Documentation and Reporting
Teresa V. Hurley
MSN,RN
Charting
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The process of recording vital information
that is communicated to others.
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Facts and figures that are specific, clear and
precise
Contains correct language, medical terms and
abbreviations
Observations, interventions and communications
Reports to authorities as child or elder abuse
Charting
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Assessment of quality and effectiveness of
nursing care
Permanent record
Assessment of quality and effectiveness of
nursing care
Legal Document in the event of litigation or
prosecution
If not charted, legally it was not done
Charting
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Legal Requirements
-regulated by state laws
-professional standards
-Joint Commission on Accreditation of Health Care
Organizations [JCAHO]
Charting Specifics
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Black ball point pen because it microfilms best
Errors are corrected by drawing a single line through
the error. Above write “Mistaken Entry” [ME] and your
initial.
No white-out, erasers, eradicators, covering-up
materials
Error no longer written. Juries associate it with an
actual nursing mistake
Charting Specifics
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Each entry is signed with your first initial, last
name and status
J. Smith, SN
 R. Jones, RN
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Script not printing is used for the signature
and it should appear at the right hand
margin of the narrative note.
Charting Specifics
Notes are written on each succeeding line
 Lines are not omitted
 A horizontal line is drawn to “fill up” a partial
line
 Each entry is dated and timed
 Begin with a Capital letter
 End with a period
Does not have to be complete sentences
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Charting Specifics
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Be accurate
Describe behaviors
Use approved abbreviations and symbols
Spell correctly
Used correct terminology and grammar
Write legibly [Printing is acceptable]
Chart only what you have done
Do not double chart [data appears on a flow sheet]
except when the patient has a change in their
condition
Charting Specifics
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If you forgot to chart something do so on the next
available line putting the time of the event and not
the time you are actually charting it
Physician visits
Time client left and returned to unit including
transportation and destination
Medications: dosage, route, site, pain relieved, time
worked, and/or side effects
Treatments
Charting Specifics
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Chart objective facts
-ate 100% and not “good appetite”
-client/patient c/o placed in quotes
“stabbing; “chest pain”; “going down” his “left arm”
-objective observations
-skin cold and clammy; diaphoretic,
-v/s B/P 70/40; Pulse 122 bpm, irregular, 1+;
Charting Format
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Assessment at the start of the shift
Changes in mental, psychological,
physiological conditions
Reactions to procedures or medications
Teaching
-Document what was taught
and the client’s response
Charting Systems
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Source-oriented
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Data entered according to the source [i.e. nurse,
MD, social worker, respiratory therapy etc.]
Form of charting is a narrative
Overall picture is difficult to ascertain
Narrative Charting
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Used with flow sheets and other systems
Chronological data quickly documented
Familiar form
Used in all types of settings
Narrative Charting Disadvantages
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Lack of a systematic structure hinders
making relationships between data
Requires time
May lack information concerning client
outcomes
Quality Assurance monitoring more difficult
Relevant data found in several places
Charting Systems
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Problem-oriented
-Data organized based on problems
-Each member of the health team documents
on the same problem
-The overall picture can be seen easily
-Focus is on the client and not on the person
or department reporting
Problem-Oriented Medical Records
POMR
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Focus is on the client
One set of progress notes is used by all
persons caring for the client
Format is called SOAP or SOAPIE
POMR: SOAP or SOAPIE
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Subjective
Objective
Assessment
Plan
Implementation
Evaluation
Charting Systems
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Computer-Assisted
-Data legible
-Quick access to data and information between departments
-Easily retrievable
-Quick assess to data
-Confidentiality maintained
-Bedside computers increase accuracy and speed of charting
-Meet JCAHO standards
-Increase speed and completeness of reimbursement
Disadvantages of Computer-Assisted
Charting
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Expensive to purchase and update
Problems with “downtime” interfere in
charting and receiving information
Increase charting time if not enough
terminals
Reliance on technology instead questioning
data which may be wrong
REPORTING: INTRASHIFT
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Verbal reports during your shift to other team
members
-Significant changes in Vital signs
-Unusual reactions to treatments,
procedures, medications
- Changes in physical or psychological
condition
Reporting
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Intershift
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Verbal or tape recorded
Client’s Name, Age, Room Number, MD,
Diagnosis, Date of Surgery
Changes or unusual occurrences
Laboratory results, studies, tests to be done on
next shift
Physical or psychological problems
REPORTING: MD NOTIFICATION
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Significant changes in physical assessment,
abnormal laboratory findings, test results
Identify self to MD by name, status, unit and
client’s name
State exact reason why you are calling
Current vital signs, laboratory results,
medications etc. should be available
REPORT to NURSING
ADMINISTRATORS
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Written or Verbal each shift
Data on critically ill clients
Unusual occurrences
Problems with clients, families or other
disciplines
INCIDENT REPORT
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Unusual Occurrence, Variance or Incident
Report [IR]
Helps to document quality care
Identify areas where staff development is
needed
Maintain detailed record of incident for
possible legal action