Documentation!Documentation!

Documentation and ReportsDocumentation and Reports• Communicate information about

clients healthcare needs• Ensures that all goals and

interventions are directed towards same goal

Report vs. RecordReport vs. Record• Report

– Oral or written– Between staff, other health

professionals, lab reports

• Record– Permanent written communication– Legal part of chart

Guidelines for Good Guidelines for Good ChartingCharting

• Fact– Stick to them– Descriptive/objective– Vague– Response to medications– Clients own words

• Accuracy– I & O– Wound size– Wound length– Abbreviations– Correct spelling!!!– Don’t chart for others– Sign name, no nicknames

• Concise– Playing vs. running, laughing

• Current– Delays in reporting can result in delay of

treatment– Delay can be interpreted as negligence– Report ASAP– Bed baths, I & O don’t have to be

immediate but in timely manner– Keep notepad in pocket– Know military time!

• Organization– Chart in order things occurred

• Confidentiality– All patient info is CONDIFENTIAL!!

Common Types of ReportingCommon Types of Reporting• Change of shift

– Oral, recorded, during rounds– Report quickly and efficiantly

• Health status• Kind of care required• Changes in therapy• Behavior changes• Allergies• Nursing intervention results• IV and meds• Don’t label grumpy, mean

Common Types of ReportingCommon Types of Reporting• Telephone• Transfer reports• Incident reports

– Not part of the chart– Used when something abnormal

happens

DocumentationDocumentation• Purposes

– Communicate info to health care team– Keep track of interventions and goals

• Legal guidelines–Table 25-1 pg. 480– Always use ink– Always sign your name– Never destroy charting or mark through it– Time and date notes– If you did not chart it, it never happened!!!

Methods of DocumentationMethods of Documentation• Problem oriented medical record

– Places emphasis on problems– Organized by problems– Compiled of

• Data base• Problem list• Care plan• Progress notes

• Modified problem oriented• Source records• Charting by exception

– Eliminates redundancy– Makes it concise– Easy to document normal findings– Critical for nurses to chart abnormal!

• Focus charting• Case management plan and critical

pathways– Incorporates multidisciplinary approach– Broken down into critical pathways

Other Record Keeping Other Record Keeping FormsForms

• Nursing History– Completed when a client is admitted– Complete assessment– Provides baseline data

• Graphic sheets– Allows doctors and nurses to easily and quickly

enter data– Vital signs– Routine care– Have codes to enter data

• Standardized care plans– Pre-printed guidelines for patients with

similar problems

• Discharge summary forms– Discharge planning begins on admission– Education on medications– Summarized patient instructions for

home

• Nursing kardex• Computerized documentation

– Advantages– Disadvantages