Documentation & Reporting in Nursing

By Matt Vera, RN - Jun 9, 2013

Documentation is anything written or printed that is relied on as a record of proof for

authorized persons. Documentation and reporting in nursing are needed for continuity of care
it is also a legal requirement showing the nursing care performed or not performed by a
nurse.

Purposes

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

Documentation Systems

1. Source – Oriented Record

1. The traditional client record

2. Each person or department makes notations in a separate section or sections of the
client’s chart
3. It is convenient because care providers from each discipline can easily locate the
forms on which to record data and it is easy to trace the information
o Example: the admissions department has an admission sheet; the physician
has a physician’s order sheet, a physician’s history sheet & progress notes
4. NARRATIVE CHARTING is a traditional part of the source-oriented record

2. Problem – Oriented Medical Record (POMR)

1. Established by Lawrence Weed

2. The data are arranged according to the problems the client has rather than the source
of the information.

The four (4) basic components:

1. Database – consists of all information known about the client when the client first
enters the health care agency. It includes the nursing assessment, the physician’s
history, social & family data
2. Problem List – derived from the database. Usually kept at the front of the chart &
serves as an index to the numbered entries in the progress notes. Problems are listed in
the order in which they are identified & the list is continually updated as new
problems are identified & others resolved
 3. Plan of Care – care plans are generated by the person who lists the problems.
Physician’s write physician’s orders or medical care plans; nurses write nursing
orders or nursing care plans
4. Progress Notes – chart entry made by all health professionals involved in a client’s
care; they all use the same type of sheet for notes. Numbered to correspond to the
problems on the problem list and may be lettered for the type of data

Example: SOAP Format or SOAPIE and SOAPIER

S – Subjective data
O – Objective data
A – Assessment
P – Plan
I – Intervention
E – Evaluation
R – Revision

Advantages of POMR:

 It encourages collaboration
 Problem list in the front of the chart alerts caregivers to the client’s needs & makes it
easier to track the status of each problem.

Disadvantages of POMR:

 Caregivers differ in their ability to use the required charting format

 Takes constant vigilance to maintain an up-to-date problem list
 Somewhat inefficient because assessments & interventions that apply to more than
one problem must be repeated.

3. PIE (Problems, Interventions, and Evaluation)

 Groups information in to three (3) categories

 This system consists of a client care assessment floe sheet & progress notes
 FLOW SHEET – uses specific assessment criteria in a particular format, such as
human needs or functional health patterns
 Eliminate the traditional care plan & incorporate an ongoing care plan into the
progress notes

4. Focus Charting

a. Intended to make the client & client concerns & strengths the focus of care
b. Three (3) columns for recording are usually used: date & time, focus & progress notes

5. Charting by Exception

 Documentation system in which only abnormal or significant findings or exceptions

to norms are recorded
 Incorporates three (3) key elements:
o Flow sheets
 o Standards of nursing care
o Bedside access to chart forms

6. Computerized Documentation

 Developed as a way to manage the huge volume of information required in

contemporary health care
 Nurses use computers to store the client’s database, add new data, create & revise care
plans & document client progress.

7. Case Management

 Emphasizes quality, cost-effective care delivered within an established length of stay

 Uses a multidisciplinary approach to planning & documenting client care, using
critical pathways.

Nursing Care Plan (NCP)

Two Types:

1. Traditional Care Plan – written for each client; it has 3 columns: nursing diagnoses,
expected outcomes & nursing interventions.
2. Standardized Care Plan – based on an institution’s standards of practice; thereby helping to
provide a high quality of nursing care

KARDEX

 Widely used, concise method of organizing & recording data about a client, making
information quickly accessible to all health professionals. Consists of a series of cards
kept in a portable index file or on computer generated forms.

Information may be organized into sections:

1. Pertinent information about the client

2. List of medications
3. List of IVF
4. List of daily treatments & procedures
5. List of Diagnostic procedures
6. Allergies
7. Specific data on how the client’s physical need is to be met
8. A problem list, stated goals & list of nursing approaches to meet the goals

Nursing Discharge & Referral Summaries

These are completed when the client is being discharged or transferred to another institution
or to a home setting where a visit by a community health nurse is required. Regardless of
format, it includes some or all of the following:

1. Description of client’s physical, mental & emotional state

 2. Resolved health problems
3. Unresolved continuing health problems
4. Treatments that can be continued (e.g. wound care, oxygen therapy)
5. Current medications
6. Restrictions that relate to activity, diet & bathing
7. Functional/self-care abilities
8. Comfort level
9. Support networks
10. Client education provided in relation to disease process
11. Discharge destination
12. Referral Services (e.g. social worker, home health nurse)

Guidelines for Good Documentation and Reporting

1. Fact – information about clients and their care must be factual. A record should
contain descriptive, objective information about what a nurse sees, hears, feels and
smells
2. Accuracy – information must be accurate so that health team members have
confidence in it
3. Completeness – the information within a record or a report should be complete,
containing concise and thorough information about a client’s care. Concise data are
easy to understand
4. Currentness – ongoing decisions about care must be based on currently reported
information. At the time of occurrence include the following:
o a. Vital signs
o b. Administration of medications and treatments
o c. Preparation of diagnostic tests or surgery
o d. Change in status
o e. Admission, transfer, discharge or death of a client
o f. Treatment for a sudden change in status
5. Organization – the nurse communicate in a logical format or order
6. Confidentiality – a confidential communication is information given by one person
to another with trust and confidence that such information will not be disclosed

Sumber : Vera, Matt. 2013. Documentation & Reporting in Nursing. Nurseslabs.

Fundamental Of Nursing. http://nurseslabs.com/documentation-reporting-in-nursing/.
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