DOCUMENTATION
Documentation
If it is not charted,
it wasn’t done!!!
Documentation
The written or printed legal record of all pertinent
interactions with the client.
It reflects quality of care and accountability in
providing care.
Health personal communicate through:
• Discussion
• Reports
• Records
Documentation
A discussion: informal oral consideration of a
subject by 2 or more health care personnel to ID
problem or establish strategies to resolve a problem
A report: is oral, written or computer based
communication intended to convey information to
others (endorsement).
A record (chart or client record): is a formal, legal
document that provides evidence of a client’s care.
Can be written or computer based.
The process of making entry on a client record is
called recording, charting, or documenting.
Documentation Purposes
Communication
Planning client care: uses data from the client records
to plan care
Auditing heath agencies: review of client records for
quality assurance purpose
Research: data can be valuable resource for research
Education: Students often use client records as
educational tools
Legal Documentation: used in the court as
evidence
Reimbursement: for obtaining payment
through medicare, the client’s record must
contain the correct diagnosis-related group
codes and reveal that the appropriate care has
been given
Health care analysis: to ID health care agency
needs, ID services that cost money and those
that generate revenue
Documentation Systems
I. SOURCE ORIENTED RECORD
The traditional client record and organized by discipline
Each person or department makes notations in a separate section
or sections of the client’s chart (Admission departments have
their own sheet, physicians have their own sheets, nurses have
their own sheets…etc)
Advantage: easy to locate discipline specific information
Disadvantage: not organized by client problem, therefore difficult
to track; fragmented and have repetition in the information which
decreases communication among health care team, an incomplete
picture of the client’s care, and lack of coordination of care
Narrative Charting:
A traditional part of the source oriented record
Consists of written notes that include routine care, normal
findings, and client problems
There is no right or wrong order to the information (may
used in emergency situations), chronological order is used
frequently
…..
II. PROBLEM ORIENTED MEDICAL RECORDS (POMR):
Documentation organized around client problems rather than the
source of information
all disciplines record on same form
Advantage: encourages collaboration, and the problem list in the
front of the chart alerts care givers to the client’s needs and makes it
easier to track the status of each problem
Disadvantages: caregivers differ in their ability to use the required
charting format, it takes constant awareness to maintain an up to date
problem list, and it is somewhat inefficient because assessments and
interventions that apply to more than one problem must be repeated.
Components: Database, problem list, Plan of care, and progress note
Data base: contains all information known about
client when the client 1st enters the health care
agency, updated according to change in health
status
Problem list: derived from the data base, problems
are listed in order in which they are identified,
redefined as patient condition changed or more
data obtained
Plan of care: made with reference to active
problem list, it generated by the person who lists
the problem, listed under each problem in progress
note
Progress notes:
Is a chart entry made by all heath professionals involved in a
client’s care
All use same type of sheet for notes
Numbered to correspond to the problems on the problem list
SOAP format is frequently used.
SOAP/SOAPIE/SOAPIER / APIE/ APIERformat:
 Subjective data
 Objective data
 Assessment
 Plan
 Intervention
 Evaluation
 Revision
III. PIE:
Groups information into three categories
Consist of flow sheet (assessment) and progress note.
Acronym for:
Problem:
Intervention
Evaluation
NANDA used to word the problem
The problem statement, intervention and
evaluation where numbered the same
Advantage: eliminate traditional CP and
incorporates an ongoing care plan
Disadvantage: all nursing note should be
reviewed before giving care to determine which
problems are current and which intervention
were effective.
IV. Focus Charting:
It intended to make the client and client concerns and
strengths the focus of care.
Three columns for recording are usually used: date and
time, focus, and progress note
Focus may be a condition, nursing diagnosis, a behavior,
or S/S, client strength
The progress notes are organized into:
DAR
D: Data: assessment phase
A: Action: planning and implementation
R: Response: evaluation phase
Summary of focus charting
Date\time
Focus
- Condition
- Nsg Dx
- S&S
21/10
9:00
pain
progress note
- Data: S&O data
- Action: P&I
- Response: E
D: abd. Incision, facial
grimacing. Rates pain
at 8 on scale 0-10
A: administer morphine
sulfate 4 mg IV
R: Rates pain at 1. states
welling to ambulate
V. Charting by Exception (CBE):
1.
2.
3.
•
Is a documentation system in which only abnormal or
significant findings or exceptions to norms are recorded
Flow sheets: as graphic records, fluid balance records, daily
nursing assessment record, skin assessment record
Standards of nursing care: eliminates much of the repetitive
charting of routine care.
Bedside access to chart form: all flow sheets are kept at the
client’s bed side to allow immediate recording and to eliminate
the need to transcribe data from the nurse’s worksheet to the
permanent record.
Advantage: is the elimination of lengthy, repetitive notes and it
makes client changes in condition more obvious.
VI. Computerized Documentation:
Used to store clients database, add data, create
and revise CP, and document client progress
It make care planning and documentation easy
It made transmission of information from one
care setting to another possible.
VII. Case Management:
Uses multidisciplinary approach to planning and
documenting client care, using critical pathway
Id the outcome that certain groups of client are expected
to achieve on each day of care
It uses critical pathway, graphics and flow sheet
Promote collaboration and teamwork among caregiver,
helps decrease length of stay, make efficient use of time
Work for client with one or two diagnosis and few
needs.
Client with multiple diagnosis difficult to document on
critical pathway.
Documenting Nursing Activities
Admission Nursing Assessment
Nursing Care Plans
Kardexes
Flow Sheets
Progress Notes
Nursing Discharge\referral
General Guideline for Recording
Date and Time
Timing
Legibility
Permanence
Accepted
Terminology
Correct Spelling
Signature
Accuracy
Sequence
Appropriateness
Completeness
Conciseness
Legal prudence
Documentation
Correcting errors in charting:
Single line through error
Write “error” above entry
Date, time and initial “errored” entry
Reporting
Purpose: to communicate specific information to a
person or group of people.
Should be concise, include pertinent information
no extraneous details
Include change of shift report, telephone report,
care plan conference, and nursing round.
Change of shift report
Is a report given to all nurses on the next
shift
Purpose: provide continuity of care for pt
May be written or given orally (face to face
or by audiotape record)
Sometimes given at the bedside, where
client and nurse participate in information
change.
Telephone Report
The nurse receive telephone report should document the
date &time, the person name giving the information, the
subject of information, then sign the notation.
information should repeated back to the sender to ensure
accuracy
Be concise and accurate, begin with name and
relationship to the client
It include (pt name, medical diagnosis, V\S, significant
lab data), keep the pt record available to give Dr any
additional information
After reporting, the nurse document the date and time,
call content.
Telephone Orders
Physician states prescribed therapy over the phone to the
registered nurse
TO transcribe to the physician order sheet, indicate as
VO or TO
Then the order should be signed by the physician in a
period of time (24hr’s)
Include the following information:
 Date & time orders accepted
 Stated order
 Signature & credentials of the nurse
 Name of the ordering physician
-
Care Plan Conference: Meeting of a group of
nurses to discuss possible solutions to certain
problems of a client
Nursing Round: procedure in which 2 or more
nurses visit selected clients at bedside to :
Obtain information that help in Nsg CP
Provide chance for the client to discuss their care
Evaluate nursing care received to pt