at least every two hoursb. Be written legibly in black inkc. Be submitted to the office weekly for paymentd. Start at the beginning of the shift not one or two hours latere. All the above
7. Medication Administration Records play a vital role in the creation and evaluation of the
Plan of Care (physician’s orders). Medication Administration records are due in theoffice:
a. Whenever it is convenient to get them inb. Immediately at the beginning of the next monthc. When the day nurse decides to mail themd. When you have a chance to take them in
8. An order for Vital Signs can be found on the Plan of Care (485)in the section named:
a. Medicationsb. Safety Measuresc. Orders for Discipline and Treatmentd. DME and Supplies
Please feel free to ask Ms. Diane Tomain, RN, MSN Director of Quality Improvement andEducation questions pertaining to documentation.
Neuropsychopharmacology (2006), 1–10& 2006 Nature Publishing GroupTime Course of the Antipsychotic Effect and the UnderlyingBehavioral Mechanisms MingLi1,5, PaulJ Fletcher2,3 and Shitij Kapur*,1,4Schizophrenia-PET program, Centre for Addiction and Mental Health, Toronto, ON, Canada; 2Biopsychology Section, Centre for Addiction andMental Health, Toronto, ON, Canada; 3Department of
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