Documenting and

Reporting

Record- aka chart or client record, is a formal,

legal document that provides evidence of a clients
care and can be written or computer based
Purposes of Client Record

1.Communication
2.Planning Health Care
3.Auditing Health Agencies
4.Research
5.Education
6.Reimbursement
7.Legal Documentation
8.Health Care Analysis

Documentation Systems
1. Source-Oriented Record

The traditional client record . Each person or

department makes notations in a separate section or
sections of the clients chart. Information about a
particular problem is distributed throughout the record.

Narrative charting is a traditional part of the

source- oriented record. It consists of written notes that
include routine care, normal findings, and client
problems. There is no right or wrong order to the
information, although chronological order is frequently
used.

2. Problem-Oriented Medical Record

(POMR), or problem- oriented record (POR),
established by Lawrence Weed in the 1960s,
the data are arranged according to the
problems the client has rather than the source
of the information. Members of the health care
team contribute to the problem list, plan of
care, and progress notes. Plans for each active
or potential problem are drawn up, and
progress notes are recorded for each problem.

 The POMR has four basic components:

a. Database - consists of all information known about the
client when the client first enters the health care agency. It
includes the nursing assessment, the primary care
providers history, social and family data, and the results of
the physical examination and baseline diagnostic tests. Data
are constantly updated as the clients health status changes.
b. Problem list -It is usually kept at the front of the chart and
serves as an index to the numbered entries in the progress
notes. Problems are listed in the order in which they are
identified, and the list is continually updated as new
problems are identified and others resolved. All caregivers
may contribute to the problem list

c. Plan of care - Primary care providers write physicians orders or medical care plans; nurses write
nursing orders or nursing care plans. The written
plan in the record is listed un- der each problem in
the progress notes and is not isolated as a separate
list of orders.
d. Progress notes- ex. SOAP

SSubjective data consist of information obtained

from what the client says. It describes the clients
perceptions of and experience with the problem

 OObjective data consist of information that is

measured or observed by use of the senses (e.g.,
vital signs, laboratory and x-ray results).

AAssessment is the interpretation or conclusions

drawn about the subjective and objective data

PThe plan is the plan of care designed to resolve

the stated problem. The initial plan is written by
the person who enters the problem into the record

 IInterventions refer to the specific

interventions that have actually been performed
by the caregiver.

EEvaluation includes client responses to

nursing interventions and medical treatments.
This is primarily reassessment data.

RRevision reflects care plan modifications

suggested by the evaluation. Changes may be
made in desired outcomes, interventions, or
target dates.

3. PIE - documentation model groups information

into three categories. PIE is an acronym for
problems, interventions, and evaluation of nursing
care. This system consists of a client care
assessment flow sheet and progress notes.
4. Focus Charting -is 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 notes.

 The focus may be a condition, a nursing diagnosis, a

behavior, a sign or symptom, an acute change in the

clients condition, or a client strength.

(D) data, The data category reflects the assessment

phase of the nursing process and consists of observations

of client status and behaviors, including data from flow
sheets (e.g., vital signs, pupil re-activity). The nurse
records both subjective and objective data in this section.

The action category reflects planning and implementation

and includes immediate and future nursing actions. It may

also include any changes to the plan of care.

The response category reflects the evaluation phase of the

nursing process and describes the clients response to any
nursing and medical care.

Documenting Nursing
Activities
General Guidelines in Documentation
1. Date and Time

Document the date and time of each recording. This is essential not

only for legal reasons but also for client safety. Record the time in the
conventional manner (e.g., 9:00 AM or 3:15 PM) or according to the 24hour clock (military clock), which avoids con- fusion about whether a
time was AM or PM
2. Timing

Follow the agencys policy about the frequency of documenting, and

adjust the frequency as a clients condition indicates; for example, a
client whose blood pressure is changing requires more frequent
documentation than a client whose blood pressure is constant. As a
rule, documenting should be done as soon as possible after an
assessment or intervention. No recording should be done before
providing nursing care.

3. Legibility

All entries must be legible and easy to read to

prevent interpretation errors. Hand printing or
easily understood handwriting is usually
permissible. Follow the agencys policies about
hand- written recording.

4. Permanence
All entries on the clients record are made in
dark ink so that the record is permanent and
changes can be identified.

4. Abbreviations
5. Correct Spelling
6. Signature
7. Accuracy -clients name and identifying

information should be stamped or written on

each page of the clinical record. Before making
any entry, check that it is the correct chart. Do
not identify charts by room number only; check
the clients name. Special care is needed when
caring for clients with the same last name.

8. Completeness- Record all assessments,

dependent and independent nursing interventions,
client problems, client comments and responses to
inter- ventions and tests, progress toward goals,
and communication with other members of the
health team.

Care that is omitted because of the clients

condition or refusal of treatment must also be
recorded. Document what was omitted, why it was
omitted, and who was notified.

9. Sequence -Document events in the order in

which they occur; for example, record assessments,
then the nursing interventions, and then the clients
responses. Update or delete problems as needed.
10. Appropriateness -Record only information that
pertains to the clients health problems and care.
11. Conciseness -Recordings need to be brief as
well as complete to save time in communication.
The clients name and the word client are omitted.

12.Legal Prudence-Accurate, complete

documentation should give legal protection to
the nurse, the clients other caregivers, the
health care facility, and the client.