Subtitle

Documentation and RecordingCommunication 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 patient’s 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 client’s 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• Student’s 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 patient’s 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– ABC’s–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• IV’s• 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