CHARTING BASICS

What Is Documentation? Documentation means to give written information that is proof or support of something that has been done or observed. Simply put, a medical record is the record of all care that is provided. If it is not recorded, it did not happen. If it is recorded incorrectly, it happened incorrectly. A nurses documentation provides a clear picture of the status of the patient, the actions of the nurse, and the patient outcomes. easons for documentation! To facilitate communication "hrough documentation, nurses communicate to other nurses and care providers their assessments about the status of patients, nursing interventions that are carried out and the results of these interventions. Documentation of this information increases the li#elihood that the patient will receive consistent and informed care or service. "horough, accurate documentation decreases the potential for miscommunication and errors. To promote good nursing care Documentation encourages nurses to assess patient progress and determine which interventions are effective and which are ineffective, and identify and document changes to the plan of care as needed. To meet professional and legal standards Documentation is a valuable method for demonstrating that, within the nurse$ patient relationship, the nurse has applied nursing #nowledge, s#ills and %udgment according to professional standards. "he nurses documentation may be used as evidence in legal proceedings such as lawsuits, coroners in&uests, and disciplinary hearings through professional regulatory bodies. In a court of law, the patients health record serves as the legal record of the care or service provided. 'ursing care and the documentation of that care will be measured according to the standard of a reasonable and prudent nurse with similar education and e(perience in a similar situation. To assure reim ursement of the cost of care In health care, sometimes private insurance and )edicare will deny payment if documentation is not satisfactory or is not done at all. *ayment can be denied if documentation is missing or incomplete. +ood documentation has five important characteristics. It should be! ,- factual. /- accurate. 0complete. 1- current 2timely-. and 3- organi4ed. If the accuracy of a nurses charting is &uestioned in a court of law, &uestions might be raised about the credibility of both the documentation and the nurse 2 ', /550-. "he timeliness of documentation will be dependent upon the patient. 6hen patient acuity, comple(ity and variability are high, documentation will

be more fre&uent than when patients are less acute, less comple( and7or less variable. *atients who are very ill, considered high ris#, or have comple( health problems generally re&uire more comprehensive, in$depth and fre&uent documentation.

T!pes of charting Flow sheets and checklists are fre&uently used to document routine and ongoing assessments and observations such as personal care, vital signs, inta#e and output, etc. Information recorded on flow sheets or chec#lists does not need to be repeated in the progress notes. Focus charting progress notes are used to document patient progress in meeting established goals. 8ommon formats include S9A*, S9A*I: , *I:, and DA . 6hat information is included in the progress notes; *rogress notes 2nurses notes- are used to communicate nursing assessments, interventions carried out, and the impact of these interventions on patient outcomes. In addition, progress notes are intended to include! patient assessments prior to and following administration of * ' medications. information reported to a physician or other health care provider and, when appropriate, that providers response. all patient teaching. all discharge planning, including instructions given to the patient and7or family and planned community follow$up. all pertinent data collected in the course of providing care, including data collected through technology such as monitoring devices 2e.g., strips produced during cardiac or fetal monitoring-. and action ta#en by the nurse on behalf of the patient 2including calls to physician and discussions with other health care team members-. :(amples of DA notes DA is a form of focus charting. A note is written to provide documentation related to a specific focus. "he focus might be a nursing diagnosis, patient problem, sign or symptom, change in patients condition, or any significant event. "he progress note is written in DA format which stands for Data$Action$ esponse. Data! Sub%ective and7or ob%ective information that supports the stated focus or describes the patient status at the time of a significant event or intervention. Action! 8ompleted or planned nursing interventions based on the nurses assessment of the patients status and any changes to the care plan deemed appropriate. Response! Description of the patients response to nursing or medical care and progress in achieving outcomes7goals. DA notes do not need to always have all three components. Some notes will %ust contain one or two of the three parts. Example 1 <ocus! 'ausea related to anesthetic D! States she=s nauseated. >omited ,55ml clear fluid at //33 A! +iven 8ompa4ine ,mg I> at /055. ! eports no further nausea at /003. 'o further vomiting.

Example 2 <ocus! Acute pain related to surgical incision D! eports pain as ?7,5, grimaces and groans with movement @* ,317AA. Bad received *9 analgesic at //55. A! +iven morphine ,mg I> at /003. epositioned on left side. ! eports pain as ,7,5 at /033. @* ,0A7A/. Example 3 <ocus! is# for infection related to incision sites D! Incision site in front of left ear e(tending down and around the ear and into nec#C,1 cm in length$$without dressing. Dac#son$*ratt drain in left nec# below ear secured in place with suture. A! Assess site and emptied drain. "aught patient SES of infection. ! 'o swelling or bleeding. bruising below left ear noted. D* drained /5mF bloody drainage. States understanding of teaching. Example 4 <ocus! Delayed surgical recovery D! 879 di44iness after trying to get 99@ to use the bathroom. A! Assisted patient bac# in bed and with use of bedpan by 8'A. "aught how to dangle legs and get 99@ slowly. "aught coughing and deep breathing e(ercises, turning in bed, and use of anti$embolism stoc#ings. ! >oided /55mF in bedpan. Did cough and deep breathing appropriately. Fungs clear bilaterally. Anti$embolism stoc#ings on. Example 5 <ocus! )edications D! 6ife stated patient ta#es Synthroid 5.,/3 mg daily, has for ,/ years. A! *hysician notified, order received, Synthroid given. Note" 8omplete sentences arent used. It is assumed that a note in a particular patients chart is written about that patient. It is assumed that the nurse writing the note performed the actions unless otherwise indicated. "he reasons for the action usually arent included nor are the nurses thoughts about the situation.

S#$$AR% What to do" o 8hec# to be sure you have the correct chart before you begin writing o )a#e sure your documentation reflects the nursing process o 8hart completely but be concise 2and accurateGo 8hart time for each entry o Document une(pected findings7occurrences o 8hart precautions or preventative measures o <or procedures, include the following! what was done, when it was done, who did it, how it was done, how the patient tolerated it, adverse reactions, if any. o ecord each phone call to or from a physician, including e(act time, message, and response. o 8hart as soon as possible after providing care. o 8hart a patients refusal of treatment or medications. o If you remember something important after you have completed your documentation, write late entry and ma#e the note. n hand!written "orms# o 6rite F:+I@FH using a permanent blac# in# pen 2other colors do not photocopy wello If you ma#e a mista#e, draw a line through the error, and indicate it as an error, and then initial it. What not to do" o Dont chart a symptom such as c7o pain without also writing what you did about it. o Dont alter a chartI.this is a criminal offense. o Dont add information at a later date without indicating that you did so. o Dont date the entry so that it appears to have been written at an earlier time. o Dont use shorthand or abbreviations that are not standard. o Dont write vague descriptions such as large amount of drainage o Dont ma#e e(cuses, such as meds not given because not available. o Dont chart what someone else says unless you use &uotations and state who said it. o Dont chart an opinion. o Dont use words that suggest a negative attitude, such as weird or nasty. o Dont chart ahead of time. If something happens it will loo# bad to go bac# and ma#e that correction. o )isspelled words and bad grammar are as bad as illegible handwriting. o Dont record staffing problems. o Dont document that an incident report was completed. o Dont leave any blan# spaces. o Dont save a space for a colleague who forgot to chart.

o Dont chart care that was not given. "his is fraud and cause for loss of license. &lectronic health records" o 'ever reveal or allow anyone access to your personal identification number or passwords 2these are, in fact, electronic signatures-. o Fog off when not using a system or when leaving a terminal. o Shred any print information containing patient information. o etrieve printed information promptly. SBAR J Situation, @ac#ground, Assessment, ecommendation J is a standardi4ed way of communicating. Improving the communication between caregivers can prevent negative patient outcomes and strengthen a teamwor# approach to care. "he S@A techni&ue provides common e(pectations such as what will be communicated, how it=s structured, and what are the re&uired elements. It allows communication to be focused on the problem and not the people. "his is very important when staff members are communicating hand$off information at the change of shifts. "he S@A techni&ue also provides a way to hand$off relevant information in the presence of the patient, allowing active participation of the patient in his or her care. "he patient is central to all information surrounding care activities. *atients can as# &uestions or add information to the discussion. "hrough this process, the patient sees the staff wor#ing as a team and is assured that all involved #now and agree on the plan of care. :vidence suggests that better$informed patients are less an(ious and more li#ely to follow medical advice. Situation' "he KSK component should ta#e about A to ,/ seconds. "he nurse states what=s happening now. If giving a shift report to the ne(t caregiver, the nurse states the patient=s name, why the patient is on the unit, and introduces the nurse coming on duty to the patient. <or e(ample! K)s. D, this is "ina Dones, the registered nurse who will be caring for you today. "ina, )s. D is here to have rehab after her right #nee replacement.K "o be effective, you must be concise, clear, and to the point when giving the report, leaving irrelevant information out of the conversation. Bac(ground' During the K@K component, the nurse gives the ne(t caregiver brief bac#ground information specific to the patient=s relevant history. "his section sets the conte(t for what=s being discussed, which may include the patient=s diagnosis, history of procedures done, and family situation. <or e(ample! K)s. D had a right #nee replacement on Dune 0rd by Dr. Smith. She has a history of hypertension, diabetes, and arthritis. She lives with her husband who=s retired and able to care for her at home when discharged.K Assessment' During the KAK component, the nurse reports the current condition of the patient. <or e(ample! K@lood glucose levels have been stable, vital signs within normal limits, and the incision line is clean and dry with no drainage noted. "he dressing was

changed today. )s. D is able to ambulate to the restroom with a contact guard of one and the use of a wal#er. Ber pain has been reported as a ? on a 5$to$,5 scale and she was given two hydrocodone pills at L a.m. "he hydrocodone appears to be helping her, especially when given before therapy.K Recommendation' During the K K component, the nurse states what he or she thin#s would be the desired response to the patient=s care of the day. She may suggest that discharge planning be initiated by discussing needs with the patient, contacting the physician with discharge plans, and conveying to the rest of the care team what needs to be done before discharge. Hou don=t need to read the entire patient profile or orders. <or e(ample! K)s. D is scheduled for discharge this <riday and will need to spea# to the discharge planner today.K emember, not everything about the patient needs to be conveyed, %ust what=s pertinent to the situation at that time. Also remember that effective communication ta#es two! As# if there are any &uestions and remind team members and the patient that you=ll be available should further clarification be needed.
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RN to )h!sician SBAR &*amples $cenario 1# An ' on the )edical <loor has an order for a patient to receive an e(am that re&uires I> contrast. "he patients creatinine level is /.L. "he ordering physician needs to be called to clarify this order. Situation! Dr. Smith, this is Darlene on )ed7Surg at 9)B. I have an order for a *: study for )r. )arino. Bis creatinine is elevated and I wanted to clarify the order with you. @ac#ground! I see that )r. )arino came into the :D with right$sided chest pain and difficulty breathing. "he 8" for rule$out *: was ordered. Assessment! )r. )arinos creatinine level is /.L, far above the allowable level for a rule$out *: study. ecommendation! I thin# that the order should be changed from a 8" for rule$out *: to an order for a >N scan. $cenario 2# A nurse wants to report a change in patient condition to the physician. Situation! Dr. "homas, this is Fisa in I8O at 9)B. I am caring for )r. Dones, in room 3. )r. Dones has had a change in his heart rhythm.

@ac#ground! )r. Dones had his hip surgery two days ago and has been going in and out of controlled A$fib since his surgery, with rates in the high L5s. )r. Dones has a history of A$fib and was on 8oumadin 3 mg7day and Digo(in 5./3 mg7day prior to his hip replacement. Be has not had any Digo(in or 8oumadin since his surgery. Assessment! "his morning, )r. Dones has gone into an uncontrolled A$fib, with a rate in the ,/5$,05 range. Be is currently asymptomatic and his vital signs are stable, with a blood pressure of ,/57A5. Be is resting comfortably in his room. ecommendation! I am thin#ing that a ,/$lead should be ordered for )r. Dones. 6ould you li#e his Digo(in and7or his 8oumadin to resume; Are there any other tests you would li#e to order; I will call you if )r. Dones converts or becomes symptomatic. 6ould you li#e me to call you with any other information; $cenario 3# A patient is being admitted to 9@ in early labor. "he ' needs to give an update to the on$call 9bstetrician. Situation! Bello, this is Denny from 9@ at 9)B calling to let you #now that )rs. 6inslow has been admitted in early labor. @ac#ground! )rs. 6inslow presented to the :D around ,P55 this evening. She is a 15$ year$old +ravida,para/. She started in labor at 5L55 today. She is BQ, +@S positive, and ubella immune. Ber Bepatitis status is un#nown. Ber membranes are intact. )rs. 6inslow has an allergy to *enicillin, reaction un#nown, but became allergic to *enicillin as a child. Assessment! )rs. 6inslow has been on the monitor for 05 minutes, is contracting every 3 minutes. She is dilated to 0 cm, ?5R effaced, and J, station. @aseline <B" is ,05, with average variability. there are accelerations of ,3$beats7minute and no decelerations. Ber vital signs are stable at LA.L <, @* ,057PA, *ulse ,55, and /1. )rs. 6inslow does not want an epidural. ecommendation! )ay I enter your FED order set; Since Dane is B@SA+ positive, what treatment would you li#e; 6ould you li#e any other lab tests; Bow would you li#e me to contact you today; $cenario 4# A patient who is post$surgical an#le repair is having unsuccessful pain control. "he ' needs to get an order for improved pain coverage. Situation! Bello, this is on from )ed7Surg at 9)B. Im caring for )r. "ree in room 0. Im calling regarding his pain control.

@ac#ground! )r. "ree is a //$year old who had surgical repair of a fractured an#le / days ago. Be has had very minimal pain control since his surgery. Be has an order for "ylenol P35 mg & 1 hours for minimal to moderate pain and )orphine I>, ,$1 mg & / hours for severe pain. Be does not have any allergies to medications. "his is his first time having any type of surgery or significant in%ury. Assessment! )r. "ree ran#s his pain as a L7,5, with a &uality of being sharp and radiating to his mid$calf area. Be is reluctant to ambulate out of bed, even refusing to get into a chair at the bedside. Bis pedal pulses are e&ual, the surgical site is 6'F, and all of his vital signs are stable. ecommendation! I thin# that )r. "ree would benefit from some longer$lasting pain medications. 6hat would you prefer to order; Are there any e(ams or labs you would li#e to order; 6hat should I call you for in the future regarding his pain control;
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