Subtitle

Documentation and
Recording
Communication with the Healthcare
Team
Document and Reporting
Ensures quality of care
Regulatory agencies require it
Medicare reimbursement depends
upon it
Shows nursing action
Serves as a legal document
Reporting
Summary of activities, observations,
and actions performed
Objective and non-judgmental
Reports
Oral or written
Shift report
Verbal reports to physicians
Miscellaneous
Written lab reports
Dietary reports
Social workers notes
PT, OT, Speech therapies
Types of Reports
Change of shift
Oral, audiotape, rounds
Telephone
Transfer
Incident
Any event not consistent with routine care
of client
Concise, objective
Not a part of the chart
Oral, audiotape, rounds
Confidentiality
Law protects any information gained
by exam, observation, conversation,
or treatment
Information not discussed or shared
with anyone not directly involved in
patients care
Nurses are legally and ethically
obligated to keep patient information
confidential
Medical Records
Permanent written communications
Continuing account of care status
Discussion, discharge planning,
conferences, consultations
All caregivers can benefit from
information and plan accordingly
Purpose of Records
Communication
Financial billing
Education
Assessment
Research
Auditing and monitoring
Legal documentation
Documentation
Anything written or printed that is
relied upon as a record of proof for
authorized persons
Standards for Documentation
Federal regulations-Medicare and
Medicaid
State and Federal regulations
JCAHO
Professional standards ANA
Facility policies- charting techniques
and responsibilities
Legibility
All charting should be easy to read
Reduces errors
May be used in court years after care
given
Factual
Descriptive, objective information
Decreases misinterpretation
Do not use seems, appears,
apparently, good well
Subjective information is
documented with clients own words
in quotations
No opinions
Complete and Concise
Thorough, exact, brief, and NO blah,
blah, blah blah
Clear and succinct
Eliminate irrelevance
Short and to the point (long notes
difficult to read)
Too abbreviated gives impression of
being hurried and incomplete
Timeliness
Delay in reporting can result in serious
omissions and delays in care
Late entries may be interpreted as negligence
Certain things must be reported at time of
occurrence
Routine activities need not be charted
immediately
Military time used
No leaving until important information
recorded
Avoids errors and duplication of care
Accurate
Reliable and precise
Exact measurements when possible
Use only accepted abbreviations
Spell correctly
More accuracy
No charting for someone else
Students notes are countersigned by
person who assured care was given
Descriptive entries signed with full
name and status (first initial, last
name, and title)
Guidelines for Documentation
and Reporting
Certain abbreviations not acceptable
Abbreviations used
Organization
Logical format and order
Chronological flow of events
Chart Components
Data base
Assessment data
Problems list
Care plan
Progress notes
Narrative
Flow sheets
Discharge planning summaries
Documentation Methods
Problem oriented medical record
S.O.A.P. or S.O.A.P.I.R
P.I.E.
Source records
Charting by exception
Flow sheets
Focused charting
D.A.R.
Problem Oriented Medical
Record
Focus on patients problems
Follows the nursing process
Organized by problems or diagnoses
Coordinated care
Advantages of POMR
Easy to retrieve information and
follow progress
Easy to monitor for QA purposes
SOAP notes establish structure that
reflects what nurses do
PIE Charting
PIE
Daily assessment data appears on
flow sheets
Continuing problems documented
daily
Focuses exclusively on single client
problem

Source Records
Each discipline has a separate
section of the chart for recording
Can easily locate proper section
Examples: admission sheet,
physician's order sheet, history and
physical, flow sheets, nurses notes,
medication record
Charting by exception
Reduces repetition
Clearly defined standards of practice
and predetermined criteria
Nurses documents only significant
findings or exceptions
Preventive and wellness-focused
functions not documented
Focus Charting - DAR
Easily understood and adaptable to
most settings
Reflects analysis and conclusions
Does not indicate problem
assessment
Standardized Care Plans
Pre-printed and established
guidelines for clients with similar
problems
Improved continuity
Less time to document
Inhibits unique or individualized
therapies
Writing the Nursing Care Plan
Prioritize problems
ABCs
Maslow
Problems perceived by patient
Formats
5 columns
Assessment data or defining characteristics
Diagnosis
Goals/outcomes
Interventions
Evaluation
Concept Map
Same five components linked by rationales
Better indicates process of critical thinking
Critical Pathways
Documentation tool to integrate
standards of care for multiple
disciplines
List problems, key interventions,
expected outcomes, expected
timelines
Attempt to control and decrease
length of stay
Discharge Summaries
Multidisciplinary involvement is
required by HCFA
Client leaves hospital in timely
manner with the necessary resources
Client signs original for chart and
takes copy home
Kardex
Information
Medication
IVs
Treatments
Diagnostic procedures
Allergies
Data
Problem list
Computer Documentation
Saves time in storage and retrieval
Information is permanent
Various departments can coordinate
information
Can be used at the bedside
Protocol Charting
Newest method
Primary use in outpatient care
Written for use as a references or
guide for care
Individualized, current, according to
intended purpose