Kelli Shugart RN,MS

Documentation- written or typed, legal

record of all pertinent interactions with the
patient
Contains data used to:
Facilitate

patient care
Serve as financial and legal record
Help in clinical research
Support decision analysis

Patient Record- is a compilation of a

patients health information
Joint Commission on Accreditation of
Healthcare Organizations (JCAHO)- specifies
that nursing care data be implemented into
the patient record.
Patient

assessment
Nursing diagnosis
Patient needs
Nursing interventions
Patient outcomes

Aim: complete, accurate, concise, current,

factual, and organized data communicated in
a timely and confidential manner to
facilitate care coordination and serve as a
legal document.
Content
Timing
Format
Accountability
confidentiality

Should be:
Consistent

with professional and agency

standards
Complete
Accurate
Concise
Factual
Organized
Timely
Legally prudent
confidential

Crucial Omissions
Meaningless repetitious entries
Inaccurate entries
Length of time

Problems

Undermine

nurses credibility as a professional

discipline
Cause legal problems for the nurse responsible

All info about patients is considered private

or confidential.
Written

on paper
Saved on computer
Spoken out aloud

Names
Address
Telephone number
Fax number
Social security
Reason person is sick or in the hospital, office, or
clinic
Treatment
Information about PMH

Might be found in:

Patient

medical record
Computer systems
Telephone calls
Voice mails
Fax transmissions
E-mails that contain patient info
Conversations about patients between clinical
staff

Giving info over phone

Discussing a patient in areas where you can
be over heard (elevators/cafeteria)
Discussing a patient you are not directly
involved with
Leaving patient medical info in a public area
Failing to log off computer
Sharing or exposing passwords
Improperly accessing, reviewing, and/or
releasing confidential info

Workers must undergo HIPPA training and sign

confidentiality agreements
Patients have a right to:
See

and copy their health record

Update their health record
Get a list of the disclosures a healthcare
institution has made independent of disclosures
made for the purposes of treatment, payment,
and healthcare options
Request a restriction on certain uses or
disclosures
Choose how to receive health info

Everyone who has access to the record

(direct caregivers) is expected to maintain
its confidentiality
Most agency grant nursing students access for
education purposes.must hold info in
confidenceNever use patients name when
preparing written or oral reports
Agency policy indicates which personnel are
responsible for recording on each form in the
record
Policy also indicates order of chart

Policy may indicate frequency to record

entries
What to record
Manner to identify self
Kelli

Shugart, RN, GBCN

Sally Cabbage Patch, SN, GBCN

Which abbreviations are acceptable see

table 17-2

Communication
Diagnostic and therapeutic orders
Verbal orders-order must be given directly by
the physician, or nurse practitioner to a
registered nurse or registered pharmacist
The only circumstance in which an attending
physician, nurse practitioner, or house officer
may issue orders verbally is in a medical
emergency, when they are present but
unable to write the actual order.

The RN who receives the order will:

1.
2.
3.
4.

Record the orders in the medical record

Read the order back to verify accuracy
Date and note the time
Record V.O. (verbal orders), name of the MD
who issued the orders, followed by the nurses
name and title

Example:
Give 0.25mg po lanoxin Daily, starting in Am
9/18/09 V.O. Micheal Smith, MD/Kelli
Shugart, RN

It is the responsibility of the physician or

nurse practitioner who issued the verbal
order to:
1. Review the order for correctness
2. Sign the orders with his or her name, title,
and pager number
3. Date and note the time he or she signs the
orders
It is the responsibility of the unit secretary
and/or the registered professional nurse to
see that the orders are transcribed according
to procedure

Agency policy must be followed

Every T.O. must be repeated back to ensure
that the nurse correctly understands what
was ordered.
Must be on an order sheet
Co-Signed by physicians within a specific
time
Fax orders must be legible and issued from a
credentialed and privileged individual

Follow similar protocol as V.O. (1-3)

4. Record T.O. (telephone order) and the full
name and title of the physician or nurse
practitioner (NP) who issues the orders.
5. Sign the orders with name and title
It is the responsibility of the physician or NP
dictating the orders to sign them as soon as
practical. With exception of orders for
narcotics, anticoagulants, and antibiotics,
which must be signed within 24 hours.

Care Planning
Quality review
Research
Decision analysis
Education
Legal documentation
Reimbursement
Historical documentation

Source oriented Records

Advantage

Each discipline can easily find and chart data

Disadvantage

Data fragmented

Problem-Oriented Medical Record- (POMR)

Example Box 17-3
Advantage

Entire health team works together to determine list of

problems
Collaborative plan of care
Progress notes clearly focus on patient problems

Major parts of POMR:

Defined

database
Problem list
Care plan
Progress notes

SOAP- originated from medical record

SOAPE
SOAPIE
SOAPIER (Intervention, Evaluation, Response)

PIE- Problem, Intervention, Evaluationoriginated from nursing

Example figure 17-2
Does

not develop separate plan of care

At beginning of each shift patient problems are
identified, numbered and documented in progress
notes, and worked up using PIE format
Resolved problems are dropped

Advantage
Continuity

and saves time (no separate Plan of Care)

Disadvantage
Nurses

have to read all nursing notes to determine

problems and planned interventions

Focus charting
Focus may be on a patients
Strength
Problem
Need

Topics may include

Patient

concerns and behaviors

Therapies and responses
Changes in condition
Significant events

Focus
Narrative

section uses the Data, Action, Response

(DAR) format- example figure 17-3

Advantage
Holistic

emphasis on patient
Ease of charting

Disadvantage
Some

nurses argue that the DAR categories are

artificial and not helpful when documenting care

Charting by exception (CBE)- figure 17-4

Advantages
Decreased

charting time
Greater emphasis on significant data
Easy retrieval of significant data
Timely bedside charting
Standardize assessment
Greater interdisciplinary communication
Better tracking of important patient responses
Lower cost

Disadvantage limited usefulness in response

to negligence claims against nurses

Case Management Model

Advantages
Collaboration
Communication
Teamwork

among disciplines
Efficient use of time increases quality

Disadvantage
Works

for typical patient

Case Management Model

Collaborative

Pathways/critical pathways/care
mapping figure 17-5
Variance Charting

Personal Health Records (PHRs)

Computerized Records
Guidelines/strategies

for safe computer charting

Never share passwords

Dont leave computer unattended
Follow protocol when correcting errors, mistaken
entry add correct info, date and initial entry. If
wrong chart, write mistaken entry wrong chart.
Never create, delete or change entries
Back up files
Dont leave info about patient for others to see
Never use email to send protect health info
Follow policy for documenting sensitive material

Initial nursing assessment- Database

Kardex and Patient Care Summary
Plan of Care- student example chapter 14
Diagnosis
Goals
Expected

outcomes
Interventions

Critical/collaborative pathways-chapter 14,

figure 17-5
Abbreviated

case management plan

Progress notes
See

Table 17-5 for advantages and disadvantages

Flow Sheets
Graphic

(clinical) Record
24 Hour Fluid Balance Record
Medication Record
24 Hour Patient Care Record and Acuity Charting
Forms

Discharge and Transfer Summary

Home Healthcare Documentation
Long-Term Care Documentation

Potential legal problemssee

BOX 17-4, page 381

Reporting
Face

to face
Telephone
Messengers
Written
Audiotaped
Computer messages

Table 17-6 see advantages and disadvantages

Change of Shift Reports

Telephone/telemedicine Reports
Transfer and Discharge Reports
Report to Family and Significant Others
Incident Reports

Basic identifying information about each

patient
Current appraisal of each patients health
status
Changes

in medical conditions and patient

response to therapy
Where patient stands in relation to identified
diagnoses and goals

Current orders (nurse and physician)

Summary of each newly admitted patient
Report on patient transferred or discharged

Consultations and Referrals

Nursing and Interdisciplinary team Care
Conferences
Nursing Care Rounds