Chapter 16
Documentation and
Reporting
Documentation as
Communication
 Communication is a dynamic,
continuous, and multidimensional
process for sharing information.
 Reporting and recording are the major
communication techniques used by
health care providers.
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Documentation as
Communication
 The medical record serves as a legal
document for recording all client activities
by health care practitioners.
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Documentation as
Communication
 Documentation is defined as written
evidence of:
• The interactions between and among health
professionals, clients, their families, and
health care organizations
• The administration of tests, procedures,
treatments, and client education
• The results or client’s response to these
diagnostic tests and interventions
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Documentation as
Communication
 Nurses rely on charting, records, and
systems that support the implementation
of the nursing process.
 Systematic documentation is critical to
presenting the care administered by
nurses in a logical fashion.
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Documentation as
Communication
 Critical thinking skills, judgments, and
evaluation must be clearly communicated
through proper documentation.
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Purposes of Health Care
Documentation
 Professional Responsibility and
Accountability
 Communication
 Education
 Research
 Legal and Practice Standards
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Purposes of Health Care
Documentation
 Recording provides written evidence of
what was done for the client, the client’s
response, and any revisions made in the
care plan.
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Purposes of Health Care
Documentation
 Recording documents compliance with
professional practice standards and
accreditation criteria.
 Written records are a resource for review,
audit, reimbursement, and research.
 Documentation provides a written legal
record to protect the client, institution and
practitioner.
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Purposes of Health Care
Documentation
 Education
• Health care students use the medical record
as a tool to learn about disease processes,
diagnoses, complications, and interventions.
• Clinical rounds and case conferences rely
heavily on information contained in the
medical record.
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Purposes of Health Care
Documentation
 Research
• Researchers rely heavily on medical records
as a source of clinical data.
• Documentation can validate the need for
research.
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Purposes of Health Care
Documentation
 Legal and Practice Standards
• In 80% to 85% of malpractice lawsuits
involving client care, the medical record is
the determining factor in providing proof of
significant events.
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Legal and Practice Standards
 Informed Consent
 Advance Directives
 American Nurses Association (ANA)
Standards of Care
 State Nurse Practice Acts
 Joint Commission on Accreditation of
Health Care Organizations (JCAHO)
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Legal and Practice Standards
 Informed consent means that the client
understands the reasons and risks of the
proposed intervention.
 Witnessing confirms that the person who
signs the consent is competent.
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Legal and Practice Standards
 An advance directive allows the client to
participate in end-of-life decisions.
 The Patient Self-Determination Act of
1990 requires health care facilities to
document whether the client has such a
directive.
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Legal and Practice Standards
 American Nurses Association Standards
of Care make explicit the role of data
collection and documentation in nursing
practice.
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Legal and Practice Standards
 State Nurse Practice Acts have
established guidelines to ensure safe
practice.
 Require evidence of compliance through
documentation.
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Legal and Practice Standards
 The Joint Commission on Accreditation of
Health Care Organizations (JCAHO)
requires documentation of compliance
with its standards of care requirements.
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Purposes of Health Care
Documentation
 Reimbursement
• Peer review organizations (PROs) are
required by the federal government to
monitor and evaluate care.
• Medical record documentation is the
mechanism for the PRO review.
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Purposes of Health Care
Documentation
 Reimbursement
• Diagnosis-Related Groups (DRG)
- The medical record must provide documentation
that supports the DRG and appropriateness of
care.
- If nurses fail to document the equipment or
procedures used daily, reimbursement to the
facility can be denied.
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Purposes of Health Care
Documentation
 Reimbursement
• Consolidated Omnibus Budget (COBRA)
Reconciliation Act
- Any COBRA client receiving care in an
emergency room must be stabilized before being
transferred to another facility.
- Facilities in violation of COBRA laws are fined
and may lose their eligibility for Medicare and
Medicaid funding.
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Principles of Effective
Documentation
 Nursing notes must be logical, focused,
and relevant to care, and must represent
each phase of the nursing process.
 Nursing documentation based on the
nursing process facilitates effective care.
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Elements of Effective
Documentation
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Use of Common Vocabulary
Legibility
Abbreviations and Symbols
Organization
Accuracy
Documenting a Medication Error
Confidentiality
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Elements of Effective
Documentation
 Use of Common Vocabulary
• Enhances the quality of documentation.
• Supports the efforts of research.
• Improves communication and lessens the
chance of misunderstanding between
members of the health team.
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Elements of Effective
Documentation
 Legibility
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•
•
•
•
Print if necessary.
Do not erase or obliterate writing.
Draw one line through an erroneous entry.
State the reason for the error.
Sign and date the correction.
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Elements of Effective
Documentation
Correcting a documentation error
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Elements of Effective
Documentation
 Abbreviations and Symbols
• Always refer to the facility’s approved listing.
• Avoid abbreviations that can be
misunderstood.
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Elements of Effective
Documentation
 Organization
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Start every entry with the date and time.
Chart in chronological order.
Chart in a timely fashion to avoid omissions.
Chart medications immediately after
administration.
• Sign your name after each entry.
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Elements of Effective
Documentation
Charting a late entry
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Elements of Effective
Documentation
 Charting a prn
medication
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Elements of Effective
Documentation
 Accuracy
• Use factual, descriptive terms to chart
exactly what was observed or done.
• Use correct spelling and grammar.
• Write complete sentences.
• Maintain continuity of care by recording with
respect to notes made on previous shifts.
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Elements of Effective
Documentation
 Documenting a Medication Error
• Chart the medication on the MAR.
• Document in the nurses’ progress notes:
- Name and dosage of the medication
- Name of the practitioner who was notified of the
error
- Time of the notification
- Nursing interventions or medical treatment
- Client’s response to treatment
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Elements of Effective
Documentation
 Confidentiality
• The nurse is responsible for protecting the
privacy and confidentiality of client
interactions, assessments, and care.
• The client’s significant others, insurance
companies, or other parties not directly
involved in care provided by the health team
may not have access to clients’ records.
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Methods of Documentation
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Narrative Charting
Source-Oriented Charting
Problem-Oriented Charting
PIE Charting
Focus Charting
Charting by Exception (CBE)
Computerized Documentation
Case Management with Critical Paths
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Methods of Documentation
 Narrative Charting
• Describes the client’s status, interventions
and treatments; response to treatments is in
story format.
• Narrative charting is now being replaced by
other formats.
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Methods of Documentation
 Source-Oriented Charting
• Narrative recording by each member
(source) of the health care team on separate
records.
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Methods of Documentation
 Problem-Oriented Charting (POMR)
• Uses a structured, logical format called
S.O.A.P.
- S: subjective data
- O: objective data
- A: assessment (conclusion stated in form of
nursing diagnoses or client problems)
- P: plan
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Problem-Oriented Charting
(POMR)
 Uses flow sheets to record routine care.
 A discharge summary addresses each
problem.
 SOAP entries are usually made at least
every 24 hours on any unresolved
problem.
 SOAP was developed on a medical
model.
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Problem-Oriented Charting
(POMR)
 SOAPIE and SOAPIER refer to formats
that add:
• I: Intervention
• E: Evaluation
• R: Revision
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Problem-Oriented Charting
(POMR)
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Methods of Documentation
 PIE Charting
• P: Problem
• I: Intervention
• E: Evaluation
 Key components are assessment flow
sheets and the nurses’ progress notes
with an integrated plan of care.
 PIE charting is a nursing model.
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Methods of Documentation
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Methods of Documentation
 Focus Charting
• A method of identifying and organizing the
narrative documentation of all client
concerns.
• Includes data, action, response.
• Uses a columnar format within the progress
notes to distinguish the entry from other
recordings in the narrative notes.
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Methods of Documentation
 Charting by Exception (CBE)
• The nurse documents only deviations from
preestablished norms.
• Avoids lengthy, repetitive notes.
• Enables the identification of trends in client
status.
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Methods of Documentation
 Computerized Documentation
• Increases the quality of documentation and
save time.
• Increases legibility and accuracy.
• Enhances implementation of the nursing
process. Enhances the systematic approach
to client care.
• Provides clear, decisive, and concise key
words (standardized nursing terminology).
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Methods of Documentation
 Computerized Documentation
• Provides access to other data, enhancing
critical thinking.
• Information is quickly coordinated and
integrated by other departments.
• Facilitates statistical analysis of data.
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Methods of Documentation
 Point-of-Care System
• A handheld portable computer is used for
inputting and retrieving client data at the
bedside.
• Provides each health care practitioner with
all pertinent client data to ensure continuity
of care without duplication.
• Provides crucial client information in a timely
fashion.
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Methods of Documentation
 Case Management Process
• A methodology for organizing client care
through an illness, using a critical pathway.
• A critical pathway is a monitoring and
documentation tool used to ensure that
interventions are performed on time and that
client outcomes are achieved on time.
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Forms for Recording Data
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Kardex
Flow Sheets
Nurses’ Progress Notes
Discharge Summary
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Forms for Recording Data
 The Kardex is used as a reference
throughout the shift and during changeof-shift reports.
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Client data
Medical diagnoses and nursing diagnoses
Medical orders
Activities
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Forms for Recording Data
 Flow sheets reduce the redundancy of
charting in the nurses’ progress notes.
 The information on flow sheets can be
formatted to meet the specific needs of
the client.
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Forms for Recording Data
 Nurses’ progress notes are used to
document the client’s condition, problems
and complaints, interventions, responses,
achievement of outcomes.
 Progress notes can be completely
narrative or incorporated into a
standardized flow sheet.
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Forms for Recording Data
 Discharge Summary
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Client’s status at admission and discharge
Brief summary of client’s care
Interventions and education outcomes
Resolved problems and continuing need
Referrals
Client instructions
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Trends in Documentation
 Standardized data bases are required to
ensure accuracy and precision in nursing
information systems.
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Trends in Documentation
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Nursing Minimum Data Set (NMDS)
Nursing Diagnoses (Taxonomy II)
Nursing Intervention Classification (NIC)
Nursing Outcomes Classification (NOC)
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Reporting
 Verbal communication of data regarding
the client’s health status, needs,
treatments, outcomes, and responses
 Summary of current critical information to
facilitate clinical decision making and
continuity of client care
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Reporting
 Reporting is based on the nursing
process, standards of care, and legal and
ethical principles.
 Reports require participation from
everyone present.
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Reporting
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Summary Reports
Walking Rounds
Telephone Reports and Orders
Incident Reports
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Summary Reports
 Commonly occur at change of shift (or
when client is transferred).
• Assessment data
• Primary medical and nursing diagnoses
• Recent changes in condition, adjustments in
plan of care, and progress toward expected
outcomes
• Client or family complaints
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Walking Rounds
 Nursing, physician, interdisciplinary
 Occur in the client’s room and include the
client
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Telephone Reports and Orders
 Report transfers, communicate referrals,
obtain client data, solve problems, inform
a physician and/or client’s family
members regarding a change in the
client’s condition.
 Telephone orders are documented in the
nurses’ progress notes and the physician
order sheet.
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Documenting a Telephone Order
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Incident Reports
 Used to document any unusual
occurrence or accident in the delivery of
client care.
 The incident report is not part of the
medical record, but it may be used later
in litigation.
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