Chapter 17
Documenting, Reporting, and
Conferring
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Characteristics of Effective
Documentation
• Consistent with professional and agency standards
• Complete
• Accurate
• Concise
• Factual
• Organized and timely
• Legally prudent
• Confidential
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Using the 24-hr Cycle Military Clock for
Documenting Times
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What Is Confidential?
• All information about patients written on paper, spoken
aloud, saved on computer
– Name, address, phone, fax, social security
– Reason the person is sick
– Treatments patient receives
– Information about past health conditions
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Potential Breaches in Patient
Confidentiality
• Displaying information on a public screen
• Sending confidential e-mail messages
• Sharing printers among units with differing functions
• Discarding copies of patient information in trash cans
• Holding conversations that can be overheard
• Faxing confidential information to unauthorized persons
• Sending confidential messages overheard on pagers
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Patient Rights
• See and copy their health record
• Update their health record
• Get a list of disclosures
• Request a restriction on certain uses or disclosures
• Choose how to receive health information
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Policy for Receiving Verbal
Orders in an Emergency
• Record the orders in patient’s medical record
• Read back the order to verify accuracy
• Date and note the time orders were issued in emergency
• Record VO, the name of the physician followed by nurse’s
name and initials
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Policy for Physician Review
of Verbal Orders
• Review orders for accuracy
• Sign orders with name, title, and pager number
• Date and note time orders signed
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Duties of RN Receiving a Telephone Order
• Record the orders in patient’s medical record
• Read orders back to practitioner to verify accuracy
• Date and note the time orders were issued
• Record TO, full name and title of physician or nurse
practitioner who issued orders
• Sign the orders with name and title
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Purposes of Patient Records
• Communication with other healthcare professionals
• Record of diagnostic and therapeutic orders
• Care planning
• Quality of care reviewing
• Research
• Decision analysis
• Education
• Legal and historical documentation
• Reimbursement
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Purposes of Recording Data
• Facilitate patient care
• Serve as a financial and legal record
• Help in clinical research
• Support decision analysis
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Methods of Documentation
• Source-oriented records
• Problem-oriented medical records
• PIE charting
• Focus charting
• Charting by exception
• Case management model
• Computerized records
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Sample PIE Patient Care Note
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Sample Focus Patient Care Notes
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Case Management Models
• Collaborative pathways
• Variance charting
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Major Components of POMR
• Defined database
• Problem list
• Care plans
• Progress notes
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Formats for Nursing Documentation
• Initial nursing assessment
• Kardex and patient care summary
• Plan of nursing care
• Critical collaborative pathways
• Progress notes
• Flow sheets
• Discharge and transfer summary
• Home healthcare documentation
• Long-term care documentation
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Types of Flow Sheets
• Graphic record
• 24-hour fluid balance record
• Medication record
• 24-hour patient care records and acuity charting forms
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Medicare Requirements for
Home Healthcare
• Patient is homebound and still needs skilled nursing care
• Rehabilitation potential is good (or patient is dying)
• The patient’s status is not stabilized
• The patient is making progress in expected outcomes of
care
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Four Basic Components of RAI (Resident
Assessment Tool)
• Minimum data set
• Triggers
• Resident assessment protocols
• Utilization guidelines
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Benefits of RAI
• Residents respond to individualized care
• Staff communication becomes more effective
• Resident and family involvement increases
• Documentation becomes clearer
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Change of Shift Report
• Basic identifying information about each patient
• Current appraisal of each patient’s health status
– Changes in medical conditions and patient response
to therapy
– Where patient stands in relation to identified
diagnoses and goals
• Current orders (nurse and physician)
• Summary of each newly admitted patient
• Report on patient transferred or discharged
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Two Nurses Confer at Change of Shift
Report
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Methods of Reporting
• Face-to-face meetings
• Telephone conversations
• Messengers
• Written messages
• Audio-taped messages
• Computer messages
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Conferring About Care
• Consultations and referrals
• Nursing and interdisciplinary team care conferences
• Nursing care rounds
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Question
Tell whether the following statement is true or false.
A nurse who fails to log off a computer after documenting
patient care has breached patient confidentiality.
A. True
B. False
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Answer
Answer: A. True
A nurse who fails to log off a computer after documenting
patient care has breached patient confidentiality.
Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins
Question
Tell whether the following statement is true or false.
A patient has the right to obtain, review, and revise the
patient information in his or her health record.
A. True
B. False
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Answer
Answer: B. False
A patient has the right to obtain and review, but not
revise the patient information in his or her health record.
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Question
Tell whether the following statement is true or false.
One of the purposes of creating a patient record is to
evaluate the quality of care patients have received and
the competence of the nurses providing that care.
A. True
B. False
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Answer
Answer: A. True
One of the purposes of creating a patient record is to
evaluate the quality of care patients have received and
the competence of the nurses providing that care.
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Question
Which of the following methods of documentation is
unique in that it does not develop a separate plan of care
but instead incorporates the plan of care into the
progress notes?
A. Source-oriented records
B. Problem-oriented records
C. PIE (problem, intervention, evaluation)
D. Focus charting
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Answer
Answer: C. PIE (problem, intervention, evaluation)
Rationale:
Pie charting incorporates the plan of care into progress
notes in which problems are identified by number.
In source-oriented records, each healthcare group keeps
data on its own separate form.
Problem-oriented records are organized around patient
problems rather than around sources of information.
Focus charting brings the focus of care back to the
patient and the patient’s concerns.
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Question
PIE notes, SOAP notes, focus charting, and charting by
exception are examples of which of the following formats
for nursing documentation?
A. Critical/collaborative pathways
B. Progress notes
C. Flow sheets
D. Discharge summary
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Answer
Answer: B. Progress notes
Rationale:
Progress notes inform caregivers of the progress a
patient is making using the specified formats.
Critical/collaborative pathways are standardized plans of
care developed for a patients with designated diagnoses.
Flow sheets are documentation tools included in the
progress notes that record routine aspects of care.
Discharge summaries are clinical reports written to
summarize the patient record.
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