As much as physicists like equations, nurses dislike documentation. It is often a thorn in their side and frequently perceived as time taken away from the actual job of “nursing,” giving care to the patient. But it is also recognized as required by law and necessary for optimal care. Nursing combines giving care with making assessments and recording both.
We have, over many years, developed our home-care documentation to be user-friendly and require minimal charting time, thus decreasing time taken away from caring for the patient. Some documents have taken the form of checklists requiring only initialing the completed actions for medication administration and treatments. Our assessment sheet, which is organized by systems and is a one-page, two-sided document, provides for merely checking-off or circling most assessment criteria. Minimal writing is necessary – but space is also available when needed.
Our forms have worked well in our practice. Whether used for nursing professionals or family in-home caregivers, these are merely “to-do” lists and “observation” forms. They provide a list of what needs to be done and when it must be done. Additionally, by noting what, when, or how something looked today, for example, it provides a means for comparison to see if there is improvement or a decline from one day to another. Once written and/or checked off, it no longer has to be remembered. It can be factually referenced later, if needed. It eliminates “I think….” And if the area, box, or section of the form isn’t completed, it’s a reminder that something wasn’t done and needs to be. In the nursing profession there is an adage: “if it wasn’t charted, it wasn’t done. “
In this part of the book, we give a brief description of the documents we use, leaving more detailed descriptions to the appended material near the end of the book. Please refer to the Exhibits section for document samples. Some information has been changed for patient privacy or redacted for space limitations. Field descriptions and medical information pertaining to the forms appear also.
PHYSICIAN’S ORDERS: MEDICATIONS, EXHIBIT 2A, EQUIPMENT & TREATMENTS, EXHIBIT 2B
We obtain renewed medication and treatment orders from the patient’s primary care physician every 90 days. This is done for insurance purposes as well as to provide the nurses with ongoing orders for their practice. Generally, it is nothing more than a list of all that is necessary for the patient’s continuing care. Once submitted to the physician, he evaluates and signs off on the orders, and they are returned to us. See the Exhibits section of this book for details.
EMERGENCY PLAN, EXHIBIT 3
This needs to be near the front of the patient’s ”chart” or book, although unlikely to be needed.
Responses for potential emergencies are described for the following:
- Loss of electrical power
- Loss of ventilator
Not all possible emergencies can or should be covered, just those whose severity and probability are greatest. Please refer to the Exhibits section for this document sample.
REFERENCE INFORMATION AND CONTACTS, EXHIBIT 4
This merely provides a complete and detailed listing of patient specifics, physician contacts, and other pertinent information pertaining to the household and the patient.
- Patient information
- Miscellaneous contact information
- Physician and pharmacy information
- Emergency transport information
- Vent settings
Please refer to the Exhibits section for this document sample.
MONTHLY NURSING TREATMENT FORMS: EXHIBIT 5A (page 1) & EXHIBIT 5B (page 3)
Simply stated, this document is a “to-do” list of requirements for the patient’s care. Like any “to-do” list, the purpose is to ensure what needs to be done is not forgotten. It eliminates forgetting to perform tasks and prevents essential information from being omitted during the nurses’ reporting-off period. In addition, it provides a method to track and reorder inventory, since it provides what equipment is used and how often it must be replaced. Lastly, besides assuring that essential activities are completed, it holds nurses or caregivers responsible for ensuring the item was done, as well as done correctly.
These tasks are done periodically, such as on each shift or on a daily, weekly or monthly basis. They include patient treatments, such as dressing changes, as well as changing equipment to ensure continued and optimal operation…for example, changing the in-line suction apparatus. In our practice, we also use the Treatment Sheets as reminders to the nursing staff to, for example, check the Communication Book, and we try to ensure their practice is safe for them by reminding them to use Universal Precautions.
Toward the back of this book, two exhibits of this patient’s
six-page document are provided to illustrate various time frames and how to depict when a certain task may require attention when not completed on a daily basis. Please refer to the Exhibits section for this document sample.
DAILY MEDICATION ADMINISTRATION RECORD – PAGE 1:
PRN MEDICATION ADMINISTRATION RECORD – PAGE 6:
Often referred to as the “MAR”, this follows the same pattern as the treatment form. However, instead of the activities which need to be performed, the administration of medications and feedings are noted.
This is another “to-do” list but is solely dedicated to the administration and application of medications, ointments, creams, suppositories and any other substances that may “go into or onto” a patient for treatment of a condition prescribed by a physician. Again, only a sample of the MAR is provided: the first and sixth pages of eight, in this patient’s case, are shown.
NURSING REVIEW/ASSESSMENT FORM: PAGE 1: EXHIBIT 7A &
PAGE 2: EXHIBIT 7B
Assessments are crucial for evaluating and appraising a patient. The patient is observed in a step-by-step pattern, system-by-system. Use of touch, smell, sight, and hearing are all vital in the assessments’ completion. The Assessment Form is the manner by which the assessment is documented. It provides a history of the patient’s medical condition, which then allows for comparisons as well as to understand what is normal for that person.
At the beginning of each nursing shift, the oncoming nurse begins completion of the Nursing Review / Assessment Form. This one-page, two-sided document is used to evaluate the patient’s current physical and emotional condition; log medication administrations; track treatments; ensure proper equipment settings and changes; and generally provides a permanent record to ensure vital information isn’t lost or misreported. While a general physical assessment will be completed early in the shift, the form is used throughout the entire period to document any changes in the patient’s condition and record completed actions.
The form used for the patient is broken down into thirteen sections. Most categories pertain to the major body systems. However, there are also sections for general information, equipment checks, nursing and shift identification, as well as allowing space for notes. A large amount of information is recorded simply by selecting or circling items. Not only does this serve to remind nurses what to assess and aid in its full completion, it also minimizes handwriting legibility problems.
Used for ventilator-required patients with pulmonary problems, vent settings are dictated by a pulmonologist. For this patient, each shift these setting are checked to ensure they are accurate and have not been mistakenly changed, which potentially could be life-threatening.
Whether the patient is able to eat by mouth or uses a gastric tube for all fluids and nutrition, the amount the patient ingests is vital to know. Too much fluid could cause edema, hypertension (high blood pressure), and could create pulmonary problems if the fluid backs up into the lungs. Too little fluid can result is hypotension (low blood pressure) and decreased perfusion (oxygen supply) to vital organs. Recording nutrition is imperative to ensure that sufficient quantities of protein, water and nutrients are available to promote healing, maintain skin, and provide fuel for continued functioning of the body at the cellular level.
The neurologic system is comprised of the brain, brain stem, spinal cord, which completes the central nervous system, and also included are various nerves located throughout the entire body, the peripheral nervous system. It is a complex system, using neurochemicals and transmitters and cellular structures to take external input from the environment via our senses and internal input from bodily functioning to transform them into usable, functional, and creative data which we perceive as life.
This section is used to assess and detail neurologic function and changes throughout the shift. In general, only two main points are assessed for this patient and are highlighted in an appendix.
The respiratory system ensures the body is provided with oxygenated blood via the smallest functioning unit in the lungs, the alveolus. It is at this cellular level that carbon dioxide is exchanged for oxygen. In addition to the lungs, other essential members of the system include the pharynx, epiglottis, larynx, trachea, bronchus and its tapering limbs, and the associated respiratory muscles and diaphragm.
This section is used to assess and detail respiratory function and changes throughout the shift. In addition to assessing pulmonary function and treatments, a portion reflects equipment changes that are often required on a daily basis.
The cardiovascular system is comprised of the heart and all the blood vessels; that is, the veins and arteries. The system functions to distribute oxygenated blood received from the lungs and deliver it throughout the body via the arteries. Venous return to the heart via veins takes deoxygenated carbon-dioxide-rich blood back to the heart to return it to the lungs for oxygenation and CO2 removal. Assessment of this system includes blood pressure readings and heart rate, which are detailed under Vital Signs (V/S), as well as pulses, tissue perfusion and fluid backup called “edema”. This section is used to assess and detail cardiac and venous function and changes throughout the shift.
The gastrointestinal system, often abbreviated as “GI” system, begins at the mouth and extends throughout the body to the end of the large colon at the anus. It processes food using many complex sequences and functions to transform bulk into minute substances for use at the cellular level. While processing food, the system also conserves water and returns it to the body, and prepares what is unusable for elimination via stool. The GI system is comprised of the oral cavity, esophagus, stomach, small intestine, and large intestine. However, various other organs also contribute and play key roles in the proper functioning of this system. These accessory organs are the salivary glands, gallbladder, pancreas, and liver.
Patients that do not obtain nutrition by mouth require all substances for survival be directly received into the stomach or the jejunum section of the small intestine via a tube placed surgically. This patient had a percutaneous endoscopic gastrostomy (PEG) to place a tube into the stomach, out from stomach wall through the skin to outside the body with which to deliver nutrition. Daily care and assessment is essential for the continued functioning of the tube, and this section is used to assess and detail gastrointestinal changes throughout the shift.
The urinary system captures liquid waste from the body and voids it by way of urine production and elimination. Through a process initiating from the kidneys, which are located on each flank or side of the body, all fluid is filtered. What is necessary for the body at that time is restored: non-essential substances as well as extra fluid are eliminated. Other organs involved in the voiding process include the ureters which bring urine to the bladder where it is stored and eventually eliminated by way of the urethra.
The reproductive system is close to the urinary system, although these are two separate systems. Both systems are assessed at the same time, and although no separate fields are dedicated to the genital-reproductive system, and since menses has stopped, it is documented as one system for this patient.
For this patient, urinary catheterization is not performed. The patient has routine Depends (disposable diaper) changes at regular three-to-four-hour intervals with implementation of absorbent inserts to help keep skin dry. Another option is urinary catheterization, which allows for urine to flow freely: a tube is inserted into the urethra until reaching the bladder. Urine then flows into and is collected in a bag for accurate measurement and assessment. Catheterization can be done intermittently throughout the day without leaving a tube in place. Sterile procedure must be followed to keep from causing an infection in the urinary tract.
MUSCULOSKETAL / SKIN
Also essential to the body are the muscles and skin. Muscles provide metabolism, strength, and functionality for motor actions or even tasks related to the most basic functions such as breathing and pumping of the heart. Skin is the largest system of the body. It acts as a protective layer, promotes temperature regulation by perspiration, and is an indicator of other bodily system functionality, such as cardiovascular, respiratory, and gastrointestinal intake and elimination.
Skin breakdown can cause severe and devastating effects. Skin breakdown starts as a non-blanchable area (one that doesn’t turn pink from white when pressure is removed from the site), a reddened patch often on a bony prominence. Tissue breakdown occurs quickly, and in the most severe cases, can extend to the bone. Depending on the patient’s underlying condition, breakdown can occur in as little as two hours. Once breakdown starts, it is difficult to stop and recover from the process.
This section is used to assess and care for the muscles, bones, and skin as well as document care to eliminate skin breakdown throughout the shift.
Psycho-social aspects of a patient pertain to the emotional, psychological, and social characteristics. They are assessed and documented to provide insight on how well the patient is adapting to the illness and the care and how they outwardly present concerns or emotional well-being.
This section is used to assess and detail psycho-social well-being and changes throughout the shift.
DEPENDS CHANGE RECORD: EXHIBIT 8
Another form we developed was to solely track fecal output. One of the most challenging aspects in nursing is bowel regulation, especially in a bed-ridden patient on liquid nutrition. Optimal bowel function requires bulk, as in fresh vegetables, fruit, and whole grains. Hydration is vital so that the body doesn’t take all the fluid from the stool, resulting in an impaction. However, too much hydration may result in fluid overload, affecting electrolyte imbalances, edema, and backup in the cardiac and pulmonary systems. Bowel function also requires movement, both by the body and by peristaltic activity of the gastric and colon muscles. Medications can also impair normal function, producing either too much output or not enough. For example, opioid pain medications can induce constipation.
To track, record, and provide ease in reporting, we developed the Depends Change Record.
At one glance, any nurse or caregiver can look to see a past and present status of bowel elimination, including quantity and quality of the stool – both very important. It also provides a time when diaper (we use Depends disposable diapers) changes are to be made. So it performs a dual task: when to do a change (for us, usually q3h=every 3 hours) – and what occurred during each change.
To ensure elimination, we have in place measures to promote bowel activity because we were able to provide the physician with documentation. Physician-ordered bowel protocols include daily administration of Miralax, alternate days of other bowel-movement promoting medications, and PRN medications to help evacuation if necessary after 48 hours without such movements. As such, bowel elimination is no longer the problem it once was, and it hasn’t been a significant problem for quite some time.
There is another purpose of the Depends Change Record besides keeping track of bowel function. It provides a means to decrease the risks of bedsores. Once a bedsore begins, usually as a benign, small reddened area that doesn’t turn white when the skin is depressed (non-blanchable), it can quickly turn into an open wound that can damage skin, fat tissue, and muscles, continuing to the bone. By changing these disposable diapers often, we get to assess any breakdown at a very early stage. Since the patient is being moved, this activity allows for improving general skin care with treatments such as applying lotions to the back, and for auscultating lung sounds with a stethoscope, or performing pulmonary treatments.
Wetness and pressure are two contributors to bedsores that are also decreased by using frequent Depends changes. Urine and feces are caustic to skin during prolonged exposure. Changing diapers at regular intervals reduces the time the patient’s skin is in contact with these. After cleaning and drying the skin, we apply a water-proof ointment, such as A+D, to the skin as further protection, providing a barrier from these corrosive, acidic substances.
Constant pressure on the skin at bony prominences, such as the coccyx bone at the base of the spine, is also reduced during the disposable diaper changes, as the patient must be rolled to do the change. Even limited changing of positions throughout the course of the day greatly enhances the viability of the skin. It relieves pressure from lying on the bones, decreases shearing forces that occur as the body moves downward in bed by gravity, and provides enhancement to blood flow. This does not replace turning and positioning a regular intervals; it just adds a beneficial factor.
This two-sided form is merely a table. Completion requires only the nurse’s initials and use of a code to quantify and qualify the stool.
RX MEDICATION TRANSLATION: EXHIBIT 9
STOPPING…PULLING THE PLUG
Both of our patients at home expressed the desire to continue to live, even with restrictions, and neither had “Living Wills” or Do Not Resuscitate (DNR) orders, which indicate the situations under which they would not want heroic efforts undertaken to save their lives. This made our decisions easy in case something life-threatening should occur. The younger patient has had over a decade of life that she has generally enjoyed after her life-threatening episode in the hospital. The elderly patient, after nearly dying in the hospital, returned home, had a few “good” months, then lapsed into a period of long sleeps and only occasional lucidity, sometimes seeming to enjoy the company of her nurses and relatives, but usually seeming to be unaware.
Based on my experience with my wife, I [DWC] wrote the following several years ago:
Some people argue that it is a waste to spend our resources on the disabled, especially as they get older. I disagree.
We value things on the basis of their usefulness and their scarcity. Water is useful, but widely available, thus generally inexpensive. Silver has practical and monetary uses and is relatively scarce, so it is much more expensive than water.
We do not know how long we will live. As we get older, we know there is less time left; it is scarcer. If we can make good use of it, enjoy it, be helpful, whatever, then the scarcity enhances its value. Even if what we do is not as good as it was years before, the years we have left can be quite precious. Tina’s life is precious, as is my own.
Some social planners come from another perspective, viewing public funds for medical care as investments. Babies who are unwanted or unlikely to survive do not merit investment, in this view. Your productive value goes up as you grow up, become educated, enter the work force. Toward retirement, your productivity may decline. At the very least, you have only a few more years in which to produce. These planners are reluctant to “invest” much more in you. Time to “pull the plug” on Grandpa or Grandma. Get that Do Not Resuscitate (DNR) order signed and let them expire with the next heart attack. This approach is “rational” from a public-expenditure viewpoint, though it takes no account of the value of the ill person to himself and those who care about him. It is part of a slippery slope that goes from not treating to euthanizing.
Tina’s care has been expensive. We’ve spent money and IBM has spent more and Medicare has had a share. We certainly expected to help pay our medical costs. IBM recruited me partly though the attractiveness of its medical benefits program, which I knew we might someday need. When IBM wanted to cut its work-force, I volunteered, again considering future medical coverage needs. That leaves Medicare: decades of withdrawals from my pay checks have gone to this program, with the notional “locked-box account” for coverage of my family and me. As with other insurance, some people end up needing more and others less, a lottery of sorts. Fair enough, we thought. Now, some suggest we are “selfish” to be getting “more than our share” of medical coverage. We are not exactly winners of a lottery, but no one argues that winners of lotteries are “selfish” for collecting “more than their share.”
Although I am glad we have done what we could for my [DWC’s] mother, it is less clear that she benefited from the heroic efforts made.
Sometimes, stopping will be less dire: the patient is cured, or the patient is not cured but needs a different environment to heal.