Documentation Guidelines

Greater Baltimore Medical Center

General Documentation
Information
Most nursing documentation is completed on the
computer using Meditech PCS
Agency nurses will be required to take an 8 hour
Meditech course taught by GBMC before
beginning to work at the hospital
This class will cover order entry, documentation,
and barcoding medication delivery / using the
electronic medication administration record

Patient Care System (PCS)

PCS is the system for documentation that
reflects the nursing process, encourages clear
and concise charting, is legally sound, and
focuses on patient interventions to support
patient outcomes
All information entered through PCS can be
viewed in the EMR (Enterprise Medical
Record)

With PCS, you are able to:

Fill out the Admission Database

Record vital signs and I&Os
Document the patients Past Medical History
Document your head-to-toe assessment (using System
Flowsheets)
Enter nursing notes
Add Care Plans and record outcomes
View and print Kardexes and patient reports
Enter lab, radiology, respiratory, diet, and nursing orders through
order entry
Document medication administration through the electronic MAR

Shift
A shift is defined as 12 hours
Documentation that is required q shift is to be
documented once every 12 hours, unless
physician orders or unit specific policies dictate
otherwise
Change in patient status or change of care
provider necessitates a repeat of the q shift
documentation (i.e. Patient System Flowsheets)

Real Time Documentation

Documentation completed at the time the intervention is
performed
In the event that real-time documentation is not possible,
documentation that occurs within one hour of the
intervention is acceptable, except for those interventions
with a time interval less than one hour (i.e. q15min)
Any documentation entered into Meditech after the one hour
time interval must be retrospectively documented by
defining the exact time the intervention was actually
completed
Continuous reassessment of the patient is a nursing
expectation, with documentation expected as changes occur

Standard of Care
Upon admission, each patient will have the
appropriate Standard of Care (SOC) added to
their intervention list in Meditech
The SOC is a predefined set of interventions that
are designed for that patients population
Once the SOC and all physician orders are
entered through Meditech order entry, the
intervention list the nurse will document from
will be complete and ready to be documented on

Plan of Care
The plan of care for the patient includes all
computer documentation, entered orders, as well
as a defined Care Plan
Every admitted patient must have a care plan added
within 24 hours of admission
Care plans all have problems and expected
outcomes that are documented against once every
12 hours
Care plans can be updated as needed to reflect new
problems or change in patient status

Notes
Nursing notes are entered on
a patient in the following situations:

Admission
Transfer
Discharge
When an unusual event occurs or with change of
patient status
When an appropriate intervention cannot be found to
document on

Documentation Details
A nurse can skip a question on an
assessment if he/she is unable to assess the
question due to patient condition or if the
question is not applicable for the patient at
that time
Any retrospective documentation can be
entered up to 3 days following patient
discharge

Documentation Details
Changes to documentation may only be
made by the person who recorded the
documentation
Partially documented entries,
documentation editing, and undoing
documentation can be completed by
clicking in the History column for the
appropriate intervention

Transfer of Patients
Transferring unit will change the status of any
appropriate interventions from Active to
Complete by clicking in the Status column
Completed Admissions Documentation
System Flowsheet

Receiving unit stops all nursing orders initiated in

order entry, enters transfer orders according to policy
and procedure, and the nurse will add on the correct
system flowsheet for the patient on the intervention
list using the Add Intervention Function

Order Entry
All paper physician order sheets
must be faxed to pharmacy upon
admission
Pharmacy will enter any medications and IVs into
Meditech the list of current medications can be
viewed in the EMR by clicking on the Medications
tab
All non-medication orders will be entered by the
nurse or secretary into the Meditech order entry
system

Order Entry
It is the RNs responsibility to verify ALL orders
(lab, radiology, nursing, etc.) are entered into
Meditech from the Physician Order Sheet (Use
Order History in the EMR)
Initial each individual order with red ink after
verification that the order is in Meditech
After all orders have been entered and verified, a
Kardex will be printed from the Meditech desktop
using the Reports button

Verification of Physician Orders

For ancillary department orders requiring
pager notification (Respiratory Therapy)
the time of the page is written on the order
sheet next to the order
Co-sign each set of
physician orders with
initials, title, date, and time

24-hour Chart Checks

Performed on 11pm 7am shift

Review ALL orders written during the
previous 24 hours and verify they are in
Meditech by accessing the EMR (order
history section, sorted by date)
Sign entire physicians order sheet with
name/initials, title, date and time in red
ink

Legal Medical Record

Combination of the Patients PCS archived
discharge summary and the archived notes, as
well as any documentation from the paper chart
The Medical Records Department archives
these items 60 days after discharge
The discharge summary and notes are available
upon request from the Medical Records
Department

Admission Documentation

Document all interventions that have a frequency of On Admission

Also required to document the following, as appropriate:
System Flowsheet
Fall Risk / Safety Assessment Tool
IV Assessment / Invasive Line Status
Pain Assessment / Reassessment
Skin Risk Assessment
CAM
General Education Record
Nursing Note with Admission Details
Add a Care Plan to patient using
Process Plan
Print Out Home Medication Report from Meditech Desktop after entering in list
of Patients Home Meds during admission

Discharge Documentation
The physician writes the discharge instructions
The nurse is responsible for reviewing all instructions
with the patient and obtaining the patient signature
Carenotes can be printed out from the Infoweb (click on
Micromedix link to access) for patient education
The nurse should make sure the patient understands the
complete list of medications the patient is to take once
being discharged (compared to any medications the
patient was taking on admission), as part of the
medication reconciliation process
Original form goes to medical records and a copy is given
to the patient upon discharge

Blood Administration
Documentation
Blood Transfusions are documented as an Intervention
Set, which can be added using the Add Intervention
link on the Intervention worklist (search for set)
The set is comprised of:
Blood Administration Verification (completed just prior to
starting infusion)
Blood Product Infusion (start time and initial rate)
Infusion Changes (any rate changes during infusion)
Blood Product Completion (completed at end of infusion)
Blood Vital Signs (baseline vitals taken at start, then q15min x 2
after initiation, then hourly)

Documentation of Wounds
Wounds are documented as an Intervention Set,
which can be added using the Add Intervention
link on the Intervention worklist (search for set)
The set is comprised of:
Wound / Pressure Ulcer Status Assessment: for initial,
weekly, and change of status wound documentation
(more detailed)
Wound Care / Dressing Change Assessment: for daily
documentation of dressing changes (focused
assessment specifically for dressing changes)

Critical Lab Values

Documentation
The lab will call the nurse (as well as the
physician) responsible for taking care of the
patient with the critical lab value
The telephonic critical result, upon receipt, will
be read back to the technologist/technician and
documented as having been read back. If that
does not happen, the technologist/technician will
request that the nurse receiving the critical result
read it back.

Critical Lab Values

Documentation
Procedure
1. Verify the result by verbally reading the result
back to the technologist/technician
2. Notify the nurse assigned to the patient of the
critical result if she/he was not the one to receive
the telephonic notification.
3. Document receiving the phone call about the
critical value, the critical result, and what you did
about the result on the Critical Lab Values
Intervention in Meditech PCS.

EMR
The Enterprise Medical Record (EMR) is where
all the documentation for your patient is located
To open the EMR from PCS, click on Open
Chart
Once in the EMR, you can click
on the options on the right side
of the screen to view documentation,
reports, labs, orders, etc.

Computer Downtime
In the event of a computer downtime, the documentation
system reverts back to paper (all paper forms will be
stocked on units)
For downtime less than 4 hours (med/surg) and 2 hours
(critical care), information that is recorded on paper will
need to be entered into PCS
For downtime exceeding 4 hours (med/surg) and 2 hours
(critical care), the paper system will replace PCS until the
end of the shift and until the system is back up the only
data that must be re-entered into PCS in this case are the
Vital Signs and the I&O, so the EMR record will be
accurate

Unscheduled Downtime
A 24-hour report, by unit, will be available
upon request from the MIS Helpdesk,
x3725. The unit is responsible for picking
up this report from the MIS department,
building 9, 5th floor. The report includes the
following documentation:

Vital Signs
Intake and Output
System Flowsheet
Pain Assessment
PCA: IV and Epidural

Scheduled Downtime
The unit is responsible for printing the following reports one
hour prior to the downtime:
Nursing Downtime Flowsheet

Click on Reports button from desktop

Click on Patient Reports
Select Flowsheet Report
In Format box, Press F9 and select Nursing DT Flowsheet
Fill in Patient Last name and press F9 in Patient section
Select correct patient and click on green check mark to print

Patient Kardex

Click on Reports button from desktop

Click on Patient Reports
Select Profile Report
Fill in Patient Last name and press F9 in Patient section
In Use Profile Format box, press F9 and select Pt Kardex Treatment
record and click on green check mark to print

Meditech Help
Can be found on the nursing page of the
Infoweb

Scroll down on the

nursing page and click
on Meditech Help
Link

What stays on paper?

Consent forms
Admission / Transfer Summaries
OR/Recovery Documentation
Physician Order Sheets
Documentation During Patient Codes
Pre-op Checklist
Discharge Instructions
Labor Event Triage up until Delivery
Monitoring Strips

Paper Documentation Guidelines

When your signature is required on any form, legibly
sign your full name and status (i.e RN)
Before using your initials on any paper form, be sure to
sign the Signature/Initial record in front of the medical
record
Use black or blue ink pen for all entries, except when
signing off medications which should be done using
red ink
If part of the paper medical record is damaged in any
way (spills, tears), do not destroy the form simply
cross-reference to a newly initiated form

Documenting a Telephone Order

from a Physician
Indicate date/time order was received
Document order as stated by physician
Read the written order back to the physician to verify
accuracy
Document under the order RBO (read back order) and
the recorders initials
Sign order: v.o. Dr. Jones / Kay Smith RN
Place a sign here sticker next to order
Flag the record green for a regular order and red for a
STAT order for the secretary

Time-Out VISA
To be completed on ALL surgical and
invasive procedures for which consents are
required. This includes bedside procedures
such as central lines, chest tubes,
thoracentesis, etc.
3 Sections: Patient Verification, Site
Marking, and Time Out for Procedure or
Operating Room

Section 1: Patient Verification

Two identifiers: patient name and date of
birth
Compare to ID band, consents, diagnostic
images, and all other patient
documentation related to the procedure
All areas on the VISA under section 1 are
to be initialed

Section 2: Site Marking

Completed whenever laterality may become an issue

Performed by physician or person performing the invasive procedure
Exceptions
If not multiple digits/structures
Procedure occurs through an orifice (dental, colonoscopy, etc)
NICU babies
Green bracelet used on operative side
when patient refuses site marking
All areas to be initialed
if appropriate

Section 3: Time-Out
Completed just prior to the beginning of the
procedure
Includes the patient
All members present for the Time-Out must be
identified
All areas to be initialed and form signed
References: Verification of Correct Site, Correct
Procedure, Correct Patient and Time-Out for
Invasive or Surgical Procedure; and Guidelines for
Completing Procedure Visa