CHARTING BASICS
What Is Documentation?
Documentation means “to give written information that is proof or support of something that
has been done or observed.” Simply put, a medical record is the record of all care that is
provided. If it is not recorded, it did not happen. If it is recorded incorrectly, it happened
incorrectly. A nurse’s documentation provides a clear picture of the status of the patient, the
actions of the nurse, and the patient outcomes.
Reasons for documentation:
To facilitate communication
Through documentation, nurses communicate to other nurses and care providers
their assessments about the status of patients, nursing interventions that are carried
out and the results of these interventions. Documentation of this information
increases the likelihood that the patient will receive consistent and informed care
or service. Thorough, accurate documentation decreases the potential for
miscommunication and errors.
To promote good nursing care
Documentation encourages nurses to assess patient progress and determine which
interventions are effective and which are ineffective, and identify and document
changes to the plan of care as needed.
To meet professional and legal standards
Documentation is a valuable method for demonstrating that, within the nursepatient relationship, the nurse has applied nursing knowledge, skills and judgment
according to professional standards. The nurse’s documentation may be used as
evidence in legal proceedings such as lawsuits, coroners’ inquests, and disciplinary
hearings through professional regulatory bodies. In a court of law, the patient’s
health record serves as the legal record of the care or service provided. Nursing
care and the documentation of that care will be measured according to the standard
of a reasonable and prudent nurse with similar education and experience in a
similar situation.
To assure reimbursement of the cost of care
In health care, sometimes private insurance and Medicare will deny payment if
documentation is not satisfactory or is not done at all. Payment can be denied if
documentation is missing or incomplete.
Good documentation has five important characteristics. It should be: 1) factual; 2) accurate; 3)
complete; 4) current (timely); and 5) organized. “If the accuracy of a nurse’s charting is
questioned in a court of law, questions might be raised about the credibility of both the
documentation and the nurse” (RN, 2003). The timeliness of documentation will be dependent
upon the patient. When patient acuity, complexity and variability are high, documentation will
be more frequent than when patients are less acute, less complex and/or less variable. Patients
who are very ill, considered high risk, or have complex health problems generally require more
comprehensive, in-depth and frequent documentation.
Types of charting
Flow sheets and checklists are frequently used to document routine and ongoing assessments
and observations such as personal care, vital signs, intake and output, etc. Information recorded
on flow sheets or checklists does not need to be repeated in the progress notes.
Focus charting progress notes are used to document patient progress in meeting established
goals. Common formats include SOAP, SOAPIER, PIE, and DAR.
What information is included in the progress notes?
Progress notes (nurses’ notes) are used to communicate nursing assessments,
interventions carried out, and the impact of these interventions on patient outcomes. In
addition, progress notes are intended to include:

patient assessments prior to and following administration of PRN medications;

information reported to a physician or other health care provider and, when
appropriate, that provider’s response;

all patient teaching;

all discharge planning, including instructions given to the patient and/or family and
planned community follow-up;

all pertinent data collected in the course of providing care, including data collected
through technology such as monitoring devices (e.g., strips produced during cardiac
or fetal monitoring); and

action taken by the nurse on behalf of the patient (including calls to physician and
discussions with other health care team members).
Examples of DAR notes
DAR is a form of focus charting. A note is written to provide documentation related to a
specific focus. The focus might be a nursing diagnosis, patient problem, sign or
symptom, change in patient’s condition, or any significant event. The progress note is
written in DAR format which stands for Data-Action-Response.
Data: Subjective and/or objective information that supports the stated focus or
describes the patient status at the time of a significant event or intervention.
Action: Completed or planned nursing interventions based on the nurse’s
assessment of the patient’s status and any changes to the care plan deemed
appropriate.
Response: Description of the patient’s response to nursing or medical care and
progress in achieving outcomes/goals.
DAR notes do not need to always have all three components. Some notes will just
contain one or two of the three parts.
Example 1 – Focus: Nausea related to anesthetic
D: States she's nauseated. Vomited 100ml clear fluid at 2255
A: Given Compazine 1mg IV at 2300.
R: Reports no further nausea at 2335. No further vomiting.
Example 2 – Focus: Acute pain related to surgical incision
D: Reports pain as 7/10, grimaces and groans with movement BP 154/88. Had received
PO analgesic at 2200.
A: Given morphine 1mg IV at 2335. Repositioned on left side.
R: Reports pain as 1/10 at 2355. BP 138/82.
Example 3 – Focus: Risk for infection related to incision sites
D: Incision site in front of left ear extending down and around the ear and into neck—14
cm in length--without dressing. Jackson-Pratt drain in left neck below ear secured in
place with suture.
A: Assess site and emptied drain. Taught patient S&S of infection.
R: No swelling or bleeding; bruising below left ear noted. JP drained 20mL bloody
drainage. States understanding of teaching.
Example 4 – Focus: Delayed surgical recovery
D: C/O dizziness after trying to get OOB to use the bathroom.
A: Assisted patient back in bed and with use of bedpan by CNA. Taught how to dangle
legs and get OOB slowly. Taught coughing and deep breathing exercises, turning in bed,
and use of anti-embolism stockings.
R: Voided 200mL in bedpan. Did cough and deep breathing appropriately. Lungs clear
bilaterally. Anti-embolism stockings on.
Example 5 – Focus: Medications
D: Wife stated patient takes Synthroid 0.125 mg daily, has for 12 years.
A: Physician notified, order received, Synthroid given.
Note:
Complete sentences aren’t used.
It is assumed that a note in a particular patient’s chart is written about that patient.
It is assumed that the nurse writing the note performed the “actions” unless otherwise
indicated.
The reasons for the action usually aren’t included nor are the nurse’s thoughts about the
situation.
SUMMARY
What to do:
o Check to be sure you have the correct chart before you begin writing
o Make sure your documentation reflects the nursing process
o Chart completely but be concise (and accurate!)
o Chart time for each entry
o Document unexpected findings/occurrences
o Chart precautions or preventative measures
o For procedures, include the following: what was done, when it was done, who did it, how
it was done, how the patient tolerated it, adverse reactions, if any.
o Record each phone call to or from a physician, including exact time, message, and
response.
o Chart as soon as possible after providing care.
o Chart a patient’s refusal of treatment or medications.
o If you remember something important after you have completed your documentation,
write “late entry” and make the note.
In hand-written forms:
o Write LEGIBLY using a permanent black ink pen (other colors do not photocopy well)
o If you make a mistake, draw a line through the error, and indicate it as an error, and then
initial it.
What not to do:
o Don’t chart a symptom such as “c/o pain” without also writing what you did about it.
o Don’t alter a chart….this is a criminal offense.
o Don’t add information at a later date without indicating that you did so.
o Don’t date the entry so that it appears to have been written at an earlier time.
o Don’t use shorthand or abbreviations that are not standard.
o Don’t write vague descriptions such as “large amount of drainage”
o Don’t make excuses, such as “meds not given because not available.”
o Don’t chart what someone else says unless you use quotations and state who said it.
o Don’t chart an opinion.
o Don’t use words that suggest a negative attitude, such as “weird” or “nasty.”
o Don’t chart ahead of time. If something happens it will look bad to go back and make that
correction.
o Misspelled words and bad grammar are as bad as illegible handwriting.
o Don’t record staffing problems.
o Don’t document that an incident report was completed.
o Don’t leave any blank spaces.
o Don’t save a space for a colleague who forgot to chart.
o Don’t chart care that was not given. This is fraud and cause for loss of license.
Electronic health records:
o Never reveal or allow anyone access to your personal identification number or passwords
(these are, in fact, electronic signatures).
o Log off when not using a system or when leaving a terminal.
o Shred any print information containing patient information.
o Retrieve printed information promptly.
SBAR – Situation, Background, Assessment, Recommendation – is a standardized way of
communicating.
“Improving the communication between caregivers can prevent negative patient outcomes
and strengthen a teamwork approach to care. The SBAR technique provides common
expectations such as what will be communicated, how it's structured, and what are the
required elements. It allows communication to be focused on the problem and not the
people. This is very important when staff members are communicating hand-off information
at the change of shifts.
The SBAR technique also provides a way to hand-off relevant information in the presence of
the patient, allowing active participation of the patient in his or her care. The patient is
central to all information surrounding care activities. Patients can ask questions or add
information to the discussion. Through this process, the patient sees the staff working as a
team and is assured that all involved know and agree on the plan of care. Evidence suggests
that better-informed patients are less anxious and more likely to follow medical advice.
Situation. The "S" component should take about 8 to 12 seconds. The nurse states what's
happening now. If giving a shift report to the next caregiver, the nurse states the patient's
name, why the patient is on the unit, and introduces the nurse coming on duty to the patient.
For example: "Ms. J, this is Tina Jones, the registered nurse who will be caring for you
today. Tina, Ms. J is here to have rehab after her right knee replacement." To be effective,
you must be concise, clear, and to the point when giving the report, leaving irrelevant
information out of the conversation.
Background. During the "B" component, the nurse gives the next caregiver brief
background information specific to the patient's relevant history. This section sets the
context for what's being discussed, which may include the patient's diagnosis, history of
procedures done, and family situation. For example: "Ms. J had a right knee replacement on
June 3rd by Dr. Smith. She has a history of hypertension, diabetes, and arthritis. She lives
with her husband who's retired and able to care for her at home when discharged."
Assessment. During the "A" component, the nurse reports the current condition of the
patient. For example: "Blood glucose levels have been stable, vital signs within normal
limits, and the incision line is clean and dry with no drainage noted. The dressing was
changed today. Ms. J is able to ambulate to the restroom with a contact guard of one and the
use of a walker. Her pain has been reported as a 7 on a 0-to-10 scale and she was given two
hydrocodone pills at 9 a.m. The hydrocodone appears to be helping her, especially when
given before therapy."
Recommendation. During the "R" component, the nurse states what he or she thinks would
be the desired response to the patient's care of the day. She may suggest that discharge
planning be initiated by discussing needs with the patient, contacting the physician with
discharge plans, and conveying to the rest of the care team what needs to be done before
discharge. You don't need to read the entire patient profile or orders. For example: "Ms. J is
scheduled for discharge this Friday and will need to speak to the discharge planner today."
Remember, not everything about the patient needs to be conveyed, just what's pertinent to
the situation at that time. Also remember that effective communication takes two: Ask if
there are any questions and remind team members and the patient that you'll be available
should further clarification be needed.”
http://journals.lww.com/nursingmadeincrediblyeasy/Fulltext/2011/09000/Looking_to_improve_your_bedside_report__Try_SBAR.14.aspx
RN to Physician SBAR Examples
Scenario 1: An RN on the Medical Floor has an order for a patient to receive an exam that
requires IV contrast. The patient’s creatinine level is 2.9. The ordering physician needs to be
called to clarify this order.
Situation: “Dr. Smith, this is Darlene on Med/Surg at OMH. I have an order for a PE
study for Mr. Marino. His creatinine is elevated and I wanted to clarify the order with
you.”
Background: “I see that Mr. Marino came into the ED with right-sided chest pain and
difficulty breathing. The CT for rule-out PE was ordered.”
Assessment: “Mr. Marino’s creatinine level is 2.9, far above the allowable level for a
rule-out PE study.”
Recommendation: “I think that the order should be changed from a CT for rule-out PE to
an order for a VQ scan.”
Scenario 2: A nurse wants to report a change in patient condition to the physician.
Situation: “Dr. Thomas, this is Lisa in ICU at OMH. I am caring for Mr. Jones, in room
5. Mr. Jones has had a change in his heart rhythm.”
Background: “Mr. Jones had his hip surgery two days ago and has been going in and out
of controlled A-fib since his surgery, with rates in the high 90’s. Mr. Jones has a history
of A-fib and was on Coumadin 5 mg/day and Digoxin 0.25 mg/day prior to his hip
replacement. He has not had any Digoxin or Coumadin since his surgery.”
Assessment: “This morning, Mr. Jones has gone into an uncontrolled A-fib, with a rate in
the 120-130 range. He is currently asymptomatic and his vital signs are stable, with a
blood pressure of 120/80. He is resting comfortably in his room.”
Recommendation: “I am thinking that a 12-lead should be ordered for Mr. Jones. Would
you like his Digoxin and/or his Coumadin to resume? Are there any other tests you would
like to order? I will call you if Mr. Jones converts or becomes symptomatic. Would you
like me to call you with any other information?”
Scenario 3: A patient is being admitted to OB in early labor. The RN needs to give an
update to the on-call Obstetrician.
Situation: “Hello, this is Jenny from OB at OMH calling to let you know that Mrs.
Winslow has been admitted in early labor.”
Background: “Mrs. Winslow presented to the ED around 1600 this evening. She is a 40year-old Gravida1para2. She started in labor at 0900 today. She is RH+, GBS positive,
and Rubella immune. Her Hepatitis status is unknown. Her membranes are intact. Mrs.
Winslow has an allergy to Penicillin, reaction unknown, but became allergic to Penicillin
as a child.”
Assessment: “Mrs. Winslow has been on the monitor for 30 minutes, is contracting every
5 minutes. She is dilated to 3 cm, 70% effaced, and –1 station. Baseline FHT is 130, with
average variability; there are accelerations of 15-beats/minute and no decelerations. Her
vital signs are stable at 98.9 F, BP 130/68, Pulse 100, and RR 24. Mrs. Winslow does not
want an epidural.”
Recommendation: “May I enter your L&D order set? Since Jane is HBSAG positive,
what treatment would you like? Would you like any other lab tests? How would you like
me to contact you today?”
Scenario 4: A patient who is post-surgical ankle repair is having unsuccessful pain control.
The RN needs to get an order for improved pain coverage.
Situation: “Hello, this is Ron from Med/Surg at OMH. I’m caring for Mr. Tree in room 3.
I’m calling regarding his pain control.”
Background: “Mr. Tree is a 22-year old who had surgical repair of a fractured ankle 2
days ago. He has had very minimal pain control since his surgery. He has an order for
Tylenol 650 mg q 4 hours for minimal to moderate pain and Morphine IV, 1-4 mg q 2
hours for severe pain. He does not have any allergies to medications. This is his first time
having any type of surgery or significant injury.”
Assessment: “Mr. Tree ranks his pain as a 9/10, with a quality of being sharp and
radiating to his mid-calf area. He is reluctant to ambulate out of bed, even refusing to get
into a chair at the bedside. His pedal pulses are equal, the surgical site is WNL, and all of
his vital signs are stable.”
Recommendation: “I think that Mr. Tree would benefit from some longer-lasting pain
medications. What would you prefer to order? Are there any exams or labs you would
like to order? What should I call you for in the future regarding his pain control?
http://www.prohealthcare.org/pdf/SBAR%20template%20RN%20to%20Doc.pdf