GUIDELINES FOR WRITING DISHCARGE SUMMARIES USING CHARTING BY EXCEPTION

1. GUIDELINES FOR WRITING DISHCARGE SUMMARIES USING CHARTING BY EXCEPTION

1. If at the time of discharge the nursing diagnosis is still active and the expected outcome is not met, or if the patient / signification orther require further assistance for care managemenet, s discharge summary is written. Example of this situations include chronic disease state, health care needs that require family or community assistance, or anticipated noncompliance with care management after discharge.
2. Discharge summaries are formulated up to 48 hours prior to patient discharge. A discharge summary with the date and the RN’s signature is first noted on the Nursering Diagnoses List. Next, it is documented as the “ Discharge Summary “ in the SOAP format on the Nurses”s Note. The following information needs to be included :
S : Summary of patient’s interpretation of health care management as it relates
to this nursing diagnosis;
O : Summary of patient’s progress during hospitalization and the current status
of the patient in relation to the nursing diagnosis.
A : Statement of the patient’s actual curren status compared to anticipation
achievement of expected outcomes ( goals );
P : Follow up plan of care through a referral or a program for self-care
management.
Uses

Nurses in acute and long-term care setting will paint this system very useful when the standards of care have been carefully defined for specific patient populations. CBE, used correctly, can be instrumental in promoting more efficient use of nursing time.

Advantages of Charting by Exception
1. Sets minimum standards for assessment and care
2. Abnormal trends are obvious
3. Abnormal data are highlighted and easily retrieved
4. Normal data or expected responses do not obscure other information
5. Charting time is reduced because the documentation of routine care and normal observations is greatly reduced
6. Transcription and duplication of charting is virtually eliminated.
7. Patient data can be recorded on the patien’s chart immediately
8. The most recent information about the patient can be left at the bedside
9. Fewer pages are needed for nursing documentation
10. The nursing can plan may be kept as a permanent record

Disadvantages of Charting by Exception
1. Concerns may arise about CBE as a timely record of useful, relevant information
2. Narative notes may be excsessivelly brief. Too much reliance may be placed upon using the checklists.
3. The potential exists for blank record or absence of charting for long intervals of time
4. Routine care may be intentionally omitted. Measured standars can be misunderstood and may obscure the need for care planning and care delivery.
5. Records of nursing judgment and evaluations may be “lost” for future analysis.
6. Isolated or unexpected events may not be fully documented
7. Does not accommodate intregated or multidisciplinary charing
8. Documentation of the nursing process may not always be evident
9. If care standards are not developed for new or evolving disese conditions problems may ensue.

2. GUIDELINES FOR USING CHARTING BY EXCEPTION ( CBE )

1. A data base is recorded for each patient and kept as part of the permanent record. A comprehensive baseline physical assessment that includes healt history and health care patterns is completed within 24 hours of admission.
2. A nursing diagnosis list is formulated and written at the time of admission. Thereafter, it serves as a “ table of content “ for all nursing diagnoses.
3. A discharge summary is written for each active nursing diagnosis at time of discharge.
4. The SOAP ( IER ) construct is used to document the patient’s response to interventions ( direction of nursing care ) throught the patien’s stay.
5. A nursing-diagnosis-based care plan is developed.
6. Specially designed protocols guide nursing interventions. A list of standardized nursing interventions has been developed to facilitate the expected clinical outcomes of specific patient populations.
7. Incidental order sheets are used to enter nursing interventions. For example, “ irrigate nasogastric tube q.2-3 hr with normal saline to maintain patency”.
8. A Kardex and care plan are developed for each patient.
9. Some computerized documentation system may generate alternative modalities.


3. CHARTING BY EXCEPTION AND THE NURSING PROCESS

A combination of steps are used to formalize the documentation of the nursing process. All components of the nursing process are used in this documentations system. Figure 96 illustrates how the steps of the process are interwoven into a properly completed record.

F. CORE Documentation System with DAE Construct

In 1985, CORE documentation was developed at St. Joseph’s Hospital in Hamilton, Ontario, Canada. It was implemented in 1986 by nurses who wanted to improve both the existing documentation system and the documentation of nursing practice.




















Figure 96 The steps in the nursing process and parallel elements of care planning and documentation. ( From Buke, L and Murphy,J; The steps in the nursing process and parallel elements of care planning and documentation. Charting by Exception. John Wiley & Sons, New York. 1998)

Thus, “ CORE” refers to the central or most important part the documentation system-the nursing process. The major component of this process-charting system include the data base , care, flow sheets, progress notes, and discharge summaries :
1. An admission assessment of the patient’s functional competence is completed by a registered nurse wthin 8 hours of admission. This assessment includes a system review and a review of the activities of daily living. Emphasis is placed on completion of a written summary directed toward nursing diagnosis and patient problems. The completed nursing data base and the care plan are placed in a Kardex ( see Figs:9.7 and 9.8)
2. Nursing care plans serve a twofold purpose. Part One (Fig 9.7) remains part of the permanent record. Part Two ( Fig 9.8) is used as a work sheet and incorporates the information from the flow sheets.
3. Flow sheets provide information about the patient’s activities of daily living and response to nursing care and about treatments and nursing activities, diagnostic procedures, and patient education. The parameters on the flow sheets correspond to the patient classification system. Examples of the flow sheets are shown in Figures 9.9 and 9.10
4. Progress notes and are organized in a three-column format ( modeled after the FOCUS charting format ). The DAE acronym stands for Data, Action, Evaluation ( Response ) and provifes a guideline with which to organize content in the progress note column ( Fig 9.11)
5. The discharge summary includes information about nursing diagnosis, patient education, and requirements for follow-up care.

Uses
This system can be used both in acute care facilities and in long-term care setting.



ST. JOSEPH’S HOSPITAL, HAMILTON. ONTARIO
DEPARTEMENT OF NURSING

GOAL(S) OF CARE


PATIENT CARE PLAN-1 DATE Nurses’s initials NURSING DIAGNOSES EXPECTED OUTCOMES Dead Line Chart NURSING INTREVENTIONS Date Nurses’s initials
























Figure 9.7 Patient care plan-1 ( Courtesy of St. Joseph’s Hospital, Hamilton, Ontario )


































PATIENT CARE PLAN-1 DATE Nurses’s initials NURSING DIAGNOSES EXPECTED OUTCOMES Dead Line Chart NURSING INTREVENTIONS Date Nurses’s initials





SAFETY NEEDS



PSYCHOSOCIAL NEEDS



SPIRITUAL/CULTURAL NEEDS
PATIENT TEACHING PLAN : DISCHARGE PLANNING Expected Discharge Date :
HOME SITUATION :
DISCHARGE RESOURCES INVOLVED :
Public Health
Home Care
Social Work
Piscement
Other

NURSE’S SIGNATUR Initials NURSE’S SIGNATUR Initials NURSE’S SIGNATUR Initials NURSE’S SIGNATUR Initials





Figure 9.7 Patient care plan-1 ( Courtesy of St. Joseph’s Hospital, Hamilton, Ontario )


ID BAND CHECKED ADMITED FROM : □ ER □ ICU □ HOME □ OTHER ____________ VIA______ ACCOMPANIED BY _____

VITAL SIGN T________P_______R_______BP/ST/SIR_______________Ly_______WEIGHT ________Kg HEIGHT ________Cm