WEEK 12 MODULE

INTRODUCTION

Effective communication among health professionals is vital to the quality of client care.
Generally, health personnel communicate through discussion, reports, and records. A
discussion is an in- formal oral consideration of a subject by two or more health care
personnel to identify a problem or establish strategies to resolve a problem. 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.

A record, also called a chart or client record, is a formal, legal document that provides
evidence of a client’s care and can be written or computer based. Although health care
organizations use different systems and forms for documentation, all client records have
similar information. The process of making an entry on a client record is called
recording, charting, or documenting. Each health care organization has policies about
recording and reporting client data, and each nurse is accountable for practicing
according to these standards. Agencies also indicate which nursing assessments and
interventions can be recorded by RNs and which can be charted by unlicensed
personnel. In addition, The Joint Commission requires client record documentation to be
timely, complete, accurate, confidential, and specific to the client. Health care reform
has been pivotal in the process of increasing the use of the electronic health record
(EHR).

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”. The client’s record is also
protected legally as a private record of the client’s care. Access to the record is
restricted to health professionals involved in giving care to the client. The institution or
agency is the rightful owner of the client’s record. This does not, however, exclude the
client’s rights to the same records. Changes in the laws regarding client privacy became
effective on April 14, 2003. The new HIPAA regulations maintain the privacy and
confidentiality of protected health information (PHI). HIPAA refers to the Health
Insurance Portability and Accountability Act of 1996. PHI is identifiable health
information that is transmitted or maintained in any form or medium, including verbal
discussions, electronic communications with or about clients, and written com-
munications (Hebda & Czar, 2013).

SAFETY ALERT!

Take safety measures before faxing confidential information. A fax cover sheet should
contain instructions that the faxed material is to be given only to the named recipient.
Consent is needed from the client to fax information. Make sure that personally
identifiable information (e.g., client name, Social Security number) has been removed.
Finally, check that the fax number is correct, check the number on the display of the
machine after dialing, and check the number a third time before pressing the “send”
button.

For purposes of education and research, most agencies allow student and graduate
health professionals access to client records. The records are used in client
conferences, clinics, rounds, client studies, and written papers. The student or graduate
is bound by a strict ethical code and legal responsibility to hold all information in
confidence. It is the responsibility of the student or health professional to protect the
client’s privacy by not using a name or any statements in the notations that would
identify the client. Ensuring Confidentiality of Computer Records because of the
increased use of EHRs, health care agencies have developed policies and procedures
to ensure the privacy and confidentiality of client information stored in computers. In
addition, the Security Rule of HIPAA became mandatory in 2005. This rule governs the
security of electronic PHI. The following are some suggestions for ensuring the
confidentiality and security of computerized records:

1. A personal password is required to enter and sign off computer files. Do not share
this password with anyone, including other health team members.

2. After logging on, never leave a computer terminal unattended.

3. Do not leave client information displayed on the monitor where others may see it.

4. Shred all unneeded computer-generated worksheets.

5. Know the facility’s policy and procedure for correcting an entry error.

6. Follow agency procedures for documenting sensitive material, such as a diagnosis of

AIDS.

7. Information technology (IT) personnel must install a firewall to protect the server from
unauthorized access.

PURPOSES OF CLIENT RECORDS

Client records are kept for a number of purposes including communication, planning
client care, auditing health agencies, research, education, reimbursement, legal
documentation, and health care analysis.

An accurate client health record provides details about the care a client has received
and the client’s overall response to care. Accurate documentation provides the staff with
a means for accountability and reflection on the delivery of client care (Prideaux, 2011).
To enhance the accuracy in documenting care, Paans, Sermeus, Nieweg, and van der
Schans (2010) identified the PES structure as a guideline for nursing care. The letter P
represents the client’s problem or diagnosis. The etiology or cause of the problem is
represented by E, and S represents the signs and symptoms the nurse should be
assessing. The use of this structure enhances nurses’ ability to exercise clinical
reasoning.

Communication
The record serves as the vehicle by which different health professionals who interact
with a client communicate with each other. This prevents fragmentation, repetition, and
delays in client care.

Planning

Client Care Each health professional uses data from the client’s record to plan care for
that client. A primary care provider, for example, may order a specific antibiotic after
establishing that the client’s temperature is steadily rising and that laboratory tests
reveal the presence of a certain microorganism. Nurses use baseline and ongoing data
to evaluate the effectiveness of the nursing care plan.

Auditing Health Agencies

An audit is a review of client records for quality assurance purposes. Accrediting

agencies such as The Joint Commission may review client records to determine if a
particular health agency is meeting its stated standards.

Research

The information contained in a record can be a valuable source of data for research.
The treatment plans for a number of clients with the same health problems can yield
information helpful in treating other clients.

Education

Students in health disciplines often use client records as educational tools. A record can
frequently provide a comprehensive view of the client, the illness, effective treatment
strategies, and factors that affect the outcome of the illness.

Reimbursement

Documentation also helps a facility receive reimbursement from the federal government.
For a facility to obtain payment through Medicare, the client’s clinical record must
contain the correct diagnosis- related group (DRG) codes and reveal that the
appropriate care has been given. Codable diagnoses, such as DRGs, are supported by
accurate, thorough recording by nurses. This not only facilitates reimbursement from the
federal government, but also facilitates reimbursement from insurance companies and
other third-party payers. If additional care, treatment, or length of stay becomes
necessary for the client’s welfare, thorough charting will help justify these needs.

Legal Documentation

The client’s record is a legal document and is usually admissible in court as evidence. In
some jurisdictions, however, the record is considered inadmissible as evidence when
the client objects, because information the client gives to the primary care provider is
confidential. Health Care Analysis Information from records may assist health care
planners to identify agency needs, such as over utilized and underutilized hospital ser-
vices. Records can be used to establish the costs of various services

GENERAL GUIDELINES FOR RECORDING

Because the client’s record is a legal document and may be used to provide evidence in
court, many factors are considered in recording. Health care personnel must not only
maintain the confidentiality of the client’s record but also meet legal standards in the
process of recording.

Date and Time

Document 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 3:15 pm) or according to the 24-hour clock (military clock), which avoids
confusion about whether a time was am or pm

Timing

Follow the agency’s policy about the frequency of documenting, and adjust the
frequency as a client’s condition indicates; for example, a client whose blood pressure is
changing requires more frequent documentation than a client whose blood pressure is
constant. As a rule, documenting should be done as soon as possible after an
assessment or intervention. No recording should be done before providing nursing care.

Legibility
All entries must be legible and easy to read to prevent interpretation errors. Hand
printing or easily understood handwriting is usually permissible. Follow the agency’s
policies about handwritten recording.

Permanence

All entries on the client’s record are made in dark ink so that the record is permanent
and changes can be identified. Dark ink reproduces well on microfilm and in duplication
processes. Follow the agency’s policies about the type of pen and ink used for
recording. In regards to EHRs, changes are made in accordance with the software
guidelines. It is important for the nurse to understand the policies and procedures of the
health care institution regarding documentation.

Accepted Terminology

Abbreviations are used because they are short, convenient, and easy to use. People
are often in a hurry and use abbreviations when texting or text paging. Abbreviations
are convenient; however, they are often ambiguous. This ambiguity places the client at
risk for medical errors and significant harm, possibly even death (Galliers, Wilson,
Randell, & Woodward, 2011).

Ambiguity occurs when an abbreviation can stand for more than one term, leading to
misinterpretation. For example, a client was being treated for a viral infection and died
as a result of the use of the abbreviation HD for an order of “acyclovir unknown dose
with HD.” HD was to represent hemodialysis, and the dosage (unknown) needed to be
adjusted due to the client’s renal impairment. The order was misunderstood and the
dosage of acyclovir was not adjusted in consideration of the client’s renal impairment.

Therefore, it is important to use only commonly accepted abbreviations, symbols, and

terms that are specified by the agency. Many abbreviations are standard and used
universally; others are used only in certain geographic areas. Many health care facilities
supply an approved list of abbreviations and symbols to prevent confusion. When in
doubt about whether to use an abbreviation, write the term out in full until certain about
the abbreviation.

https://www.medicinenet.com/common_medical_abbreviations_and_terms/article.htm

https://www.asha.org/siteassets/uploadedFiles/slp/healthcare/Medicalabbreviations.pdf
In 2004, The Joint Commission developed National Patient Safety Goals (NPSGs) to
reduce communication errors. These goals are required to be implemented by all
organizations accredited by the commission. As a result, the accredited organizations
must develop a do-not-use list of abbreviations, acronyms, and symbols. This list must
include those banned by The Joint Commission

Correct Spelling

Correct spelling is essential for accuracy in recording. If unsure how to spell a word,
look it up in a dictionary or other resource book. Two decidedly different medications
may have similar spellings; for ex- ample, Fosamax and Flomax.

CLINICAL ALERT!

Incorrect spelling gives a negative impression to the reader and, thereby, decreases the
nurse’s credibility.

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.”
Some agencies have a signature sheet and after signing this signature sheet, nurses
can use their initials. With computerized charting, each nurse has his or her own code,
which allows the documentation to be identified. The following title abbreviations are
often used, but nurses need to follow agency policy about how to sign their names:

RN registered nurse LVN licensed vocational nurse LPN licensed practical nurse NA
nursing assistant NS nursing student PCA patient care associate SN student nurse

Accuracy

The client’s name and identifying information should be stamped or written on each
page of the clinical record. Before making an entry, check that the chart is the correct
one. Do not identify charts by room number only; check the client’s name. Special care
is needed when caring for clients with the same last name. Notations on records must
be accurate and correct. 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); to
write that a client “was crying” (observation) is preferable to noting that the client “was
depressed” (interpretation). Similarly, when a client expresses worry about the
diagnosis or problem, this should be quoted directly on the record: “Stated: ‘I’m worried
about my leg.’” When describing something, avoid general words, such as large, good,
or normal, which can be interpreted differently.

For example, chart specific data such as “2 cm × 3 cm bruise” rather than “large bruise.”
When a recording mistake is made, draw a single line through it to identify it as
erroneous with your initials or name above or near the line (depending on agency
policy). Do not erase, blot out, or use correction fluid. The original entry must remain
visible. When using computerized charting, the nurse needs to be aware of the agency’s
policy and process for correcting documentation mistakes. Write on every line but never
between lines. If a blank appears in a notation, draw a line through the blank space so
that no additional information can be recorded at any other time or by any other per-
son, and sign the notation.

CLINICAL ALERT!

Avoid writing the word error when a recording mistake has been made. Some believe
that the word error is a “red flag” for juries and can lead to the assumption that a clinical
error has caused a client injury.

Sequence

Document events in the order in which they occur; for example, record assessments,
then the nursing interventions, and then the client’s responses. Update or delete
problems as needed.

Appropriateness

Record only information that pertains to the client’s health problems and care. Any other
personal information that the client conveys is inappropriate for the record. Recording
irrelevant information may be considered an invasion of the client’s privacy and/or
libelous. A client’s disclosure that she was addicted to heroin 15 years ago, for
example, would not be recorded on the client’s medical record unless it had a direct
bearing on the client’s health problem.

Completeness

Not all data that a nurse obtains about a client can be recorded. How- ever, the
information that is recorded needs to be complete and helpful to the client and health
care professionals. Nurses’ notes need to reflect the nursing process. Record all as-
sessments, dependent and independent nursing interventions, client problems, client
comments and responses to interventions and tests, progress toward goals, and
communication with other members of the health team. Care that is omitted because of
the client’s condition or refusal of treatment must also be recorded. Document what was
omitted, why it was omitted, and who was notified.
CLINICAL ALERT!

Do not assume that the person reading your charting will know that a common
intervention (e.g., turning) has occurred because you believe it to be an “obvious”
component of care.

Conciseness

Recordings need to be brief as well as complete to save time in communication. The

client’s name and the word client are omitted. For example, write “Perspiring profusely.
Respirations shallow, 28/min.” End each thought or sentence with a period.

Legal Prudence Accurate, complete documentation should give legal protection to the
nurse, the client’s other caregivers, the health care facility, and the client. Admissible in
court as a legal document, the clinical record provides proof of the quality of care given
to a client. Documentation is usually viewed by juries and attorneys as the best
evidence of what really happened to the client.

CLINICAL ALERT!

Complete charting, for example, by using the steps of the nursing process as a
framework, is the best defense against malpractice.

REPORTING

The purpose of reporting is to communicate specific information to a person or group of

people. A report, whether oral or written, should be concise, including pertinent
information but no extraneous detail. In addition to change-of-shift reports and
telephone reports, reporting can also include the sharing of information or ideas with
colleagues and other health professionals about some aspect of a client’s care.

Documentation is anything written or printed that is relied on as a record of proof for

authorized persons. Documentation and reporting in nursing are needed for continuity of
care it is also a legal requirement showing the nursing care performed or not performed
by a nurse.

1. Source – Oriented Record

The traditional client record

Each person or department makes notations in a separate section or sections of the
client’s chart

It is convenient because care providers from each discipline can easily locate the forms
on which to record data and it is easy to trace the information

Example: the admissions department has an admission sheet; the physician has a
physician’s order sheet, a physician’s history sheet & progress notes

NARRATIVE CHARTING is a traditional part of the source-oriented record

2. Problem – Oriented Medical Record (POMR)

Established by Lawrence Weed

The data are arranged according to the problems the client has rather than the source
of the information.

The four (4) basic components:

Database – consists of all information known about the client when the client first enters
the health care agency. It includes the nursing assessment, the physician’s history,
social & family data

Problem List – derived from the database. Usually kept at the front of the chart & serves
as an index to the numbered entries in the progress notes. Problems are listed in the
order in which they are identified & the list is continually updated as new problems are
identified & others resolved

Plan of Care – care plans are generated by the person who lists the problems.
Physician’s write physician’s orders or medical care plans; nurses write nursing orders
or nursing care plans

Progress Notes – chart entry made by all health professionals involved in a client’s care;
they all use the same type of sheet for notes. Numbered to correspond to the problems
on the problem list and may be lettered for the type of data

Example: SOAP Format or SOAPIE and SOAPIER

S – Subjective data

O – Objective data

A – Assessment
P – Plan

I – Intervention

E – Evaluation

R– Revision

Advantages of POMR:

It encourages collaboration

Problem list in the front of the chart alerts caregivers to the client’s needs & makes it
easier to track the status of each problem.

Disadvantages of POMR:

Caregivers differ in their ability to use the required charting format

Takes constant vigilance to maintain an up-to-date problem list

Somewhat inefficient because assessments & interventions that apply to more than one
problem must be repeated.

3. PIE (Problems, Interventions, and Evaluation)

Groups information in to three (3) categories

This system consists of a client care assessment floe sheet & progress notes

FLOW SHEET – uses specific assessment criteria in a particular format, such as human
needs or functional health patterns

Eliminate the traditional care plan & incorporate an ongoing care plan into the progress
notes

4. Focus Charting

a. Intended to make the client & client concerns & strengths the focus of care

b. Three (3) columns for recording are usually used: date & time, focus & progress
notes
5. Charting by Exception

Documentation system in which only abnormal or significant findings or exceptions to

norms are recorded

Incorporates three (3) key elements:

Flow sheets

Standards of nursing care

Bedside access to chart forms

6. Computerized Documentation

Developed as a way to manage the huge volume of information required in

contemporary health care

Nurses use computers to store the client’s database, add new data, create & revise
care plans & document client progress.

7. Case Management

Emphasizes quality, cost-effective care delivered within an established length of stay

Uses a multidisciplinary approach to planning & documenting client care, using critical
pathways.

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Nursing Care Plan (NCP)

Two Types:

1. Traditional Care Plan – written for each client; it has 3 columns: nursing diagnoses,
expected outcomes & nursing interventions.

2. Standardized Care Plan – based on an institution’s standards of practice; thereby

helping to provide a high quality of nursing care

KARDEX
Widely used, concise method of organizing & recording data about a client, making
information quickly accessible to all health professionals. Consists of a series of cards
kept in a portable index file or on computer generated forms.

Information may be organized into sections:

Pertinent information about the client

List of medications

List of IVF

List of daily treatments & procedures

List of Diagnostic procedures

Allergies

Specific data on how the client’s physical need is to be met

A problem list, stated goals & list of nursing approaches to meet the goals

Nursing Discharge & Referral Summaries

These are completed when the client is being discharged or transferred to another
institution or to a home setting where a visit by a community health nurse is required.
Regardless of format, it includes some or all of the following:

Description of client’s physical, mental & emotional state

Resolved health problems

Unresolved continuing health problems

Treatments that can be continued (e.g. wound care, oxygen therapy)

Current medications

Restrictions that relate to activity, diet & bathing

Functional/self-care abilities

Comfort level

Support networks
Client education provided in relation to disease process

Discharge destination

Referral Services (e.g. social worker, home health nurse)

Guidelines for Good Documentation and Reporting

Fact – information about clients and their care must be factual. A record should contain
descriptive, objective information about what a nurse sees, hears, feels and smells

Accuracy – information must be accurate so that health team members have confidence
in it

Completeness – the information within a record or a report should be complete,

containing concise and thorough information about a client’s care. Concise data are
easy to understand

Currentness – ongoing decisions about care must be based on currently reported

information. At the time of occurrence include the following:

a. Vital signs

b. Administration of medications and treatments

c. Preparation of diagnostic tests or surgery

d. Change in status

e. Admission, transfer, discharge or death of a client

f. Treatment for a sudden change in status

Organization – the nurse communicate in a logical format or order

Confidentiality – a confidential communication is information given by one person to

another with trust and confidence that such information will not be disclosed