Fundamentals Lecture – 1/20/20

DOCUMENTATION
- Series of permanent record of a client information of care
Ethical and Legal Considerations
a. Confidentiality
- The American Nurses’ Association code of ethics 2001 states that “… the nurse has a duty to
maintain confidentiality of patient information.”
Types of Documentation
 Narrative Charting
- Traditional method ‘
- Chronologic accounts written in order
 SOAP
- Subjective, objective, assessment, plan
 SOAPIE
- Subjective, objective, assessment, plan, intervention, evaluation
 PIE
- Problem, intervention, evaluation
 Focus Charting
- Use of column format to chart data, action and response (FDAR)
- Usually focus is the nursing diagnosis
Electronic Documentation
 EHR (Electronic Health Record)
- Experts believe that implementing HER across the health care delivery system will decreases
costs and improve the quality of patient care
 PCC EHR audit log
 POMR (Problem oriented medical record)
- Database Problem list Plan of Action Notes on Progress
NINE TYPES OF NURSING DOCUMENTATION ERRORS
1. Sloppy, illegible handwriting
2. Incomplete or missing documentation
3. Not questioning incomprehensible orders
4. Failure to date, time, and sign a medical entry
5. Adding entries later on
6. Using the wrong abbreviations
7. Lack of documentation or omitted medication/treatment
8. Documenting subjective data
9. Entering information into the wrong chart
FIVE GUIDELINES FOR QUALITY DOCUMENTATION
1. Factual
2. Accurate
3. Concrete
4. Complete
5. Organized
Acuity Rating System
 Nurses can acuity ratings to determine the hours of care and number of staff required for a
given group of patients every shift or every 24 hours
 Based on type and number of number interventions required by a patient over a 24 hour
period
Change Shift Report
 Level 1: Restriction : see patient immediately
 Level 2: Emergency
 Level 3: Urgency
 Level 4: Less urgency
 Less 5: Non urgency
Documenting Communication with Providers and Unique Events
 Telephone calls made to a provider
- Document every every call
 Telephone and Verbal Orders
- Telephone orders (Tos)
- Verbal orders (Vos)
Guidelines for Telephone and Verbal Orders
1. Clearly determine the pt’s name, room number and diagnosis
2. Write to (telephone and order) or VO (verbal order), date, time, patient’s name, complete
order, sign the name of doctor and nurse
3. Read back any prescribed orders to the physician
4. Reviewed and signed by 2 nurses
 Incidence or occurrence reports
- Used to document any event that is not consistent with the routine operation of a health
care unit or the routine care of a patient
When Incident Occurs
- Document an objective description of what happened
- What you observed and the follow up action taken including notification of the doctor and
nursing administration
Guidelines for Recording and Reporting
DO’s DON’T’s
 Chart a change in client’s condition and  Leave a blank space for a colleague to
show the follow up questions were chart later
taken  Chart in advance of the event for
 Read the nurses’ notes prior to care to someone else
determine if there has been a change in  Alter a record even if requested by a
the client condition superior or a physician
 Be timely  Record assumptions or words reflecting
 Use objective, subjective, specific, bias with vague terms
factual descriptions
 Correct charting errors
 Chart all teaching
 Record the client’s actual words by
 putting quotes around words
 Chart the client’s response to
intervention
 Review your notes – they are clear and
reflect what you want to say