Documentation
Documentation
 Nurses are legally and ethically bound to keep
patient information confidential
 Nurses must work to protect patient records
from unauthorized readers
 Documentation is required by the ANA
standards for practice and nurse practice acts
in all states
Nursing charting is used for:
 Communication of patient
needs/progress/therapy between healthcare
providers
 Financial billing
 Chart reviews by researchers, accreditation
agencies, and lawyers in event of malpractice
suits
Charting guidelines
 Be sure to review chart p. 486
 Do not use White-Out on any patient charts or
records
 Anyone reading the chart afterward may wonder
what you are trying to cover up
 Altering patient charts is a criminal offense
 Document times accurately
 Malpractice suits have been won due to
inaccuracies in documentation about when care
was delivered
 Do not use abbreviations that are not accepted
by the facility
Charting guidelines
 Only enter factual information, not opinions
like:
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“The patient was very cranky today”
“The patient’s wound stunk really bad”
“The patient had a good day today”
“Patient appeared more whiny today”
 If you make a mistake, draw a single line
through it, write “error” and sign your name
afterward
 Always include the date and time with each
entry with your signature and credentials (RN)
Methods of Recording
 Narrative Documentation
 Traditional for recording nursing data
 Storylike format
 Disadvantages: tendency to have
repetitious info; time consuming; require
the reader to sort through much info
Methods of Recording
 Problem-Oriented Medical Record (POMR)
 Method of documentation that places emphasis
on the client’s problems
 Data are organized by problem or diagnosis
 Major sections:
 Database
 Problem list
 Nursing care plan
 Progress Notes:
 SOAP charting/ SOAPIE
 PIE format: has a nursing origin, simplifies
documentation
Source Records
 The client’s chart is organized so that
each discipline (nursing, medicine,
social work, respiratory therapy) has
a separate section in which to record
data
Charting
 Focus of charting will reflect specialty areas of
care. For instance:
 Rehab: patient mobility, continence, compliance
with therapy
 Critical care: monitors, lines, ventilator settings
 Labor & delivery: dilation of cervix, fetal heart
rate, pain management
 Specialty areas will often have specific flow
sheets for charting as well as blank areas for
narrative charting as well
Watch your handwriting!
 Even though doctors’ handwriting is a running
joke, it is very important that your charting is
legible!
 Illegible entries can be misinterpreted- not
good if the charting is used in a malpractice
lawsuit
 Only black ink is acceptable!
 Do not leave any blank spaces in the chartsomeone may come later and add information
in your notes
Charting
 Old saying:
“If it wasn’t charted, it wasn’t done!”
 Important for billing and if chart is ever called
into evidence in a lawsuit
 Hospitals are now facing huge fines for fraudbilling for procedures/treatments that were not
done
 If information is not recorded, it is not
available for other members of the healthcare
team caring for the patient
Charting
 Must be current and up to date
 Best to chart when assessment is done or care
is delivered, not at the end of the shift
 Frequency depends on unit and care:
 Code blue: may chart every minute
 Nursing home: may be daily or weekly
 Do not repeat medical diagnoses from the
patient’s chart or normal findings from the
physical assessment flow sheet
Charting
 If you chart about a problem, chart what you
did about it
 “Patient complained of severe incisional painmorphine 10 mg given with relief stated
afterward”
 Charting style varies by facility
 Narrative notes
 Flow charts
 Computer entry
 Do not chart ahead of time- patients refuse
treatments/medications all the time!
Charting
 If you do a procedure on another nurse’s
patient, chart on that patient’s chart- include
the appropriate information and sign your
name
 DO NOT chart on procedures that you did not
do
 If another nurse does a procedure on your
patient, chart as such:
 “18 French Foley catheter inserted by S.
O’Meara RN, patent with clear yellow urine”
Charting by Exception (CBE)
 An approach used to
 eliminate redundancy,
 ensure concise documentation of routine
care
 emphasize abnormal findings
 Identify trends in clinical care.
Shift report
 At the end of each shift, nurses give report
about their patients to the on-coming nurse
 May be given face-to-face, written down, or on
audiotapes
 Purpose is to provide continuity of care
 Important information is relayed so that nurses
can provide appropriate care
Shift report
 Must be done quickly and efficiently
 Should include:
 Background information (admitting
diagnosis, physician, room number)
 Assessment findings and lab values
 Treatments and patient education
 Family information
 Priority needs
 Discharge planning
Telephone reports
 Should be documented when significant
events or changes in a patient’s condition
have occurred
 Documenting phone calls:
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When call was made
Who made call and who was called
Who the information was given to
What information was given
What information was received
If no order was received from the physician,
document as such
Telephone & verbal orders
 Physicians may give orders over the phone to
an RN
 Order needs to be verified by repeating it
clearly to the physician
 RN is responsible for writing the order in the
patient’s record
 Telephone orders may only be given to RNs,
not LPNs
 Telephone orders may not be left with unit
secretaries or on voice mail
Incidents
 An incident is any event that is not consistent
with the routine care for a patient or nursing
unit
 Examples of incidents:
 Malfunctioning patient equipment
 Patient falls or injuries
 Needlestick injuries
 Medication errors
Incident reports
 Should be filled out for any kind of incident
that occurs
 If in doubt, ask nursing supervisor
 Specific reports may be needed for some
incidents such as:
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adverse medication effects
medication injuries
needlestick injuries
patient falls
 Are filled out in addition to any appropriate
entries that are made in the patient’s chart
regarding the incident
Incident reports
 DO NOT chart in the narrative/ patient’s chart
that an incident report was filled out:
 Incident reports are for internal investigations
within the facility only, and are reviewed by
facility supervisors and managers
 If the presence of an incident report is included
in the patient’s chart, it may be subpoenaed as
evidence in a malpractice lawsuit