Documentation

Purpose for documentation of patient care

- to provide a written account of patient’s condition, treatments, progress, and response to care
- legal record
- continuity of patient care

Nursing note entries cont.

- late nursing note:
-write “late entry” in AM/PM column followed by time and date of entry.
- a nursing note may be more than 1 page or less than 1 page
- if your nursing note is less than 1 page, draw a line through empty spaces and label with ‘no
further entries”

Medications that require a nursing note

- one time drug orders
- STAT orders
- Pre-op medication/sedatives
- PRN medications

What is a SOAP NOTE

- a soap note consists of a subjective, objective, assessment, and plan data.
Subjective:
- what the patient is telling you
- “use quotation marks when needed”
- avoid personal judgments
Objective:
-the data you obtain from vital signs, physical exams, previous lab, and x-ray findings
Assessment:
- what you diagnosis will be using the information gathered from the subjective and
objective
Plan:
- what your actions are going to be to help resolve medical condition
- this can include medications (with instructions), labs, x-rays, patient education, f/u,
consultations, etc.

Nursing note entries also include:

- mental status
- orientation
- observed mood/behavior
- expressed concerns
- physical assessment
-abnormal VS (must be written in red ink and circled)
- sensory/perceptual
- neurological
- skin
- respiratory
- gastrointestinal
- genitourinary
-musculoskeletal
- reports of discomfort
- nursing care, treatments, and procedure

More nursing note information that needs documentation

- visits made by pertinent people or other hospital staff

- pateint’s response to meds
- pateint’s tolerance of procedures or tx’s.
- document name, rank of physician or nurse notified about
-this includes VS, physical/mental changes
-this also includes positive changes
- safety measures
- patient transportation
- all entries must be signed by person writing note(s)
- remember if it is not documented or signed it didn’t happen, and that could spell disaster

DOCUMENTATION AND REPORTING

COMMUNICATION
- is a dynamic, continuous, and multi-dimensional process for sharing information.

* Generally, health personnel communicate through discussions, reports, and records.

Discussion – an informal oral consideration of a subject by two or more health care personnel
to identify a problem or establish strategies to resolve a problem.

Report- is oral, written, or computer-based communication intended to convey information to

others.
Record- is always written; it is a formal, legal documentation of a client’s progress.

The process of making an entry on a client record is called recording or charting.

MEDICAL RECORD DOCUMENTS

DOCUMENT INFORMATION
Face/ Admission Biographical data: name, date of birth, address, phone #, Social Security #,
Sheet marital status, employment, race, gender, religion, closest relative;
insurance coverage; allergies; attending physician; admitting medical
diagnosis; statement of advance directive if applicable.
Consent form Admit: gives the institution and physician the right to treat
Surgery: explains the reason for the operation in lay terms, the risks for
complications, and the client’s level of understanding.
Blood transfusion: permission to administer blood or blood products
Medical History Results of the client’s initial history and physical assessment as performed
and physical by the health care provider
examination
Prescriber order Medical orders to admit and the treatment plan
sheet
Progress notes Evaluation of the client’s response to treatment; may contain the progress
recording of interdisciplinary practitioners
Consultation Initiated by the physician to request the evaluation or services of other
sheet practioners
Diagnostic results Contains the results from laboratory and diagnostic tests (x-ray,
hematology)
Nursing admit Recording of data obtained from the interview and physical assessment
assessment conducted by the RN
Nursing plan of Contains the treatment plan (eg, nursing diagnosis or problem list, initiation
care of standards of care or protocols).
Graphic sheet Data recording regarding vital signs and weight.
Flow Sheet Contains all routine interventions that can be noted with a check mark or
other simple code; allows for a quick comparison of measurement
Nurses’ progress Additional data that do not duplicate information on the flow sheet (eg.
notes Client’s achievement of expected outcome or revision of the plan of care).
Medication Contains all medication information for routine and PRN drugs: date, time,
Administration dose, route, site (for injections).
Record (MAR)
Patient education Recording of the nurses’ teaching of the client, family, or other caregiver
record and the learner’s response.
Health care team Treatment and progress record for nonmedical and non-nursing
record practitioners, when the physician’s progress notes are not used by other
practitioners (eg. Respiratory, physical therapy, dietary).
Discharge plan A multidisciplinary form used before discharge from a health care facility
and summary containing brief summary of care rendered and discharge instructions (eg.
Food-drug interactions, referrals or follow-up appointments).
Advance directive If the client has advance directives, they are reviewed at the time of
or living will admission and placed in the medical record.

PURPOSES OF CLIENT RECORDS

Permanent record. Written in chronological order. Filed in medical records dept. for future
use/reference
Sharing information. Facilitates exchange of information between staff. Prevents duplication
errors (meds, dressing change, activity, diets, etc.)
Patient confidentiality
 Never leave chart in a public place.
 Discuss contents only with persons directly involved in the patient’s care or those
that are authorized by the patient.
 Do not discuss pt or pt info in public places, eg. Elevators, cafeteria.

Quality assurance. A peer review process conducted by a staff nurse and physician.
Establishes and reflects agency standards

Accreditation. DOH and other accrediting agencies. Sets minimum standards for staffing

Reimbursement. Lack of documentation may result in denial for payments from medicare
and private insurance companies. This puts the burden of payment on the patient.

Research & Education. The information contained in a record can be valuable source of data
for research.

Legal evidence. Records are considered legal or potential legal documents. May be
subpeonaed as evidence by attorney or nursing boards. Check for deviations from facility
policy or standards. A written legal record to protect the client, institution, and practitioner.

Times that charting is required

-Admission/initial assessment
-Head-to-toe shift assessment
- Presence of monitoring devices & measurements
- Any procedures/therapies
 - Medication administration
- Client concerns
- Client progress or change in condition-whether it is good or bad it has to be documented
-Results of STAT orders
-Clients activities throughout the shift
-Client teaching
-Discharge instructions
-Plan of care/critical pathways

Patient’s rights/agency policy

*Patients have the right to the information in their charts

*They do not have the right to see the chart on demand or remove anything from the chart, or
remove the chart from the facility. Often patient need to submit a written request to have their
information released, and then they must specify exactly what information is to be released
and to whom.

*The chart is a legal record of care and should be available only to members of that
client’s health care team.

*Significant others, insurance companies, or other parties not directly involved in the care
provided by the health care team may not have access to the client’s records.

* In many teaching hospitals clients records may be used for educational and research purposes
but are also held to the same standards of privacy protection

*A patient’s chart is the property of the facility. It is the facility which sets the policy and
makes appointments for viewing of the chart.

Legal and Practice Standards

 The Basics that should be remembered

 Make sure each page has client ID

 1. Date & Time – chat in a timely fashion to prevent the omission of pertinent data:
It is POOR practice to wait until the end of the shift to chart on all of the
clients
- Sequence / Chronology of Events
- Lapse in Time – always be oriented in time, document as soon as the client encounter is
concluded to ensure accurate recall of the data
- Late Entries
- Blocked Time (the time of the shift)
- Military vs. Standard Time

2. Client’s History

3. Subject & Objective

4. Changes in Health Status

 Your actions - what were done (interventions or plans to be implemented)

 Clients response
 Client outcomes/result as evidenced by (objective)
5. Client Outcomes - during the evaluation
 Expected
 Deviations
6. Your Signature
 Full name, Credentials, Job title, Initials/ full signature. Eg. Sheila Fernandez RN,
CCRN

Additional considerations:

- All entries must be signed by person writing note(s)

- Remember, if it is not documented or signed, it didn’t happen, and that could spell disaster
- Client/Family Education/Instructions.
- Referrals to Community Resources.
- Authorizations and Consents.
INFORMED CONSENT means the client/patient understands the reasons for and the risks of
the proposed intervention and agrees to the treatment by signing a consent form.

- Telephone Calls
“Read Back” IS VERY IMPORTANT
 Date and time of call
 Physician's name and “T/O” to indicate order
 Verbal order, written word-for-word
 Documentation that you've read back the order, to be sure you heard it
correctly
 Documentation that you've transcribed it according to your facility's policy
 Your name

- Faxes & Computerized Records

 Facts on Faxing Records
 Computer Charting
Safeguards for Faxing
 1. Check the number before you dial.
 2. Check the number on the fax machine display.
 3. Re-check the number before you press the “send” button.

- Computerized Documentation
 Easier form of communication
 Legible
 As legal as when you manually chart

Guide to Computer Documentation

 Double-check entries
 Password security
 Do NOT share your code!
 “HIPPA” computer display
 Log off
 Printouts
 Backup files
 Patient data, Confidentiality, and Disclosure
 IF IN OTHER COUNTRIES OR STATES: KNOW state's rules and regulations
 facility's policies and procedures
 permanent part of the medical record
 Good computerized documentation not only can help you in court, but it can also
keep you out of court in the first place.

NURSING RESPONSIBILITIES

DO’s
- Check that you have the correct chart before you begin writing.
- Make sure each page has client ID
- Time-Sequenced Organization
- Reflect The Nursing Process
- Write Legibly and Neatly
- Permanent Black Ink (facility protocol)
- Complete / Concise / Accurate/ Factual
- Use Common Vocabulary
- Use ONLY AUTHORIZED (institutional) abbreviations and symbols
 Wrong Way: Communication with patient's family begun today to specify the
manner in which his condition is progressing and suggest a probable consequence of that
progression.
 Right Way: I contacted Mr. Boon’s wife at 1415 hours. I explained that his cardiac
status was worsening and that he was being prepared for a cardiac catheterization procedure
scheduled for 1600 hours.
- Medications
Chart the time you gave a medication, the administration route, and the patient's
response.

- Precautions / Preventive Measures

Side rails, Restraints

- Nursing Procedures
Name of procedure Who performed it How well the client tolerated it
When it was performed How it was performed Adverse reactions

- Late Entry – If you remember an important point after you've completed your documentation,
chart the information with a notation that it's a "late entry." Include the date and time of the late
entry.
possible reasons:
- The chart was not available
- Entries need to be added after noted were completed
- Information was documented on the wrong record
Note: follow facility policy for late entries
 Common practice is to enter the date and time and label “late entry” to indicate that it is
out of sequence.

- Discharge instructions – should be complete and well understood by the client and/or family
as warranted by the situation
M-
 E-
T-
H-
O-
D-
S-

- Commonly misspelled words and correct grammar– practice proper spelling and correct
grammar

- Look-a-Like / Sound-a-Like – be very wary of these words. . . very common with

medicines

- Continuation – of care is reflected in the chart

 When writing the chart it should be noted when ending on the bottom of the
page
 When continuing a note over 2 pages, sign the bottom of the first page and at
the top of the next page write the date & time and "continued from previous
page."

- Triplicate / Carbonated Copies – to make sure that there are available copies of the
document other than that of the original for record keeping.

- Document Non-Compliance
• Refusing to comply with dietary restrictions.
• Getting out of bed without asking help.
• Ignoring follow-up appointments at the clinic, emergency department, out-patient or
doctor’s office.
• Leaving against medical advice (AMA)
• Refusing to take medications.

Consequences of Inadequate Documentation

- Fragmented care
- Repetition of tasks
- Delayed therapy
- Omitted therapy
- Delayed recovery
 DON’Ts
- Adding Information
- Dating the entry
1. Dates / Times ARE IN CONFLICT
- Inaccurate Information.
- Never change another person’s entry even if it is incorrect
- Destroying records
- Unapproved Abbreviations - Don't use shorthand or abbreviations that aren't widely
accepted.
- Shorthand – Don't use shorthand or abbreviations that aren't widely accepted.
- Vague - Don't write imprecise descriptions, such as "bed soaked" or "a large amount."
- Make Excuses
- Chart for someone else
- Make Chart Opinions
- Use Negative Language
- Use vague terms
- Chart ahead - Don't chart care ahead of time - something may happen and you may be
unable to actually give the care you've charted. Charting care that you haven't done is
considered FRAUD.
- Misspelled words
- Incorrect Grammar
- Chart staffing problems
- Chart staff conflicts
- Chart casual conversations - Don't chart what someone else said, heard, felt, or smelled
unless the information is critical. In that case, use quotations and attribute the remarks
appropriately.
- Leave empty lines / spaces
- Violate client confidentially

When you make a Mistake,

DO NOT
- White out / Eraser
- The word “Error”
- Correct the Entry - BY WRITING OVER
- write smileys

 If you will make charting mistake use a single line to cross out the error, then Date,
Time and Sign the correction
TYPES OF PATIENT RECORDS
- SOURCE-ORIENTED
- PROBLEM-ORIENTED

 SOURCE ORIENTED
 Most traditional
 Different disciplines chart on separate forms.
 Each reader must consult various parts of the record to get a complete picture.
 Records become bulky
 PROBLEM ORIENTED
 Commonly referred to as POR
 Organized according to problem
FOUR PARTS:
A. DATA BASE. The patient present health status
B. PROBLEM LIST. Numbered list of health problems
C. INITIAL PLAN. Plan to help overcome health problems
D. PROGRESS NOTES. All disciplines chart on same page

METHODS (STYLES) OF CHARTING

 NARRATIVE
 SOAP
SOAPIER
 FOCUS
DATA
ACTION
RESPONSE

 PIE
 EXCEPTION CHARTING

1. NARRATIVE
 Chronological
 Baseline charted every shift
 Lengthy, time- consuming
 Separate pages for each
 Source-oriented

2. SOAP
 Used for problem-oriented charts
 S – SUBJECTIVE. What patient tells you.
 O – OBJECTIVE. What you observe, see..
 A – ASSESSMENT. What you think is going on based on your data
 P – PLAN. What you are going to do.
CAN ADD TO BETTER REFLECT NURSING PROCESS
 I – INTERVENTION (Specific interventions implemented)
 E – EVALUATION. Patient response to interventions.
 R – REVISION. Changes in treatment

EXAMPLE OF SOAP CHARTING:

#1 ALTERATION IN COMFORT. ABDOMINAL PAIN.
S –complains of pain in
O – is pale and holding right side
A – Recurring abdominal pain
P – Put on NPO and notify physician

3. FOCUS CHARTING
- USES NARRATIVE DOCUMENTATION (DAR)
 DATA – Subjective or objective that supports the focus (concern)
 ACTION – Nursing intervention NURSING INTERVENTION
 RESPONSE – Patient response to intervention

EXAMPLE OF FOCUS CHARTING

D – Complaining of pain at incision site on lumbar region
A – Repositioned for comfort. Demerol 50 mg IM given.
R – (Charted at a later time/date) states a decrease in pain “feels much better.”

4. PIE CHARTING
 Similar to SOAP charting
 Both are problem-oriented
 PIE comes from the Nursing Process, SOAP comes from a Medical Model.
P - Problem
I -Intervention
E -Evaluation

SAMPLE OF PIE CHARTING

P#1 Risk for trauma related to dizziness.
I. P#1 Instructed to call for assistance when getting OOB. Call light in reach.
E. P#1 Consistently call for assistance before getting OOB. Continues to
experience dizziness.
5. CHARTING BY EXCEPTION
 Uses flowsheets
 Emphasis on abnormal (What is abnormal for this patient.
 Although it may be abnormal for the “normal” person, if it is abnormal for your
patient on a consistent basis, it is no longer considered an “exception”.
6. COMPUTERIZED CHARTING
 Change password frequently and never share.
 Can be voice-activated, touch-activated.
 Date and time automatically recorded
 Abbreviations and terms are selected by a menu provided by the facility
 Terminals are usually easily accessible in patient rooms, convenient hallway
locations.
 Make sure terminal cannot be viewed by unauthorized persons.

FORMS FOR RECORDING DATA

 KARDEX
- Concise method of organizing and recording data.
- Readily accessible to health care team.
- Series of flip cards
- Ensure continuity of care
- Tool for change of shift report
- For planning & communication purposes.
- Quick reference
- Changed as needed
- Not part of permanent record

Parts of a Kardex:
Personal Data
Basic needs
Allergies
Diagnostic tests
Daily Nursing Procedures
Medications and IV therapy, BT.
Treatments like O 2 , steam inhalation, suctioning, change of dressings, mechanical
ventilation.

 WALKING ROUNDS
 CHANGE – OF – SHIFT REPORTS OR ENDORSEMENT
1. For continuity of care
2. It is based on health care needs of the client
3. It is not mere reciting the content of the KARDEX
During CHANGE- OF- SHIFT REPORT
 Person to person
 Be prepared
 Avoid gossip socialization

note-Change of shift reports should include:

name
room #
what’s wrong with PT
age
DR
how often VS need to be done
Dressing
External devices-IV, what rate, etc.
Specific info- no code, no intubation. If pt needs to get up. How often?
Any changes in condition
Teaching- what you are teaching, is PT performing correctly, does PT
verbalize or demonstrate understanding. If not, where is the problem
You need to know who is giving report if it is taped or voicemail

 TRANSFER REPORTS –done when transferring a client from unit to another

 INCIDENT REPORTS - Used to document any unusual occurrence or accident in the
delivery of client care. This is not included or part of a chart

COMMONLY USED ABBREVIATIONS

Abbreviati Term
on
Abd Abdomen
ABO The main blood group
system
Ac Before meals (ante cibum)
ADL Activities of daily living
Ad lib As desired (ad libitum)
Adm Admitted or admission
AM Morning (anter meridiem)
amb Ambulatory
amt Amount
approx Approximately (about)
bid Twice daily (bis in die)
BM (bm) Bowel movement
BP Blood pressure
BR Bed rest
BRP Bathroom pvileges
c (C) With
C Celsius (centigrade)
CBC Complete blood count
CBR Complete bed rest
Cl Client