King Saud University College of Nursing Medical Surgical Department

Module 10-123
Documenting

Recording

OR Charting

Prepared by:Mervat Mohamed

DOCUMENTING

A report: is oral, written, or

computer-based communication intended to convey information to others. For instance, nurses always report on clients at the end of a hospital work shift.

DOCUMENTING

A record: is written or computer-based. All

personnel involved in a patients health care contribute to the medical record by charting, recording, or documenting (process of writing information) on the health agencys forms. Medical record, also called a chart or client record, is a formal, legal document that provides information about a persons health problems, the care provided by health practitioners, and the progress of the patient. Although health care organizations use different systems and forms for documentation, all client records have similar information.

Documenting
Purposes of client records
A.

Communication: patients record serves as the

vehicle by which different members of the health team communicate and share information with each other. Assessment: nurses and other health team members gather assessment data from the patients record. Planning patient care: the entire health team uses data from the patients record to plan care for the patient. Education & research: nursing students, medical students and other health team members often use patient record as an educational tools. It provides a comprehensive view of the patients health status. The information contained in a record can be a valuable source of data for research.

B. C.

D.

Documenting
Purposes of client records
E.

Legal documentation: the clients record is a

legal document and is usually admissible in court as evidence.

F.

Health care analysis: records can be used to

establish the costs of various services and to identify those services that cost the agency money and those that generate revenue.

G.

Auditing health agencies: patients record is

used to monitor the care received by the patient and the competence of people giving that care.

Documenting
Types of Patient Records
1.

Source-Orient Records: records organized

according to the source of documented information. This type of record contains separate forms on which physicians, nurses, dietitians, physical therapists, and so on. One of the criticisms of source-oriented records is that it is difficult to demonstrate that there is a unified, cooperative approach for resolving the patients problems among caregivers.

2.

Problem-Orient Records: records organized

according to the patients health problems. Problemoriented records contain four major components: the data base, the problem list, the plan of care, and progress notes (Table 1). The information is arranged to emphasize goal-directed care, and to facilitate communication among health care professionals.

Documenting
Purposes of client records

Component Description
Database Problem list Plan of care Progress notes
Contains initial health information Consists of a numeric of the patients health problems Identifies methods for solving each identified health problem describes the patients response to what has been done & revisions to the initial plan

Table 1 common components of a problem-oriented record

Documenting
Methods of Charting
1.

Narrative charting: Narrative charting (style of

documentation generally used in source-oriented records)

involves writing information about the patient and patient care in chronologic order. (Figure 1)

Nursing Notes Date/time Nurses Remarks 13.30 pm 13.40 pm

States I am having chest pain. Its like an elephant is sitting on me B. Zook, RN Skin is pale & moist. O2 started at 5L/min Nitroglycerin tablet administered sublingual

Figure 1 Sample of narrative charting

Documenting
Types of Patient Records
2.

SOAP charting: SOAP charting (documentation style

more likely to be used in a problem-oriented record)

acquired its name from the four essential components included in a progress note:
* S : subjective data * O : objective data * A : analysis of the data * P : plan for care

SOAP charting helps to demonstrate interdisciplinary cooperation, because everyone involved in the care of a patient makes entries in the same location in the chart. (Table 2)

Documenting
Types of Patient Records

Letter
Subjective
Objective Analysis Plan

Explanation
Information reported by the patient

Nurses Remarks
S - Dont feel well

Information reported by the nurse

O - Temperature 38C

Problem identification

A Fever

Proposed treatment

P Increased fluid intake & Monitor body temperature

Table 2 SOAP Charting format

Documenting
Types of Patient Records Focus charting: Focus charting (modified form of SOAP
Charting) uses the word focus rather than problem,

because some believe that the word problem carries negative connotations. Focus charting used DAR model: D = data category reflects the assessment phase of the nursing process A = action category reflects planning & implementation phase of the nursing process. R = response category reflect the evaluation of the nursing process (Figure 2). DAR notation tends to reflect the steps in the nursing process.

Documenting
Types of Patient Records

6/6/2006
10.15 am

D (data) -

Bladder distended 2 fingers above pubis

Has not urinated since catheter was removed

A (action) Assisted to toilet. Water turned on at faucet R (response)- voided 525ml of clear urine L. Cass, SN

Figure 2 Example of DAR charting

Documenting
Types of Patient Records
4.

PIE charting:
PIE charting is method of recording the patients progress under the headings of problem, intervention, and evaluation. When the PIE method is used, assessments are documented on separate form and the patients problems are given a corresponding number (Figure 3).

Date/time
6/6 8.30 am

Nurses Remarks
P# 1 crackles heard on inspiration in the bases of R and L lungs. I# 1 splinted with pillow. Instructed to breathe deeply, open mouth, and cough at the end of expiration. E# 1 Lungs clear with coughing. L Cass, HN

Figure 3 Sample of PIE charting

Documenting
Types of Patient Records 5. Computerized Charting: Computerized charting (documenting patient information electronically) is most useful for nurses when a terminal is available at the point of care or beside

Documenting
General Guidelines for Recording
Because the clients record is a legal document and may be used to provide evidence in court, many factors are considered in recording. 1. Data & Time: Documenting the date and time of each
recording. This is essential not only for legal reasons but also for client safety. Record the time in the conventional manner (e.g. 9:00 am or 3:20 pm) or according to the 24-hours clock (military clock).
2.

Timing: follow the agencys policy about the frequency of

documenting, and adjust the frequency as a clients condition indicates; for example, a client whose blood pressure is changing requires more frequent documentation than a client whose blood pressure is constant.

3.

Legibility: all entries must be legible and easy to read

to prevent interpretation errors.

Documenting
General Guidelines for Recording
4.

Performance: all entries on the clients record are made in

dark ink so that the record is permanent and changes can be identified.

5.

Accepted Terminology: use only commonly accepted

abbreviations, symbols, and terms that are specified by the agency.

6.

Correct Spelling: correct spelling is essential for accuracy

in recording. If unsure how to spell a word, look it up in a dictionary.

7.

Signature: each recording on the nursing notes is signed by

the nurse making it. The signature includes the name and title; for example, Susan j. Green, RN or SJ Green, RN

8.

Sequence: documenting events in the order in which they

occur; for example, record assessments, then the nursing interventions, and then the clients responses.

Documenting
General Guidelines for Recording
9.

Accuracy: the clients name and identifying information

should be written on each page of the clinical record. Accurate notations consist of facts or observations rather than opinions or interpretations. It is more accurate, for example, to write that the client refused medication (fact) than to write that the client was uncooperative (opinion)

Good Luck