DOCUMENTATION

Documentation
Written evidence of:
The interactions between and among health care professionals, clients, their families, and health care organizations. The administration of tests, procedures, treatments, and client education. The results of, or clients response to, diagnostic tests and interventions

Purposes of Documentation
Professional responsibility Accountability Communication Education Quality Assurance Accreditation Research Satisfaction of Legal and Practice standards Reimbursement Assures continuity of care

PERMANENT RECORD
WRITTEN IN CHRONOLOGICAL ORDER FILED IN MEDICAL RECORDS DEPT FOR FUTURE USE/REFERENCE

Documentation as Communication

 Documentation is a communication method

that confirms the care provided to the client.

 It clearly outlines all important information

regarding the client.

SIX ITEMS THAT NURSES MUST DOCUMENT

ASSESSMENT NURSG DX AND PT NEEDS INTERVENTIONS CARE PROVIDED PT RESPONSE TO CARE PTS ABILITY TO MANAGE CONTINUING CARE AFTER DISCHARGE

Documentation as Education

 The medical record can be used by health

care students as a teaching tool.

 It is a main source of data for clinical

research.

Documentation & Research

 The medical record is a main source of data

for clinical research.

RESEARCH
DATA ON TREATMENTS, MEDS, AND THERAPY INFO FOR TUMOR BOARDS, DOCTORS ROUNDS, NURSING ROUNDS, ETC. BE AWARE OF PRIVACY ISSUES NURSES, STUDENT NURSES USE FOR CARE PLANS.

Legal & Practice Standards

 Nurses are responsible for assessing and

documenting that the client has an understanding of treatment prior to intervention.

 Two indicators of the above are Informed

Consent and Advance Directives.

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. EACH HEALTH CARE PROVIDER IS RESPONSIBLE FOR THE ABCS OF RECORDING. ACCURACY, BRIEF, COMPLETE.

Informed Consent

A competent clients ability to make health care decisions based on full disclosure of the benefits, risks, and potential consequences of a recommended treatment plan. The clients agreement to the treatment as indicated by the clients signing a consent form.

Advanced Directives

Written instructions about a clients health care preferences regarding life-sustaining measures. (e.g. living will and durable power of attorney for health care). Allows clients, while competent, to participate in end-oflife decisions.

Documentation & Reimbursement

 Accreditation and reimbursement agencies

require accurate and thorough documentation of the nursing care rendered and the clients response to interventions.

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.

Documentation & Quality Assurance

QUALITY ASSURANCE
A PEER REVIEW PROCESS CONDUCTED BY A STAFF NURSE AND PHYSICIAN ESTABLISHES AND REFLECTS AGENCY STANDARDS

Documentation & Accreditation

ACCREDITATION
JCAHO (JOINT COMMISSION ON ACCREDITATION OF HEALTH ORGANIZATION)/DSHS STATE (EXTENDED CARE) SETS MINIMUM STANDARDS FOR STAFFING THE AMERICAN NURSES ASSOCIATION SETS THE STANDARDS FOR PT CARE & DOCUMENTATION FOR NURSES

ACCESS TO CHARTS
PATIENTS RIGHTS WHO OWNS CHART AGENCY POLICY

PATIENT CONFIDENTIALITY
NEVER LEAVE CHART IN A PUBLIC PLACE. DISCUSS CONTENTS ONLY WITH PERSONS DIRECTLY INVOLVED IN THE PATIENTS CARE OR THOSE THAT ARE AUTHORIZED BY THE PATIENT. THESE PEOPLE SHOULD BE LISTED BY NAME. ASK FOR ID PRIOR. DO NOT DISCUSS PT OR PT INFO IN PUBLIC PLACES, EG. ELEVATORS, CAFTERIA.

ACCESS TO CHARTS
PATIENTS RIGHTS/AGENCY POLICY
PATIENTS HAVE THE RIGHT TO THE INFO 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.

ACCESS TO CHARTS
WHO OWNS THE CHART
A PATIENTS CHART IS THE PROPERTY OF THE FACILITY. IT IS THE FACILITY WHICH SETS THE POLICY AND MAKES APPOINTMENTS FOR VIEWING OF THE CHART.

PRINCIPLES OF EFFECTIVE DOCUMENTATION

1. Document accurately, completely, and 2. 3. 4. 5. 6.

objectively, including any errors. Note date and time. Use appropriate forms. Identify the client. Write in ink. Use standard abbreviations.

PRINCIPLES OF EFFECTIVE DOCUMENTATION (continued)

7. Spell correctly. 8. Write legibly. 9. Correct errors properly. 10. Write on every line. 11. Chart omissions. 12. Sign each entry.

ABBREVIATIONS
YOU MUST USE YOUR FACILITYS APPROVED ABBREVIATIONS. BE AWARE THAT A LOT OF COMMONLY USED ABBREVIATIONS: EG. TID, BID, QOD, HS ARE NO LONGER ALLOWED AND SHOULD BE CURRENTLY BEING PHASED OUT OF YOUR FACILITY.

TYPES OF PATIENT RECORDS

SOURCE-ORIENTED

PROBLEM-ORIENTED

Source-Oriented Charting

 A narrative recording by each member

(source) of the health care team on separate records.

Problem-Oriented Charting

 Focuses on the clients problem and

employs a structured, logical format called SOAP charting:

   

S: Subjective data (what the client states) O: Objective data (what is observed/inspected) A: Assessment P: Plan

Methods of Documentation

Narrative PIE FDAR SOAP

SOAPIER

Charting by exception Computerized documentation Critical pathways

Narrative Charting

 This traditional method of

nursing documentation takes the form of a story written in paragraphs.

 Before the advent of flow sheets, this was

the only method for documenting care.

NARRATIVE
CHRONOLOGICAL BASELINE CHARTED QSHIFT LENGTHY, TIME-CONSUMING SEPARATE PAGES FOR EACH SOURCE-ORIENTED

SOAP
USED FOR PROBLEM-ORIENTED CHARTS S SUBJECTIVE. WHAT PT TELLS YOU. 0 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. PT RESPONSE TO INTERVENTIONS. R REVISION. CHANGES IN TREATMENT.

EXAMPLE OF SOAP CHARTING

#1 ALTERATION IN COMFORT. ABDOMINAL PAIN. S COMPLAINS OF PAIN IN RUQ O IS PALE AND HOLDING RIGHT SIDE A RECURRING ABDOMINAL PAIN P PUT ON NPO AND NOTIFY PHYSICIAN

Focus Charting

 A documentation method that uses a

column format to chart data, action, and response (DAR).

FDAR
USES NARRATIVE DOCUMENTATION (DAR)
DATA SUBJECTIVE OR OBJECTIVE THAT SUPPORTS THE FOCUS (CONCERN) ACTION NURSING INTERVENTION RESPONSE PT RESPONSE TO INTERVENTION

EXAMPLE OF FOCUS CHARTING

D COMPLAINING OF PAIN AT INCISION SITE ON LEVEL OF #7 A REPOSITIONED FOR COMFORT. DEMEROL 50MG IM GIVEN. R (CHARTED AT A LATER DATE.) STATES A DECREASE IN PAIN, FEELS MUCH BETTER.

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

PIE Charting

PROBLEM INTERVENTION EVALUATION

SAMPLE OF PIE CHARTING

P#1 Risk for trauma related to dizziness. IP#1 Instructed to call for assistance when getting OOB. Call light in reach. EP#1 Consistently call for assistance before getting OOB. Continues to experience dizziness.

Charting by Exception

 A documentation method that requires the

nurse to document only deviations from pre-established norms.

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. ADVANTAGE

COMPUTERIZED CHARTING
PASSWORD. NEVER SHARE. CHANGE FREQUENTLY. LEGIBLE 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 PT ROOMS, CONVENIENT HALLWAY LOCATIONS. MAKE SURE TERMINAL CANNOT BE VIEWED BY UNAUTHORIZED PERSONS.

Computerized Documentation: Advantages

Decreased documentation time. Increased legibility and accuracy. Clear, decisive, and concise words. Statistical analysis of data. Enhanced implementation of the nursing process. Enhanced decision making. Multidisciplinary networking.

Forms for Recording Data

Kardex Flow Sheets Nurses Progress Notes Discharge Summary

Kardex
A summary worksheet reference of basic information that traditionally is not part of the record. Usually contains:
Client data (name, age, marital status, religious preference, physician, family contact). Medical diagnoses: listed by priority. Allergies. Medical orders (diet, IV therapy, etc.). Activities permitted.

KARDEX
QUICK REFERENCE CHANGED AS NEEDED NOT PART OF PERMANENT RECORD

Flow Sheets

Vertical or horizontal columns for recording dates and times and related assessment and intervention information. Also included are notes on:
Client teaching. Use of special equipment. IV Therapy.

Nurses Progress Notes

Used to document:
Clients condition, problems, and complaints. Interventions. Clients response to interventions. Achievement of outcomes.

Discharge Summary

Highlights clients illness and course of care. Includes:

Clients status at admission and discharge. Brief summary of clients care. Intervention and education outcomes. Resolved problems and continuing care needs. Client instructions regarding medications, diet, fooddrug interactions, activity, treatments, follow-up and other special needs.

CRITICAL PATHWAY
Also known as Care Maps. Comprehensive pre-printed standard plan reflecting ideal course of treatment for diagnosis or procedure, especially with relatively predictable outcomes. Additional forms are needed to complement the pathway.

Critical Pathways

 A comprehensive, standard plan of care for

specific case situations.

 The pathway is monitored to ensure that

interventions are performed on time and client outcomes are achieved on time.

INFORMATION FOR SHIFT REPORT

Name, room and bed, age, gender Physician, admission date, and diagnosis Diagnostic tests or treatments performed in past 24 hours (results if ready) General status, any significant change New or changed physicians orders IV fluid amounts, last PRN medication Concerns about client

CHANGE OF SHIFT REPORT

PERSON TO PERSON BE PREPARED AVOID GOSSIP/SOCIALIZA TION TAPE RECORDER

Summary Reports

The outlining of information pertinent to the clients needs as identified by the nursing process. Commonly given at end-of-shift.

WALKING ROUNDS
Members of the care team walk to each clients room and discuss progress and care with each other and with the client.

Telephone Reports and Orders

Telephone communications are another way nurses:

Report transfers. Communicate referrals. Obtain client data. Solve problems. Inform a clients family members regarding a change in clients condition.

TELEPHONE ORDERS
Date and time Order as given by the physician Signature beginning with t.o. (telephone order) Physicians name Nurses signature Physician must countersign

INCIDENT REPORT
May also be called a variance. Informs administration of incident, allows risk management personnel to consider ways to prevent future similar occurrences. Alerts insurance company to potential claim and possible need to investigate.

INCIDENT REPORTS
OBJECTIVE DO NOT BLAME OR ADMIT LIABILITY WHAT DID YOU DO? DO NOT INCLUDE NAMES/ADDRESSES OF WITNESSES DOCUMENT TIME/NAME OF DOCTOR DO NOT FILE IN CHART DO NOT WRITE INCIDENT REPORT MADE

CORRECTING ERRORS
IF YOU SPILL SOMETHING ON THE CHART, DO NOT DISCARD NOTES. RECOPY, PUT ORIGINAL AND COPIED SHEETS IN CHART. WRITE COPIED ON COPY. DO NOT SCRIBBLE OUT CHARTING. AVOID USING ERROR OR WRONG PATIENT WHEN MAKING CORRECTION. FOLLOW YOUR FACILITIES POLICY. DO NOT ALTER CHARTING, IT IS A LEGAL DOCUMENT.