Documentation and Reporting

Monday, August 22, 2022 7:35 AM

Effective communication among health professionals is vital to the quality of client care. Generally,
health personnel communicate through discussion, reports and record.

Each health care organization has policies about recording and reporting client data, and each nurse is
accountable for practicing according to these standards.

INTRODUCTION

Discussion
- Discussion informal oral consideration of a subject by two or more health care personnel.
Report
- Oral, written, or computer-based communication intended to convey information to others.

Record
- Also called chart or client record.
- Formal, legal document that provides evidence of a client's care.
- Can be written or computer based.
Process of making an entry on a client record is called recording, charting, or documenting.

Documentation as Communication
- Documentation is define as written evidence
○ The interactions between and among health professionals, clients, their families, and health
care organization.
○ The administration of tests, procedures, treatments, and client education.
○ The results or client's response to these diagnostic tests and interventions.

Ethical and Legal Considerations

The American Nurses Association Code of Ethics 2001 states that the nurse has a duty to maintain
confidentiality of all patient information.

Ethical and Legal Considerations

- Confidentiality of all patient information must be maintained
- Client's record must also be protected legally as a private record of client's care.
- HIPAA regulations updated on April 14, 2003: To maintain the privacy and confidentiality of
protected health information.
- Responsibility in using records for the purpose of education and research.

Ensuring Confidentiality of Computer Records

- Personal password that is not to be shared.
- Never leave a computer terminal unattended after logging on.
- Do not leave client information displayed on the monitor where others may see it.
- Shred all unneeded computer-generated worksheets.
- Know facility's policy and procedure for correcting an entry error.
- Follow agency procedures for documenting sensitive material.
- IT personnel must install a firewall to protect server from unauthorized access.

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.

Communication with in the Health Care Team

- In today's health care system, delivery processes involve numerous interfaces and patient
handoffs among multiple health care practitioners with varying levels of educational and
occupational training
- During the course of a 4-day hospital stay, a patient may interact with at least 50 different
professionals including physicians, nurses, technicians and others.
- Lack of communication creates situations where medical errors and occur. These errors have the
potential to cause severe injury or unexpected patient death.
- Effective communication takes place along two approaches.
○ Recording
○ Reporting

Purpose of Client Records

- Communication
○ The record serves as the vehicle by which health professionals interact with each other.
○ Prevents fragmentation, repetition, and delays in care.
- Planning Client Care
○ Each health professional uses data from the client's record to plan care for that client.
○ Nurses use baseline and ongoing data to evaluate effectives of the care plan.
- Auditing health agencies
○ Review client records for quality assurance purposes.
- Research
○ Information obtained in a record can be a valuable source of data for research.
○ Treatment plans for a number of client with the same health problems can yield information
helpful in treating other clients.
- Education
○ Students in health discipline often use client records as educational tool.
○ A record can frequently provide a comprehensive view of the client, the illness and effective
treatment strategies.
- Reimbursement
○ Documentation also helps a facility receive reimbursement from the government.
○ For a patient to obtain payment through Medicare or insurance agencies the client's client
record must contain the correct diagnosis and reveal that the appropriate care has been
given.
- Legal Documentation
○ Admissible in court as evidence unless client objects because information the client gives to
primary care provider in confidential.
- Health Care Analysis
○ Identify agency needs such as overutilized and underutilized hospital services.

Types of Nursing Records

- Admission nursing assessment
- Nursing care plan
- Kardexes
- Pertinent information about patient
- Medication with date of order and time of administration
- Daily treatment and procedures
- Flow char
- Graphic Record
 - Fluid Balance Record
- Medication
- Skin assessment record
- Progress notes

Documentation System
1. Source-oriented record
○ Traditional client record
○ Each discipline makes notations in a separate section
○ Information about a particular problem distributed throughout the record
 Separate section for lab report, x-ray films, radiology report, and so on.
○ Forms and progress notes are filed in reverse chronologic order (newest on top)
- Five Basic Components
○ Admission Sheet
○ Physician's Order Sheet
○ Medical History
○ Special Records and Reports
○ Nurses' Notes
- Advantages
○ Information in chronologic order
○ Documents patient's baseline condition for each shift
○ Indicates aspects of all steps of the nursing process.
- Disadvantages
○ Documents all finding making it difficult to separate pertinent from irrelevant information.
○ Requires extensive charting time by staff
○ Discourages physicians and other health team members from reading all parts of the chart.

2. Narrative Charting
- Written notes that include routine care, normal findings, and client problems.
- Is a chronological account of the client's status, the nursing interventions performed, and client's
responses.
- A traditional method that few facilities rely on alone. Often combined with other charting
systems.

3. Problem-Oriented Medical Record

- A method recording data about the health status of a patient in a problem-solving system, in an
easily accessible way that encourages ongoing assessment and revision of the healthcare plan by
every actor in the health care team.
- Data arranged according to client problem.
- Health team contributes to the problem list, plan of care, and progress notes.

Advantages:
- Encourages collaboration
- Easier to track status of problems
Disadvantages:
- Caregivers differ in the ability to use the required charting format.
- Takes constant vigilance to maintain an up-to-date problem list.
- Somewhat inefficient because assessments and interventions that apply to more than one
problem must be repeated.

4. Uses a structured, logical format called S.O.A.P

Subjective (What patient tells you)

Objective (What you observe or see)
Assessment (What you think is going based on your data)
Plan (What you are going to do)
Intervention (Specific interventions implemented)
Evaluation (Patients response to intervention)
Revision (Changes in treatment)
Uses flow sheets to record routine care
SOAP entries are usually made at least every 24 hours on any unresolved problem

Basic Components of POMR

- Data Base (History, Physical Exam and Laboratory Data)
- Complete Problem List

Database
- All information known about the client when the client first enters the health care agency
- Includes nursing assessment, history, social and family data, physical exam result, diagnostic test
Problem List
- Derived from the data base
- Listed in order in which they are identified and others resolved

A problem is defined as anything that causes concern to patient or to caregiver, including:

- Physical abnormalities
- Psychological abnormalities and socioeconomic problems
List serves as an index to rest of record and is arranges in 4 or 5 columns
- A chronologic list of problems
- Data of each problem's onset

Plan of care
- Made with reference to active problems
- Generated by individual who lists the problems

Progress notes
- Made by all health professionals involved in a client's care
- Uses SOAP, SOAPIE, SOAPIER documentation.

5. Focus Charting (DAR)

- A method of identifying and organizing the narrative documentation of all client concerns and
strength.
- Uses a columnar format within the progress notes to distinguish the entry from other recordings
inn the narrative notes (Date and time, Focus, Progress Note)

DAR
Data
- Assessment Phase, Subjective or objective that supports the focus
Action
- Planning and implementing phase, nursing intervention
Response
- Evaluation phase, patient response to intervention.
Focus Charting
- Holistic perspective of client needs.
- Nursing process framework for progress notes.
- DAR Progress notes
Response is used alone to indicate a care of plan goal has been accomplished.

Data is used when the purpose of the note is to document assessment finding and there is no flow
sheet/checklist for that purpose.

Action and Response are repeated without additional data to show the sequence of decision making
based on evaluating patient response to the initial intervention.

6. Charting by Exception
- The nurse documents only deviations from pre-established norms (document only abnormal or
significant findings)
- Avoids lengthy, repetitive notes.
- Activities are assumed done unless charted otherwise.
- Typically includes a checklist of flow chart nurses use to check off items to acknowledge that they
were performed.

WNL - Within normal limit

WDL - Within desirable limit

7. Computerized Documentation
- Developed to manage volume of information
- Used by nurses to: Store clients database, increase the quality of documentation, increase
legibility and accuracy, information easily retrieved, speech recognition technology
-

Disadvantages:
- Costly installation computer software
- Problem in protecting client's confidentiality, as in hospital everyone has access to computer
recording
- Transition to computerized documentation presents both opportunities and challenges to nurses
and practitioners.

8. Case Management Model

- A methodology for organizing client care through an illness, using a critical pathway.
- A critical pathway is a multidisciplinary plan or tool that specifies assessments, intervention,
treatments and outcomes of health related
- Uses multidisciplinary approach critical pathway, CBE
- Variance (goal that is not met)
- Documentation of variances includes:
○ Actions taken to correct the situation
○ Justification of actions taken.

Admission Nursing Assessment

- Comprehensive admission assessment when client first admitted to nursing unit
- Ongoing assessment and reassessments recorded on flow sheets or nursing progress notes.

Nursing Care Plans

Join Commission requires clinical record to include:
- Evidence of client assessment
- Nursing diagnosis
- Nursing interventions
- Client outcomes
- Current nursing care plans
Tradition care plans
- Written for each client
Standardized care plans
- Based on institution

Kardex
- The Kardex is used as a reference throughout the shift and during change-of-shift reports
- Client data
- Medical diagnoses and nursing diagnoses
- Medical orders, list of medication
- Activities, diagnostic test, or specific data on the patient
- Concise method of organizing and recording data
- Series of cards kept in a portable index file or on computer-generated form
- Information quickly accessible

Pertinent information about the client arranged in section

- List of daily treatments and procedures
- List of diagnostic procedure
- Physical needs to be met
- Stated goals

Entries usually written in pencil

Flow Sheets
- The information on flow sheets can be formatted to meet the specific needs of the client.

Graphic Record
○ Body temperature, pulse, respiratory rate, blood pressure, weight, other significant data
Intake and output
○ All routes measured and recorded.
Medication administration record
○ Date of order, expiration date, name and dose, frequency and route of administration,
nurse's signature
Skin Assessment Record
○ Such as the Braden Assessment

Progress Notes
- Used to document the client's condition, problems and complaints, interventions, responses,
achievement of outcomes.
- Provide information about progress client is making toward achieving desired outcomes.
- Include information about client problems and nursing.

Nursing Discharge/Referral Summaries

- Completed when client discharged
○ Terms that can be readily understood
- Completed when client transferred to another institution.

Include some or all of the following:

- Description of client's physical, mental, and emotional status.
- Resolved health problems
- Treatments to be continued
- Current medications
- Include restrictions that related to activity, diet, and bathing.
Discarge Summary Template
- Admitting Diagnosis (Reason for hospitalization)
- Discharge Diagnosis (Significant Findings)
- Hospital Course (Procedures performed and findings)
- Referring Physician/Consults
- Discharge Condition/Disposition (Patient Sent)
- Education
○ Follow Up
○ Diet
○ Medications
○ Discharge
- Time Spent
- Cc (PCP and Consulting Physicians)

Long term care documentation

- Based on professional standards, federal and state regulations, policies of health care agency.
- Laws and Requirements
○ Health Care Financing Administration
○ Omnibus Budget Reconciliation Act (OBRA) of 1987
○ Medicare and Medicaid

Home Care Documentation

- Influenced by:
○ Health Care Financing Administration (1985)
○ Medicare and Medicaid
○ Other third-party layers.

General Documentation Guidelines

- Conciseness
- Accuracy
- Correct Spelling
- Sequence
- Appropriateness
- Completeness
- Legal Prudence
- Factual
- Omission
- Confidentiality
- Date and Time
- Timing
- Legibility
- Permanence
- Accepted Terminology

Reporting
- Verbal Communication of data regarding the client's health status, needs, treatments, outcomes,
and responses.
- Reporting is based on the nursing process.

Change of shift reports

○ Handoff communication
 ○ Information communicated in a consistent manner including an opportunity to ask and
respond to question
○ Provide basic identifying information

Summary/hand-off reports
○ Commonly occur at change of shift (or when client care is transferred to another health care
provider)
○ Features
 Two way, face to face communication
 Written support tools
○ SBAR Tool (Situation, Background, Assessment, Recommendation)

Walking Round Reports

○ Occur in client's room
○ Include nursing, physician, interdisciplinary team

Incident or occurrence reports

○ Used to document any unusual occurrence or accident in the delivery of client care.

Telephone Reports
○ Be concise and accurate
○ Have chart ready to give any further information needed.
○ Document date, time, and content of the call

Telephone Orders
○ Many agencies only allowed registered nurses to take telephone orders
○ Write complete order down and read it back to primary care provider to ensure accuracy.
○ Question any order that is ambiguous, unusual, or contraindicated.
○ Have primary care provider verbally acknowledge the read-back
○ Counter-sign by provider in 24 hours.

Care Plan Conference

- A meeting of a group of nurses to discuss possible solutions to certain problems to a client
- Allows each nurse the opportunity to offer an opinion about possible solutions.
- Other health care providers invited to offer expertise.

Nursing Round
- Two or more visit selected clients at bedside.
- Obtain information that will help plan nursing care and evaluate care given.
- Provides clients opportunity to discuss their care.
- Need to use terms client can understand.