Effective Documentation

and Reporting in nursing

By
James Avoka Asamani
RGN, Dip., BSc (Hons), MPhil (Candidate)
Email: avokaj@yahoo.com

Objectives
By the end of this session, we will be able to
 Explain the purposes of documentation in
health care.
 Discuss the principles of effective
documentation.
 Describe various methods of
documentation.
 Write standard nurses‟ notes


A CHINESE SAYING
If I hear, I forget
If I see, I remember and
If I do, I know!!
What is documentation?
What is Nursing Documentation?
Documentation is any written or
electronically generated information
about a client that describes the care
or service provided to that client.
Documentation is an accurate
account of what occurred and when
it occurred.
6
What is documentation?- cont’d
 Documentation is defined as written
evidence of:
• The interactions between and among
health professionals, clients, their families,
and health care organizations
• The administration of tests, procedures,
treatments, and client education
• The results or client’s response to these
diagnostic tests and interventions

Why documentation today?
Why documentation today?
 A recent study in Eastern Region findings
are worrying;
 54.2% of patient care records captured all
the nursing care rendered
 However, 45.8% of patient care records did
not capture some of the nursing care
 63% of patient care records did not have
nurses‟ progress notes written after the first
day of admission.

Common Documentation Errors
0.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
4.10%
14.30%
10.20%
51.00%
26.50%
12.20%
46.90%
53.10%
57.10%
12.20%
Percent of Patients' Folders
Found
Purposes of documentation
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Purposes of documentation
 Professional Responsibility and
Accountability
 Communication
 Education
 Research
 Legal and Practice Standards
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Professional Responsibility and
Accountability
 Recording provides written evidence of
what was done for the client, the client‟s
response, and any revisions made in the
care plan.
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Professional Responsibility and
Accountability cont‟d
 Recording documents compliance with
professional practice standards and
accreditation criteria.
 Written records are a resource for review,
audit, reimbursement, and research.
 Documentation provides a written legal
record to protect the client, institution and
practitioner.

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Education
• Health care students use the medical record
as a tool to learn about disease processes,
diagnoses, complications, and interventions.
• Clinical rounds and case conferences rely
heavily on information contained in the
medical record.
15
Research
• Researchers rely heavily on medical records
as a source of clinical data.
• Documentation can validate the need for
research.
16
Legal and Practice Standards
• In 80% - 85% of malpractice lawsuits
involving client care, the medical record is
the determining factor in providing proof of
significant events.
• Nursing care and the documentation of that
care will be measured according to the
standard of a reasonable and prudent nurse
with similar education and experience in a
similar situation.

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Legal and Practice Standards
 Informed Consent
 Advance Directives
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Legal and Practice Standards
 Informed consent means that the client
understands the reasons and risks of the
proposed intervention.
 Witnessing confirms that the person who
signs the consent is competent.
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Legal and Practice Standards
 An advance directive allows the client to
participate in end-of-life decisions.
 Patient Self-Determination laws requires
health care facilities to document whether
the client has such a directive.
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Reimbursement
• NHIS evaluates medical records to
determine if patient bills are justified
• Medical record documentation is the
mechanism for the peer review.

Types of Documentation
 Front index sheet
 Temperature chart (vital signs)
 Fluid intake and output
 Nurses notes
 Special monitoring charts
 Ward report
 Annual report
 Incident report
 Medication chart (treatment chart)
 Admission and discharge book
 Ward statistics etc.

Principles of Effective Documentation
A focus on Nurses’ progress notes
Nurses Notes/Point of Care
Documentation
 Nurses‟ note is a report of the
interventions carried out on the patient
and its outcome.
 This type of documentation is
predominantly used by nurses and
mostly referred to during court
proceedings.


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Principles of Effective Documentation
 Nursing notes must be
- logical
- focused
- relevant to care
- and must represent each phase of
the nursing process
General Principles of Documentation
• Ensure that you have the correct client
record or chart
• Document as soon as the client encounter
is concluded to ensure accurate recall of
data
• Date and time each entry.
• Sign each entry with your full legal name
and with your professional credentials
Principles of Documentation cont’d
 Do not leave space between entries.
 Never change another person‟s entry,
even if it is incorrect.
 Use quotation marks to indicate direct
client responses (e.g., “I feel lousy”).
 Document in chronological order (if
chronological order is not used, state
why).


Principles of Documentation cont’d
 Use a permanent-ink pen (black is usually
preferable because of its ability to
photocopy well).
 Document in a complete but concise
manner.
 Document all telephone calls that you
make or receive that are related to a
client‟s case.

Elements of Effective Documentation
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Elements of Effective Documentation
 Use of Common Vocabulary
 Legibility
 Abbreviations and Symbols
 Organization
 Accuracy
 Documenting a Medication Error
 Confidentiality
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Elements of Effective Documentation
 Use of Common Vocabulary
• Enhances the quality of documentation.
• Supports the efforts of research.
• Improves communication and lessens the chance
of misunderstanding between members of the
health team.
 Never use words that others don‟t understand
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Elements of Effective
Documentation
 Legibility
• Make your handwriting readable
• Print if necessary.
• Do not erase or obliterate writing even if
there an error.

Correcting a documentation error
 To correct an error in a paper-based
nurses‟ note, follow the SLIDE rule.
 Cross through the word(s) with a Single
Line, Initials, Date and time of correction
and Explanation.

(Baker, 2000)

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Elements of Effective
Documentation
Correcting a documentation error
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Elements of Effective
Documentation
 Abbreviations and Symbols
• Always refer to the facility‟s approved listing.
• Avoid abbreviations that can be
misunderstood.
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Elements of Effective Documentation
 Organizing your notes
• Start every entry with the date and time.
• Chart in chronological order.
• Chart in a timely fashion to avoid
omissions.
• Chart medications immediately after
administration.
• Sign your name and rank after each entry.
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Elements of Effective
Documentation
Charting a late entry
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Elements of Effective
Documentation
 Accuracy
• Use factual, descriptive terms to chart
exactly what was observed or done.
• Use correct spelling and grammar.
• Write complete sentences.
• Maintain continuity of care by recording with
respect to notes made on previous shifts.
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Elements of Effective
Documentation
 Documenting a Medication Error
• Chart the medication on the MAR.
• Document in the nurses‟ progress notes:
- Name and dosage of the medication
- Name of the practitioner who was notified of the
error
- Time of the notification
- Nursing interventions or medical treatment
- Client‟s response to treatment
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Elements of Effective
Documentation
 Confidentiality
• The nurse is responsible for protecting the
privacy and confidentiality of client
interactions, assessments, and care.
• The client‟s significant others, insurance
companies, or other parties not directly
involved in care provided by the health team
may not have access to clients‟ records.
Guidelines for documenting
assessment findings
Record all data that contribute directly to the
assessment (e.g., positive assessment findings
and pertinent negatives)
Document any parts of the assessment that are
omitted or refused by the client
 Avoid using judgmental language such as
“good,” “poor,” “bad,” “normal,” “abnormal,”
“decreased,” “appears to be,” and “seems.”


Guidelines for documenting
assessment findings
Avoid evaluative statements (e.g., “client is
uncooperative,” “client is lazy”); cite instead
specific statements or actions that you
observe (e.g., “client said „I hate this place‟
and kicked dustbin”)
State time intervals precisely (e.g., “every 4
hours,” “bid,” instead of “seldom,”
“occasionally”)

Guidelines for documenting
assessment findings
Do not make relative statements about
findings (e.g., “mass is the size of an egg”);
use specific measurements (e.g., “mass 3 cm
× 5 cm”)
Draw pictures when appropriate (e.g., location
of scar, masses, skin lesion, decubitus, etc.)
Refer to findings using anatomical landmarks
(e.g., left upper quadrant [of abdomen], left
lower lobe [of lung], midclavicular line, etc.)
Guidelines for documenting
assessment findings
Use the face of the clock to describe
findings that are in a circular pattern (e.g.,
breast, tympanic membrane, rectum,
vagina)
Document any change in the client‟s
condition during a visit or from previous
visits.
Describe what you observed, not what you
did.

Methods of documentation
Methods of Documentation
 Most methods of documentation fall into
one of two categories:
Documentation by inclusion and
Documentation by exception
(Coleman, 1997).
Methods of Documentation
1. Narrative documentation (Story Writing)
2. Problem-Oriented Medical Record (POMR)
or SOAP/SOAPIER and
3. Focus Charting or DAR (Data, Action,
Response)

 Any of these methods may be used to
document on an inclusion or exception basis.

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Narrative Charting

Describes the client‟s status,
interventions and treatments; response
to treatments is in story format.
Narrative charting is now being
replaced by other formats.
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Problem-Oriented Medical
Records (POMR)
• A single list of patient problems is made
every day
• Uses a structured, logical format called
S.O.A.P.
- S: subjective data
- O: objective data
- A: assessment (conclusion stated in form of
nursing diagnoses or client problems)
- P: plan
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Problem-Oriented Charting
(POMR)
 Uses flow sheets to record routine care.
 A discharge summary addresses each
problem.
 SOAP entries are usually made at least
every 24 hours on any unresolved
problem.
 SOAP was developed on a medical
model.
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Problem-Oriented Charting
(POMR)
 SOAPIE and SOAPIER refer to formats
that add:
• I: Intervention
• E: Evaluation
• R: Revision
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Problem-Oriented Charting
(POMR)
Focus Charting (Also called DAR)
 With this method, the nurse identifies a “focus”
based on client concerns or behaviours
determined during the assessment. For
example, a focus could reflect:
a. A current client concern or behaviour, such
as decreased urinary output.
b. A change in a client’s condition or behavior,
such as disorientation to time, place and
person.
c. A significant event in the client’s treatment,
such as return from surgery.

Focus Charting - DAR
Data: Subjective and/or objective
information that supports the stated focus
or describes the client status at the time of
a significant event or intervention.
Action: Completed or planned nursing
interventions based on the nurse‟s
assessment of the client‟s status.
Response: Description of the impact of
the interventions on client outcomes.

Example of DAR
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Methods of Documentation
 Computerized Documentation
• Increases the quality of documentation and
save time.
• Increases legibility and accuracy.
• Enhances implementation of the nursing
process. Enhances the systematic approach
to client care.
• Provides clear, decisive, and concise key
words (standardized nursing terminology).
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Reporting
 Verbal communication of data regarding
the client‟s health status, needs,
treatments, outcomes, and responses
 Summary of current critical information to
facilitate clinical decision making and
continuity of client care
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Reporting
 Reporting is based on the nursing
process, standards of care, and legal and
ethical principles.
 Reports require participation from
everyone present.
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Reporting
 Summary Reports
 Walking Rounds
 Telephone Reports and Orders
 Incident Reports
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Summary Reports
 Commonly occur at change of shift (or
when client is transferred).
• Assessment data
• Primary medical and nursing diagnoses
• Recent changes in condition, adjustments in
plan of care, and progress toward expected
outcomes
• Client or family complaints

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Documenting a Telephone Order
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Incident Reports
 Used to document any unusual
occurrence or accident in the delivery of
client care.
 The incident report is not part of the
medical record, but it may be used later
in litigation.
SUMMARY
 In summary, regardless of the method used,
nurses are responsible and accountable for
documenting client care including
assessments, interventions carried out, and
results of the interventions on client
outcomes.
 Clients who are very ill, considered high risk
or have complex health-care needs require
more comprehensive, in depth and frequent
documentation by the nurse providing care

And finally,
If you have been,
Thanks for
listening
Avoka‟s Research Interest
 Nursing management and leadership
 Adult Medical-Surgical nursing
 Health systems and policies
 Workload analysis
 Contact: +233 (0)246811379 /
+233(0)209409458
 Email: avokaj@yahoo.com