Professional Documents
Culture Documents
• Permanent account
• Sharing information
• Quality Assurance
• Accreditation
• Reimbursement
• Education
• Research
• Legal evidence
Client Access to Records
• 1996 Health Insurance Portability & Accounting ACT (HIPPA)
• Have right to see their medical record and billing records
• Request changes to anything they feel is inaccurate
• Be informed about who has seen their medical records
• Nurses need to review & follow each facilities’ policy on client’s
access to records
Two Types of Client Records
• Source-Orientated Records
• Traditional record (organized according to the source of
documented information)
• Each person/department makes notations in separate section (s)
using narrative charting
• Disadvantage: fragmented documentation
• Problem-Orientated Records
• Data arranged according to client’s health problems
• Arranged information of importance: goal directed care,
promote recording pertinent information & to facilitate
communication with health professionals
• Four components: data base, problem list, plan of care, &
progress notes
Methods of Charting
• Narrative charting: used in source-oriented records
• Written information-chronologic order
• No established format
• Content resembles a log or journal
• Time consuming
• Entries may omit important information or may include
information not needed
• SOAP charting: Used in problem-oriented record
• S = Subjective data -what client says; nurse quotes client’s
words
• O = Objective data- information that is measured/observed by
use of the senses (ex.=vital signs, lab & x-ray results)
• A = Assessment- analysis interpretation/conclusions drawn
from subjective/objective information --- problem list created
• P = Plan- plan of care
Method of Charting
• Focus charting: Modified form of SOAP charting
• Uses the word focus instead of problem
• Intended to make the client and client concerns & strengths the
focus of care
• Progress notes organized into DAR
• (D) data-assessment phase of nursing process
• consists of observations –objective & subjective- EX: data
from flow sheets (vital signs, pupil reaction)
• (A) Action- reflects planning & implementation
• (R) response - reflects evaluation
• DAR reflects phases of nursing process
Method of Charting
• SOAP:
• S = Subjective data -what client says; nurse quotes client’s
words
• O = Objective data- information that is measured/observed by
use of the senses (ex.=vital signs, lab & x-ray results)
• A = Assessment- analysis interpretation/conclusions drawn from
subjective/objective information --- problem list created
• P = Plan- plan of care
• SOAPIE or SOAPIER: Some agencies have added to SOAP notes
• I = Intervention-specific interventions that have actually been
performed by caregiver
• E= Evaluation- includes client responses to nursing interventions
& medical treatments
• R = Revision- reflects care plan modifications to plan of care
Method of Charting
• Focus Charting: Modified form of SOAP charting
• Uses the word focus instead of problem
• Intended to make the client and client concerns & strengths the
focus of care
• Progress notes organized into DAR
• (D) data-assessment phase of nursing process
• consists of observations –objective & subjective- EX: data
from flow sheets (vital signs, pupil reaction)
• (A) Action- reflects planning & implementation
• (R) response - reflects evaluation
• PIE charting: nursing care is documented using PIE; P =
problems; I = interventions; E = evaluation
• Nurses document assessments on a separate form –give client’s
problems a corresponding number
• Use these numbers in progress notes when referring to
interventions & client responses
Method of Charting
• Charting by Exception: Documentation -in which only abnormal
assessment findings or care that is different – deviates from the
standard are recorded
• Quick access to abnormal findings
• Does not describe normal & routine information
• Computerized Documentation: documenting information
electronically
• Information quickly accessible – labs, x-ray reports, medications,
procedure instructions, admission & discharge information, VS
etc.
• Advantages: information legible, records date & time of
documentation, fewer omissions, saves time-eliminates charting,
information easy to retrieve, abbreviations & terms consistent
• In Long-term care setting –information put into Nursing
Minimum Data Set –(MDS) source of patient care and
electronically sent for payment
•
Protecting Health Information-Privacy Standards
• All health care agencies-required to protect health information
• HIPAA legislation protects rights of U.S. citizens to retain health
insurance
• Requires Health Care Agencies to Protect the privacy of health
records & security of that data whether written, spoken or electronic
• Agencies-must submit a written notice to clients, obtain specific
authorization to release information to family, friends, attorneys,
research etc.
• Client given a written notice-identifying uses & disclosures of their
health information
• Obtain client’s signature indicating knowledge if disclosure of
information and right to learn who has seen the record
• Limits casual access to identity of client and health information
• Minimum disclosure: only disclose what is needed-not entire
record
• Beneficial disclosures: times when agencies can release
information without the client’s approval
HIPAA Legislation Affecting the Workplace
• Names -on chart must not be visible
• Clipboards must not have visible names/information
• Computer screens -away from public view
• Conversations about clients must be in a private area
• Fax machines, file cabinets etc. away from public view
• A cover sheet & statement indicating FAXed data must accompany
electronically transmitted information
• Light boxes for x-rays must be in private areas
• Documentation must be kept of people who have access to charts
• Whiteboards -free of client names-use initials only
Data Security
• Computerized data
• Assigned an access number and
password for computer and or plastic key
card for door access
• If put in password etc. wrong 3 times-block out of computer
• Automatic save or go back to menu
• Minimize screen for privacy if needed
• Do not leave computer with screen visible
• Locking out client information-except to specific people
• Blocking certain information- that personnel from other
departments can retrieve
• Storing time/location/access of person looking at client
information
• Encrypting information transmitted via internet
Documenting Information
• Each agency-own documentation policies, type of information
recorded, the people responsible for charting, and frequency for
making entries
• JCAHO-requires that medical records must identify steps of nursing
process (assessment, diagnosis, planning, implementation,
evaluation)
• Abbreviations-
– Only use Standard abbreviations,
terminology, symbols approved by agency-otherwise remove or
write out word
Indicating Time
• Document the date and time of each recording
• Some agencies use traditional time (time based on two 12-hour
revolutions on a clock)
• Identified with an hour and minute followed by AM or PM
• Some agencies use military time (time based on a 24 hour clock)
• Uses a different four digit number for each hour and minute of
the day
• Military time avoids confusion because no number is ever duplicated
and AM, PM not used.
Other Forms of Written Communication
• Nursing Care Plan – Required by JCAHO
• List of Client’s problems, goals, nursing interventions, evaluations
• Promotes-prevention, reduction or resolution of problems
• Legal document-permanent record-each entry is signed
• Nursing Kardex - Quick reference- Current information about client
and care
• Information changes frequently
• Not a permanent record -
• Checklists-Form of documentation-initials or a check mark used when
care is similar each day
• Flow Sheets -recording for frequently repeated assessment data
• Graphic record (vital signs) & Fluid Balance Sheet (I & O)
• Other Sheets:
• Medication Administration Record
• Skin & Safety/Fall Assessments
• Admissions, Transfer, Referral, Discharge
• Other facility and or state and federal required documentation
Interpersonal Communication
• Change of shift report -review client information to on-coming
shift nurse
• Client care assignments -made out beginning of shift
• Team conferences- used to exchange information-includes
personnel caring for client
• Client rounds – visit with client one-on-one or a group
• Telephone – communicate information-when not able come together
• Repeat what was told to you back before documenting- to ensure
correct information given & received
Receiving & Documenting Telephone Orders
• Write down the time, date and order given on the physician’s order
sheet
• Read order back to physician to ensure it is accurately recorded
• Record the physician’s name on the physician’s order sheet, state
“telephone order”
• Sign your name by the entry with your title
• Always follow the agency’s policies
• Some agencies have abbreviation of TORB (telephone order
read back)
Nursing Process & Documentation
• Nurses use or refer to Nursing Process as a guide to
documentation, page 129 &130
• Assessment: observing client for signs & symptoms that may
indicate actual or potential problems
• Planning: developing a plan of care-directed at preventing,
minimizing or resolving identified client problems or issues
• Implementation: Performing the plan of care developed
• Evaluation: determining if plan of care is working to minimize,
prevent or resolve identified problems
Do’s for Documentation
• All entries must be legible & easy to read
• Permanent- written in dark ink
• Correct spelling
• Your Signature with title
• Proper sequence
• Appropriateness-Completeness
• Accuracy
• If using paper material
• Mistake: Follow agency’s policy as to whether to write mistaken
entry above or beside mistake or use the word error and then
either put your initials or name
• Draw a line through mistake rather than scribble through or
obscure the words
• DO NOT erase, blot out or use correction fluid
• This is a legal document and the entry must remain visible
Do’s of Nursing Documentation
• Use dark ink (BLACK pen)
• Make sure you have correct chart/computer site before you begin
writing/typing
• Write/type legibly & spell words correctly
• Chart completely, concisely and accurately
• Remember to chart the time you gave a medication, administration
route, and client’s response (s)-
• If using a computer –nurse’s pass word is put in- then you scan the
client’s name tag/band before giving medication-as recorded on
computer-you scan the medication bar code to justify the correct
medication ordered and that it is on the medication sheet
• Once given hit save on the computer and it shows up on the screen
–the time medication given & nurse’s initials
Do’s of Nursing Documentation
• Documentation should reflect nursing process & your professional
capabilities
• Record each phone call to a MD, including the exact time, message, and
response
• Chart as soon as possible after giving care
• Log off computer when done or when leaving computer screen
• Chart a client’s change in condition and follow-up actions that were taken
• Chart all teaching
• Chart a client’s refusal for treatment/medications etc. & reason why
• Document why a medication was not given
• If you have left something out, Write “late entry” or “addendum” with the
time and chart if using paper chart
• If using computer-some will allow you to go back and edit but will show
up with that date
• Include the following information when documenting a procedure: What
procedure was performed; When it was performed; How it was performed;
How well the client tolerated it; Any problems with the procedure
The No-No’s of Documentation
• Don’t chart a symptom “c/o pain” without also charting what you
did about it
• Don’t change a client’s record…criminal offense
• Don’t use shorthand or abbreviations that are not accepted
• Don’t write vague descriptions (appears or seems)
• Don’t chart your opinions
• Don’t use negative language to describe your client
• Don’t chart ahead of time
• Never use ditto marks
• Don’t record staffing problems or record staff conflicts
• No white out or an eraser if using paper
• No empty lines or spaces
• No writing in margins
• Don’t mention an incident report in the chart-document only the
facts of the incident/accident
• Don’t name a second client in chart
• Do not chart for someone else
References
• ATI Nursing Education (2013). Fundamentals of Nursing (8th Ed)
• Timby, B.K. (2013) (10th ed.). Fundamental Nursing Skills and
Concepts. Philadelphia: PA. Lippincott Williams & Wilkins
• Images-retrieved from web site on June 13, 2015 form
www.http//:googleimages.com