One of the first things I learned in nursing school, after I put on that embarrassing apron thing over my crisp new white uniform, and after learning bed making (do they still teach that?) and hand washing, was that if its not documented, it’s not done.  I have never forgotten that credo, and know how important documenting our actions can be in supporting our care.

Elements of documentation are also required to meet standards for both AAAHC and CMS.  I recently did a summary of the requirements, so I thought I would share my findings.

Here are key elements surveyors will look for in your record:

  • The informed consent includes risks, benefits, alternatives, and is signed and witnessed.
  • The history and physical is present on chart, includes the problem, assessment, plan, that  the patient is appropriate for the procedure, plan, and is completed within 30 days of and prior to procedure.
  • There is documentation that the patient has been asked about their advance directives, and if they don’t have one, information on advance directives has been offered.
  • Documentation includes an assessment of the patient immediately prior to procedure.
  • All medications are given by written physician order.
  • All interventions are ordered (IV, blood sugar check, etc.).
  • A surgical checklist is in place.  Site marking and a time out is performed and documented on each patient.
  • Medication reconciliation is performed and documented.
  • Allergies are noted in a prominent, consistent location in the medical record.
  • A discharge summary is written immediately following the procedure by the physician:  includes findings of the procedure, and any adverse events if applicable.
  • Any discontinuation or resumption of medications are noted. (i.e.:  Coumadin, Insulin).
  • Discharge criteria are in place and the patient is assessed and verified that they have met the criteria prior to discharge by, at minimum, an RN.  The person responsible for the discharge assessment has been approved by the Governing Board.
  • Discharge orders are signed by the physician.
  • Patient identifiers are included in chart. Name, birth date, and date of service are listed.  The physician name is part of the record if the facility has multiple physicians.
  • If utilizing a paper record, a summary is included for 3 visits or greater that includes date of service, diagnosis, and procedure.
  • Interventions are dated and timed.

You may want to include these elements in your standard chart review, or assign key staff to perform a specific spot audit for verification and report as a quality study.  It would make good light schedule day project, and have you better prepared for your next survey.

I considered digging up a picture of me in that embarrassing blue apron for this post, but decided to spare you the laugh. As grateful as I am for all the things I keep with me from nursing school, including good charting, I am happy that the apron is long retired.


4 Replies to “Nursing school lessons that stuck…if it’s not charted…”

    1. Thanks Kathy! If we view the informed consent as the attestation of the discussion between the physician and the patient or authorized representative, the setting doesn’t change the requirement.

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