Documentation
Craven Ch. 15
3/17/2016
NRS 320 2012
1
Why communication is important
3/17/2016
NRS 320 2012
2
Patient Medical Record
 Purposes of the medical record
 Clear, accurate, and up-to-date patient
documentation of
 Patient’s progress
 Care provided
 Legal document
 Communication to HCT
 Assessment information/changes
 Care planning [ADPIE]
3/17/2016
NRS 320 2012
3
Patient Medical Record (Cont’d)
 Purposes of the medical record
 Quality assurance
 Reimbursement
 Research
 Education
3/17/2016
NRS 320 2012
4
Principles of documentation
 Confidential
 Accurate
 Complete
 Concise
 Objective
 Organized
 Timely
 Legible
3/17/2016
NRS 320 2012
5
Documentation
 Documentation style varies by facility
 Content should be similar
 Factual, concise LEGAL RECORD
 Arranged by Nursing Diagnosis or Focus
 Time of charting, assessment, what was
done [when/why], effect/response
 Sign name, title
 Error? One line through and initial
3/17/2016
NRS 320 2012
6
Nursing Entries in the Patient
Record
 Patient care summary or Kardex
 Admission entries
 Flow sheets
 Charting by exception [CBE]
 Nursing progress notes
 Narrative notes
 FOCUS DART notes
 Plan of care
3/17/2016
NRS 320 2012
7
Nursing Entries in the Patient
Record (Cont’d)
 Written handoff summary
 When care or patient is transferred
 Nursing discharge summary
 Usually standardized
 Medication administration record
[MAR/eMAR]
 Documentation of care in non–acute care
settings
 Incident report
 Not part of patient chart
3/17/2016
NRS 320 2012
8
DAR(T) Charting
 D = Data
 “pt. c/o pain 6/10 in L hip at 1245”
 A = Action
 “ Fentanyl 50 mcg IVP given @ 1300”
 R = Response
 “Pt. rated pain at 2/10 within 10 min”
 T = Teaching
 “Reminded pt. to request analgesics when
pain > 3/10; reviewed side effects/fall risk ”
3/17/2016
NRS 320 2012
9
DART charting
 (ND: acute pain r/t tissue trauma)
 1330: D-pt. c/o pain 6/10 in L hip. AFentanyl 50 mcg IVP given @ 1300. R- Pt.
rated pain at 2/10 within 10 min. T Reminded pt. to request analgesics when
pain > 3/10; reviewed side effects/fall risk.
_______________________CCollingsRN
3/17/2016
NRS 320 2012
10
DART Example 2
 10/5/2012 1145
 Nursing Diagnosis: Nausea R/T anesthetic
 D: Pt. states, “I feel nauseated.” vomited
100 mL of yellow/green fluid at 1055.
 A: Pt. given Compazine 10 mg IV at 1100.
Will monitor pt.'s response to med.
 R: Pt. voiced relief of nausea at 1130 and
has had no further episodes of vomiting.
 T: Call light & emesis basin in reach; sips
of ginger ale encouraged. CCollingsRN
3/17/2016
NRS 320 2012
11
Example 3
 Nursing Diagnosis: Risk for infection related to surgical incision
 10/5/2012 1400
 D: Incision site in front of left ear extending down and
around the ear and into the neck. Incision is
approximately 6” in length, edges well approximated with
sutures intact. No dressing present. Incision without
redness, swelling or drainage however, bruising noted
below the left ear. JP drain intact in left neck with
approx. 20 mL of bloody drainage.
 A: Will continue to monitor and assess incision and drain
site for any signs of redness, swelling or drainage. Will
also monitor temp. every 4 hours, change dressing PRN
 R: Currently no evidence of infection noted. Pt. afebrile.
 T: Taught pt. and family signs and symptoms of infection
to watch for upon discharge. Pt. and family voiced
understanding of information provided. CCollingsRN
3/17/2016
NRS 320 2012
12
Narrative Charting
 Usually in long-term care
 Can use DART format as in example 1
 ND/ focus in margin
 Sometimes use DRG as focus
 Combines info for shift into 1 paragraph
 Concise but complete
3/17/2016
NRS 320 2012
13
Computer Charting
 Usually in acute settings; becoming near
universal
 Chart by exception
 Use ‘Nurses Notes’, Progress Notes or
other area for DART charting
3/17/2016
NRS 320 2012
14
Legal Implications
 If it isn’t documented, it isn’t done
 Exception is CBE
 What you document is the legal record of
what happened
 Will you remember 5 or 10 years from
now?
 Balance between complete and concise
 What, When, Why, Who
 Never document until done
3/17/2016
NRS 320 2012
15
Documenting in the MAR
 Draw meds for ONE pt at a time
 Mark med cup with pt initials
 As you dispense each pill, make a dot
where you will sign
 Notice what pills look like [in case of drop]
 When taken, go back and initial
 Sign at bottom/back of page
3/17/2016
NRS 320 2012
16
eMAR [electronic MAR]
 Document administration of medications
 As soon as administered
 Generated by pharmacy
 Routine administration times indicated
 PRN meds:
 Time, reason, effectiveness
 Drug not given?
 Note reason
3/17/2016
NRS 320 2012
17
What NOT to chart
 ‘Pt. tolerated well’
 No complaints [use ‘denies pain’]
 ‘Difficult pt.’ [describe behavior instead]
 Terms you don’t understand –
 Describe sounds, drainage if not sure of
correct term
 Error-prone Abbreviations
 Table15-1, pg. 245-6
3/17/2016
NRS 320 2012
18
Documentation Discussion
 Mrs. Smith had a terrible night. She was
bloated and very nauseated. BS present X
4 quadrants. C/O doctor never coming to
see her and not being interested in how
she felt when he does.
 VS: B/P 176/74, P 92, R18, O2 Sat 95%
 C/O incisional pain; MS given. She was
also upset about her family. SDoofus,RN
3/17/2016
NRS 320 2012
19
Documentation Discussion
 Identify missing information you need to
assume care for Ms. Smith
 What legal and ethical problems does this
documentation present?
 What positive qualities are included in this
charting? Find 3
 Construct a correctly written DART chart
entry for this info; use hypothetical data as
needed.
3/17/2016
NRS 320 2012
20