Documentation

• Ensures continuity of care

• Provides legal evidence.

• Evaluates patient outcomes.

• Provides a detailed account of a patient’s plan of care, important assessments and treatments

• Documentation is anything entered into a patients electronic or written patient record

• Electronic tools such as computers support documentation and patient care

Purpose of charts/records

Communication for all healthcare team members

• Legal in case of lawsuit

Education

• For nursing and med students

Assessment

• Provides data that nurses use to identify and plan interventions

Auditing and Research

• Helps describe characteristics of pt populations

Financial Billing

• Shows the extent to which hospitals should be reimbursed for services

Patient centered care

• Patient records are a confidential, permeant and legal document containing information relevant
to pts health

• Records and reports communicate specific information about a patient health status and the
interventions that all health care team members contribute (multidisciplinary team).

• Reports are oral or written exchanges of information among caregivers.

• These can include pts health status, observations made about their behaviour, diagnostic tests
and directions for changes in therapy.

• Reports can be telephone reports, transfer of care reports or adverse event reports

• When a verbal order or critical test result is received the nurse writes it down and repeats it back
to the individual who gave the order
 • Important to have an organized pt hand off.

• Always double-check verbal orders and have a second person verify if possible.

Documentation safety guidelines

• Quality documentation and reporting must be FACTUAL, ACCURATE, COMPLETE, CURRENT AND
ORGANIZED

• Factual data contains descriptive, objective, information about what the nurse sees, hears, feels
and smells.

• The only subjective data included are what the patient actually verbalizes.

• Write subjective in quotations “Patient states ‘My stomach hurts’.”

• Must also be compliant with standards and facility policies and procedures.

Difference between subjective and objective

• Subjective what the patient feels regarding their health.

• Objective what is measurable and supportable through scientific testing.

Remember to:

• Use of exact measurements to establish accuracy.

• All entries in medical record must be dated.

• a method to identify the author of entries must exist.

• Each entry ends with caregiver's name and status.

• Example: JSmithSPN, KJonesRN

• Current documentation includes making timely entries in the records which avoids omissions
and delay in patient care.

• Military time, 24hr system is used to avoid misinterpretation of AM and PM

ONLY USED APPROVED ABBREVIATIONS, SYMBOLS and Acronyms

Hand off reports

• Hand off or report occurs during shift change or any time the patient changes caregivers.

• Effective handoff allows for face-to-face communication.

• Once handoff is complete the receiver is given time to ask questions and confirm understanding.

Components of handoff report

• Pts name

• Room number
 • Age

• Gender

• Diagnosis

• Medical history

• Discharge plan

• Vital signs

• Clinical assessments

• Changes in clinical condition

• Meds

• Fluid balance

• Patient safety risks

Medical history is only what is relevant,

Discharge plan, goals short term/ long term if any long term exists.

Always complete your own primary assessment.

Best practice when documenting

 Do not erase, use white out, or scratch out errors.

 Record all facts.
 Begin every entry with date and time
 End every entry with signature and credentials
 If order is questioned, record that you sought clarification
 Do not write retaliatory or critical comments about pt or care providers
 Correct all errors immediately with one line through error and initials
 Chart only for yourself never for others
 Record all entries legibly and in black or blue ink for paper records
Common Malpractice Issues
• Failing to document the correct time of events
• Failing to record verbal orders or have them signed
• Charting actions in advance to save time
• Documenting incorrect data
• Failing to give a report or giving an incomplete report to oncoming shift
• You must be aware of legal guidelines for documenting and reporting
Patient chart contents
• Admission Nursing History
• comprehensive history to gather baseline assessments when a patient is admitted.
• This data is used to form a care plan.
• Flow Sheets and Graphic Records
 • permit concise documentation of nursing information and patient data over time.
• Useful for the documentation of routine observations or repeated specific
measurements.
• vital signs, intake and output, hygiene measures, medication administration and pain
assessments are examples.
• Assessment Forms
• Braden scale, violence assessment, Fall risk assessment, etc.
• Patient Summary or Kardex
• Kept at nurses' station.
• Quick reference card overviewing patient needs.
• Contains basic demographics, primary medical diagnosis, current health care providers
orders for diet, activity and dressing changes, scheduled tests and procedures, safety
precautions, factors for ADLs, Next of Kin, allergies etc.
• Standardized Care Plans
• Computerized care plans.
• Incorporate nursing diagnosis or problems in a single nursing plan.
• Facilitate high quality care.
• Labs and Diagnostic Reports
• Hematology
• Chemistry
• Diagnostic imagery
• Consults
• Other physicians or multidisciplinary team members consulting on the pt
• Physician Orders
• Written orders by the physician or nurse or pharmacist
• Must be signed and have a date & time.
• Discharge Summary
• Essential info for the patient, family caregiver and health care agency
• Based on data obtained from the discharge planning process
• Family and patient must be involved.
• Components of Discharge Summary
• Use clear concise descriptions in patients own language
• Provide step by step instructions if needed
• Provide a detailed list of all medications prescribed
• Identify precautions to follow when performing self-care or medications
• Review signs and symptoms of complications to report
• List names and number of healthcare provider and community services
• List actual time of discharge, mobility and who accompanied the patient

Charting system: Can be written or computer based

• Narrative Documentation
• Problem Oriented
• Soap
• Soapie
 • Pie
• DarP
• Source Records
• Charting by Exception
• Critical Pathways
• SBAR
• Occurrence reports

Narrative document
• uses a story like format to document information about pts conditions and care.
Presented in chronological order.

Problem Oriented Medical Records

• A structured method of documenting that emphasize a patient problem
• Organizes data using the nursing process
• Data is organized by problem or diagnosis.
• Contains database, problem list, care plan and progress notes
• Pt database- contains all info to the patient
• Problem List- includes the pts physiological, psychological, sociocultural, spiritual,
developmental and environmental needs
• Plan of Care- multidisciplinary contribution to develop a plan of care for a specific
problem
• Progress notes- used to monitor and record the progress of a pts problem

Problem Oriented Medical Record: Progress Notes

• SOAP
• Subjective data—objective data—assessment—plan
• One way to structure narrative notes to document patient's progress.
• Some places add an I for intervention and an E for evaluation
•
• SOAPIE
• Subjective data—objective data—assessment—plan—intervention—evaluation
• PIE
• Problem—intervention—evaluation
• similar to that of soap charting
• Combines the care plan and progress noted into one record
• Assessment data is on flow sheets
• Number the PIE notes according to pts problems
• Resolved problems are dropped from daily documentation
• Continuing problems are documented daily
•
• Focus charting (DAR)
• Data—action—response and Plan (not all facilities use P )
• narrative format
 • It places less importance on pt problems and focuses on pt concerns such as a
sign or symptom, condition, nursing diagnosis, behavior, significant event or
change in condition
• Easily understood

Source records
• patient's charts are organized so each discipline has a separate section to record data.
• Makes it easy to locate the proper section

Charting by exception
• A system that aims to eliminate redundancy.
• makes documentation of routine care more concise
• emphasizes abnormal findings.
• identifies trends in clinical care.
• Focuses on documenting deviations from “normal.”

Clinical pathways
• A system that states the goals and important treatment interventions based on best practice and
patient expectations.
• Incorporates an interdisciplinary approach to documenting patient care.

SBAR
• situation, background, assessment and recommendation
• concrete approach for framing conversations
• Promotes the provision of safe, efficient, timely and patient centered communication.
• Used for written and verbal communication.

Occurrence incidence reports

• Safety Reports (Occurrence Reports) are not part of the legal client record.
• Used to track incidents to discover methods of prevention.
• Get to the root of the problem.
• Occurrence reports are sent to your Nursing Management or Risk Management for follow up.
• An incident report should be filed:
• In the event of an injury
• potential injury or harm to a client, staff or visitor
• Deviation from the standard policies and procedures
• By the person who witnessed it
• Document:
• objective data you observed and follow up actions in the patient chart.
• Do NOT note that an occurrence report was filed in the patient’s record.

Confidentiality
• Legally and ethically obligated to keep clients’ information confidential.
• Only staff directly involved in a client’s care have legitimate access to a client’s records.
 • Clients have the legal right to request copies of their health care record.
• must fill out the paperwork to go to privacy officer.
• Nurses are responsible for protecting clients’ information from unauthorized persons.

Handling and disposing of information.

• Confidentiality requires safe disposal of printed medical information.
• Removal of identification from all patient data for assignments to a student nurse
• Following the disposal policies for records in the institution
• Following policies for the use of fax machines