NCM 122: Fundamentals of Nursing Practice ENSURING CONFIDENTIALITY OF

COMPUTER RECORDS
DOCUMENTING AND REPORTING
1. A personal password is required to enter and
GENERALLY, HEALTH PERSONNEL sign off computer files. Do not share this
COMMUNICATE THROUGH password with anyone including other health
team members.
2. After logging on, never leave a computer
DISCUSSION terminal unattended.
An informal oral consideration of a subject by 3. Do not leave client information displayed on
two or more health care personnel to identify a the monitor where others may see it.
problem or establish strategies to resolve a 4. Shred all unneeded computer-generated
problem. worksheets.
5. Know the facility’s policy and procedure for
correcting an entry error.
REPORT 6. Follow agency procedures for documenting
Oral, written, or computer-based sensitive material, such as diagnosis of AIDS.
communication intended to convey information 7. Information technology (IT) personnel must
to others. install a firewall to protect the serve from
unauthorized access.
RECORDS
PURPOSES OF CLIENT RECORDS
Also called a chart or client record, is a formal,
legal document that provides evidence of a Communication
client’s care and can be written or computer Planning Client Care
based. Auditing Health Agencies
Research
DOCUMENTATION Education
Reimbursement
Anything written or printed that is relied on as Legal Documentation
a record of proof for authorized persons. Health Care Analysis
Documentation and reporting in nursing are
needed for continuity of care. DOCUMENTATION SYSTEMS
It is also a legal requirement showing the
nursing care performed or not performed by a Source oriented record
nurse. Narrative charting
Problem-oriented medical record
ETHICAL AND LEGAL CONSIDERATIONS Problems, interventions, evaluation (PIE)
model
The American Nurse Association Code of Focus charting
Ethics (2001), states that “... the nurse has a Charting by exception (CBE)
duty to maintain confidentiality of all patient Computerized documentation
information” (p.12). Case management
Changes in the laws regarding client privacy
became effective on April 14, 2003. SOURCE-ORIENTED RECORD
The new HIPAA regulations maintain privacy
and confidentiality of protected health The traditional client record
information (PHI). Each person or department makes notations in
o HIPPA refers to the Health Insurance a separate section or sections of the client’s
Portability and Accountability Act of chart.
1996. In this type of record, information about a
It is the responsibility of the student or health particular problem is distributed throughout the
professional to protect the client’s privacy by record.
not using a name or any statements in the
notations that would identify the client.
 NARRATIVE CHARTING

A traditional part of the source-oriented record.

It consists of written notes that include routine
care, normal findings, and client problems.
When using narrative charting, it is important
to organize the information in a clear, coherent
manner.
Using the nursing process as a framework is
one way to do this.
 PROBLEM-ORIENTED MEDICAL RECORD
Established by Lawrence Weed in the 1960s,
the data are arranged according to the
problems the client has rather than the source
of the information.
Members of the health care team contribute to
the problem list, plan of care, and progress
notes.
Plans for each active or potential problem are
drawn up, and progress notes are recorded for
each problem.
ADVANTAGES AND DISADVANTAGES OF
PROBLEM-ORIENTED MEDICAL RECORD
ADVANTAGES
It encourages collaboration
The problem list in the front of the chart alerts
caregivers to the client’s needs and makes it
easier to track the status of each problem.
DISADVANTAGES
Caregivers differ in their ability to use the
required charting format.
It takes constant vigilance to maintain an up-
todate problem list
It is somewhat inefficient because
assessments and interventions that apply to
more than one problem must be repeated.
THE POMR HAS FOUR BASIC COMPONENTS
Database
Problem List
Plan of Care
Progress Notes
1. DATABASE
Consists of all information known about the
client when the client first enters the health
care agency.
It includes the nursing assessment, the
primary care provider’s history, social and
family data, and the results of the physical
examination and baseline diagnostic tests.
Data are constantly updated as the client’s
health status changes.
2. PROBLEM LIST
Derived from the database.
It is usually kept at the front of the chart and
serves as an index to the numbered entries in
the progress notes.
Problems are listed in the order in which they
are identified, and the list is continually
updated as new problems are identified and
others resolved.
All caregivers may contribute to the problem
list, which includes the client’s physiological,
psychological, social, cultural, spiritual,
developmental, and environmental needs.
As the client’s condition changes or more data
are obtained, it may be necessary to “redefine”
problems.
3. PLAN OF CARE
The initial list of orders or plan of care is made
with reference to the active problems.
Care plans are generated by the individual
who lists the problems.
Primary care providers write physician’s orders
or medical care plans; nurses write nursing
orders or nursing care plans.
The written plan in the record is listed under
each problem in the progress notes and is not
isolated as a separate list of orders.
4. PROGRESS NOTES
A progress note in the POMR is a chart entry
made by all health professionals involved in a
client’s care; they all use the same type of
sheet for notes.
Progress notes are numbered to correspond to
the problems on the problem list and may be
lettered for the type of data.
For example, the SOAP format is frequently
used. SOAP is an acronym for subjective data,
objective data, assessment, and planning.
SOAP
SUBJECTIVE DATA
S—Subjective data consist of information
obtained from what the client says.
It describes the client’s perceptions of and
experience with the problem.
When possible, the nurse quotes the client’s
words; otherwise, they are summarized.
Subjective data are included only when it is
important and relevant to the problem.
OBJECTIVE DATA
O—Objective data consist of information that
is measured or observed by use of the senses
(e.g., vital signs, laboratory and x-ray results).
ASSESSMENT
A—Assessment is the interpretation or
conclusions drawn about the subjective and
objective data.
During the initial assessment, the problem list
is created from the database, so the “A” entry
should be a statement of the problem.
In all subsequent SOAP notes for that
problem, the “A” should describe the client’s
condition and level of progress rather than
merely restating the diagnosis or problem.
PLAN
P —The plan is the plan of care designed to
resolve the stated problem.
The initial plan is written by the person who
enters the problem into the record.
All subsequent plans, including revisions, are
entered into the progress notes.
SOAPIER
INTERVENTION
I—Interventions refer to the specific
interventions that have actually been
performed by the caregiver.
EVALUATION
•E—Evaluation includes client responses to
nursing interventions and medical treatments.
 This is primarily reassessment data.
REVISION
R —Revision reflects care plan modifications
suggested by the evaluation.
Changes may be made in desired outcomes,
interventions, or target dates.
PIE
The PIE documentation model groups
information into three categories.
PIE is an acronym for problems, interventions,
and evaluation of nursing care.
This system consists of a client care
assessment flow sheet and progress notes.
The PIE system eliminates the traditional care
plan and incorporates an ongoing care plan
into the progress notes.
A disadvantage is that the nurse must review
all of the nursing notes before giving care to
determine which problems are current and
which interventions were effective.
International’s three-part format: client’s response,
contributing or probable causes of the response, and
characteristics manifested by the client.
The problem statement is labeled “P” and
referred to by number (e.g., P #5).
The interventions employed to manage the
problem are labeled “I” and numbered
according to the problem (e.g., I #5).
The evaluation of the effectiveness of the
interventions is also labeled and numbered
according to the problem (e.g., E #5).
FOCUS CHARTING
Focus charting is intended to make the client
and client concerns and strengths the focus of
care.
Three columns for recording are usually used:
date and time, focus, and progress notes.
The focus may be a condition, a nursing
diagnosis, a behavior, a sign or symptom, an
acute change in the client’s condition, or a
client strength.
The progress notes are organized into (D)
data, (A) action, and (R) response, referred to
as DAR.
The focus charting system provides a holistic
perspective of the client and the client’s needs.
It also provides a nursing process framework
for the progress notes (DAR).
DAR
The data category reflects the assessment
phase of the nursing process and consists of
observations of client status and behaviors,
including data from flow sheets (e.g., vital
signs, pupil reactivity). The nurse records both
subjective and objective data in this section.
The action category reflects planning and
implementation and includes immediate and
future nursing actions. It may also include any
changes to the plan of care.
The response category reflects the
evaluation phase of the nursing process and
describes the client’s response to any nursing
and medical care.
CHARTING BY EXCEPTION
Charting by exception (CBE) is a
documentation system in which only abnormal
or significant findings or exceptions to norms
are recorded.
CBE incorporates three key elements (Guido,
2010):
o Flow sheets
o Standards of nursing care
o Bedside access to chart forms
1. FLOW SHEETS
Examples of flow sheets include graphic
records of a vital sign sheet.
A head and face assessment in a daily nursing
assessments record.
A Braden assessment of the skin.
2. STANDARDS OF NURSING CARE
Documentation by reference to the agency’s
printed standards of nursing practice
eliminates much of the repetitive charting of
routine care.
An agency using CBE must develop its own
specific standards of nursing practice that
identify the minimum criteria for client care
regardless of clinical area.
Some units may also have unit-specific
standards unique to their type of client.
 o For example, “The nurse must ensure NURSING MINIMUM DATA SET (NMDS)
that the unconscious client has oral
care at least q4h.” An effort to establish uniform definitions and
categories (e.g., nursing diagnoses) for
collecting, essential nursing data for inclusion
3. BESIDE ACCESS TO CHART FORMS
in computer databases.
In the CBE system, all flow sheets are kept at
the client’s bedside to allow immediate
recording and to eliminate the need to
transcribe data from the nurse’s worksheet to
the permanent record.

COMPUTERIZED DOCUMENTATION

Electronic health records (EHRs) are used 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 and revise
care plans, and document client progress
Some institutions have a computer terminal at
each client’s bedside, or nurses carry a small
handheld terminal, enabling the nurse to
document care immediately after it is given.
 CASE MANAGEMENT
The case management model emphasizes
quality, cost-effective care delivered within an
established length of stay.
This model uses a multidisciplinary approach
to planning and documenting client care, using
critical pathways.
These forms identify the outcomes that certain
groups of clients are expected to achieve on
each day of care, along with the interventions
necessary for each day.
VARIANCE
A variance is a deviation from what was
planned on the critical pathway— unexpected
occurrences that affect the planned care or the
client’s responses to care.
The case management model promotes
collaboration and teamwork among caregivers,
helps to decrease length of stay, and makes
efficient use of time.
There are two types of nursing care plans:
THE TRADITIONAL CARE PLAN IS WRITTEN
DOCUMENTING NURSING ACTIVITIES
ADMISSION NURSING ASSESSMENT
A comprehensive admission assessment, also
referred to as an initial database, nursing
history, or nursing assessment, is completed
when the client is admitted to the nursing unit.
These forms can be organized according to
health patterns, body systems, functional
abilities, health problems and risks, nursing
model, or type of health care setting (e.g.,
labor and delivery, pediatrics, mental health).
The nurse generally records ongoing
assessments or reassessments on flow sheets
or on nursing progress notes.
NURSING CARE PLANS
Traditional
Standardized.
FOR EACH CLIENT.
The form varies from agency to agency
according to the needs of the client and the
department.
Most forms have three columns: one for
nursing diagnoses, a second for expected
outcomes, and a third for nursing
interventions.
 STANDARDIZED CARE PLANS WERE
DEVELOPED TO SAVE DOCUMENTATION
TIME.
These plans may be based on an institution’s
standards of practice, thereby helping to
provide a high quality of nursing care.
Standardized plans must be individualized by
the nurse in order to adequately address
individual client needs.
KARDEX
The Kardex is a widely used, concise method
of organizing and recording data about a
client, making information quickly accessible to
all health professionals.
The system consists of a series of cards kept
in a portable index file or on computer-
generated forms.
The card for a particular client can be quickly
accessed to reveal specific data.
THE INFORMATION ON KARDEXES MAY BE
ORGANIZED INTO SECTIONS
Pertinent information about the client, such as
name, room number, age, admission date,
primary care provider’s name, diagnosis, and
type of surgery and date.
Allergies
List of medications, with the date of order and
the times of administration for each.
List of intravenous fluids, with dates of
infusions.
List of daily treatments and procedures, such
as irrigations, dressing changes, postural
drainage, or measurement of vital signs.
List of diagnostic procedures ordered, such as
x-ray or laboratory tests.\
Specific data on how the client’s physical
needs are to be met, such as type of diet,
assistance needed with feeding, elimination
devices, activity, hygienic needs, and safety
precautions (e.g., one person assist).
A problem list, stated goals, and a list of
nursing approaches to meet the goals and
relieve the problems.
FLOW SHEETS
A flow sheet enables nurses to record nursing
data quickly and concisely and provides an
easy-to-read record of the client’s condition
over time.
GRAPHIC RECORD
This record typically indicates body
temperature, pulse, respiratory rate, blood
pressure, weight, and, in some agencies, other
significant clinical data such as admission or
postoperative day, bowel movements,
appetite, and activity.
INPUT AND OUTPUT RECORD
All routes of fluid intake and all routes of fluid
loss or output are measured and recorded on
this form.
MEDICATION ADMINISTRATION RECORD
Medication flow sheets usually include
designated areas for the date of the
medication order, the expiration date, the
medication name and dose, the frequency of
administration and route, and the nurse’s
signature.
Some records also include a place to
document the client’s allergies.
SKIN ASSESSMENT RECORD
A skin or wound assessment is often recorded
on a flow sheet.
This EHR specifically utilizes the Braden
Assessment.
EHRs may include categories related to stage
of skin injury, drainage, odor, culture
information, and treatments.
PROGRESS NOTES
Progress notes made by nurses provide
information about the progress a client is
making toward achieving desired outcomes.
Therefore, in addition to assessment and
reassessment data, progress notes include
information about client problems and nursing
interventions.
The format used depends on the
documentation system in place in the
institution.
NURSING DISCHARGE AND REFERRAL
SUMMARIES
A discharge note and referral summary are
completed when the client is being discharged
and transferred to another institution or to a
home setting where a visit by a community
health nurse is required.
Many institutions provide forms for these
summaries.
Some records combine the discharge plan, SUMMARIES SHOULD ADDRESS THE
including instructions for care, and the final FOLLOWING
progress note.
Many are designed with checklists to facilitate Specific problems noted in the care plan
data recording. Mental status
Activities of daily living
Hydration and nutrition status
Safety measures needed
Description of client’s physical, mental, and Medications
emotional status at discharge or transfer. Treatments
Resolved health problems Preventive measures
Unresolved continuing health problems and Behavioral modification assessments, if
continuing care needs; may include a review- pertinent (if client is taking psychotropic
of-systems checklist that considers medications or demonstrates behavioral
integumentary, respiratory, cardiovascular, problems).
neurologic, musculoskeletal, gastrointestinal,
elimination, and reproductive problems. GENERAL GUIDELINES FOR RECORDING
Treatments that are to be continued (e.g.,
wound care, oxygen therapy) 1. DATE AND TIME
Current medications
Document the date and time of each
Restrictions that relate to (a) activity such as
recording.
lifting, stair climbing, walking, driving, work; (b)
This is essential not only for legal reasons but
diet; and (c) bathing such as sponge bath, tub,
also for client safety.
or shower.
Record the time in the conventional manner
Functional/self-care abilities in terms of vision,
(e.g., 9:00 am or 3:15 pm) or according to the
hearing, speech, mobility with or without aids,
24- hour clock (military clock), which avoids
meal preparation and eating, preparing and
confusion about whether a time was am or pm.
administering medications, and so on.
Comfort level
Support networks including family, significant
others, religious adviser, community self-help
groups, home care and other community
agencies available, and so on.
Client education provided in relation to disease
process, activities and exercise, special diet,
medications, specialized care or treatments,
followup appointments, and so on.
Discharge destination (e.g., home, nursing
home) and mode of discharge (e.g., walking,
wheelchair, ambulance).
Referral services (e.g., social worker, home
health nurse).

LONG-TERM DOCUMENTATION
HOME CARE DOCUMENTATION
2. 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.
3. 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.
4. 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.
5. ACCEPTED TERMINOLOGY
Abbreviations are used because they are
short, convenient, and easy to use.
Abbreviations are convenient; however, they
are often ambiguous.
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.
6. 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 example, Fosamax and
Flomax.
7. RECORDING 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:
 8. ACCURACY
The client’s name and identifying information
should be stamped or written on each page of
the clinical record.
Notations on records must be accurate and
correct.
Accurate notations consist of facts or
observations rather than opinions or
interpretations.
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).
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 person, and sign the notation.
Document what was omitted, why it was
omitted, and who was notified.
12. 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.
13. 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

9. SEQUENCE clinical record provides proof of the quality of
care given to a client.
Document events in the order in which they
Documentation is usually viewed by juries and
occur; for example, record assessments, then
attorneys as the best evidence of what really
the nursing interventions, and then the client’s
happened to the client.
responses.
For the best legal protection, the nurse should
Update or delete problems as needed.
not only adhere to professional standards of
nursing care but also follow agency policy and
10. APPROPRIATENESS
procedures for intervention and documentation
Record only information that pertains to the in all situations—especially high-risk situations.
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.

11. COMPLETENESS

Record all assessments, 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.
 REPORTING CHANGE-OF-SHIFT REPORTS

The purpose of reporting is to communicate The handoff communication or change-of-shift

specific information to a person or group of report is given to all nurses on the next shift.
people. Hill and Nyce (2010) identified three important
A report, whether oral or written, should be features in an effective change-of-shift report.
concise, including pertinent information but no These are: “two way, face-to-face
extraneous detail. communication; written support tools; and
In addition to change-of-shift reports and content in handover which captures intention”
telephone reports, reporting can also include (p. 44).
the sharing of information or ideas with Face-to face communication allows the
colleagues and other health professionals oncoming nurse the ability to ask questions
about some aspect of a client’s care. and gain confidence to care for the client.
The incoming and departing nurses establish
HAND OFF REPORT priorities for the care of the client in the
upcoming hours by reviewing checklists and
Incomplete handoff communication is
the client’s medical record.
associated with sentinel events that will result
\Content of the handover, which captures
in adverse health care outcomes or death
intention, includes client problems and
(Criscitelli, 2013).
interventions to care for the client’s problems.
As a result, a hospital is required to implement
a standardized approach to “handoff”
communication, which is defined as a process
in which information about
patient/client/resident care is communicated in
a consistent manner including an opportunity
to ask and respond to questions (Riesenberg,
Leitzsch, & Cunningham, 2010, p. 24).
 SBAR TOOL
The Institute for Healthcare Improvement
(2013) states that “the SBAR allows for an
easy and focused way to set expectations for
what will be communicated and how between
members of the team, which is essential for
developing teamwork and fostering a culture of
patient safety”
TELEPHONE REPORTS
Health professionals frequently report about a
client by telephone.
The nurse receiving a telephone report should
document the date and time, the name of the
person giving the information, and the subject
of the information received, and sign the
notation.
The person receiving the information should
repeat it back to the sender to ensure
accuracy.
When giving a telephone report to a primary
care provider, it is important that the nurse be
concise and accurate.
The SBAR communication tool is often used
for telephone reports. Begin with name and
relationship to the client (e.g., “This is Jana
Gomez, RN; I’m calling about your client,
Dorothy Mendes. I’m her nurse on the 7 pm to
7 am shift”).
Telephone reports usually include the client’s
name and medical diagnosis, changes in
nursing assessment, vital signs related to
baseline vital signs, significant laboratory data,
and related nursing interventions.
The nurse should have the client’s chart ready
to give the primary care provider any further
information.
After reporting, the nurse should document the
date, time, and content of the call.
TELEPHONE ORDERS
Primary care providers often order a therapy
(e.g., a medication) for a client by telephone.
Most agencies have specific policies about
telephone orders.
Many agencies allow only registered nurses to
take telephone orders.
While the primary care provider gives the
order, write the complete order down on the
physician’s order form and read it back to the
primary care provider to ensure accuracy.
Question the primary care provider about any
order that is ambiguous, unusual (e.g., an
abnormally high dosage of a medication), or
contraindicated by the client’s condition.
Have the primary care provider verbally
acknowledge the read -back of the
verbal/telephone order.
Then indicate on the physician’s order form
that it is a verbal order (VO) or telephone order
(TO).
Once the order is written on the physician’s
order form, the order must be countersigned
by the primary care provider within a time
period described by agency policy. Many acute
care hospitals require that this be done within
24 hours.
 CARE PLAN CONFERENCE

A care plan conference is a meeting of a group

of nurses to discuss possible solutions to
certain problems of a client, such as inability to
cope with an event or lack of progress toward
goal attainment.

NURSING ROUNDS

Nursing rounds are procedures in which two or more

nurses visit selected clients at each client’s bedside to:

Obtain information that will help plan nursing

care.
Provide clients the opportunity to discuss their
care.
Evaluate the nursing care the client has
received.

GROUP WORK
Mr. Anderson, an 80-year-old male, was admitted for
back pain. He has a past medical history of
hypertension. He told the admitting nurse that he has
lost interest in many of his normal activities because of
the constant pain. You read the following
documentation entry by a previous nurse:

8—Client is a complainer. I listened to him for

15 minutes with no success. BP 210/90 and
180/70. P 72, R 18.
12—Refused lunch.
2—Client fell out of bed.