Chapter 10

Documentation, Electronic Health Records, and Reporting

1.Accurate documentation, Electronic Health Records (EHRs), and systematic

reporting are fundamental to modern healthcare. They enhance patient safety,
improve care quality, and ensure efficient communication among healthcare
providers. EHRs offer real-time, patient-centered information, facilitating informed
decision-making and coordinated care. Effective reporting mechanisms support
continuous quality improvement and regulatory compliance. Collectively, these
elements contribute to a more resilient and responsive healthcare system.

2. Healthcare documentation encompasses all written or electronic records detailing a

patient's health status and the care provided, including dates of service. These
records, which may be in paper or electronic formats such as medical records, faxes,
emails, audiotapes, videotapes, and images, are essential for facilitating information
flow to support continuity, quality, and safety of care. The primary goal of
documentation is to clearly and concisely convey facts, enhancing interdisciplinary
communication.

Nurses play a pivotal role in patient care coordination and the implementation of the
nursing process. They gather accurate data to establish baseline patient information
and monitor responses to interventions, including education efforts. This
documentation is often integrated into electronic health records, reflecting the
patient's experience and serving as a foundation for goal-oriented care and outcome
evaluation.

3. Healthcare organizations establish documentation standards in line with policies and procedures, adhering
to guidelines from authoritative bodies such as The Joint Commission (TJC) and the American Nurses
Association (ANA).
The Joint Commission (TJC) Standards: TJC requires that each patient has a medical record accessible
only to authorized personnel. Documentation must be complete, legible, and detail each patient encounter,
including assessments, diagnoses, care plans, progress notes, changes in condition, dates of service, and the
observer's identity. These standards ensure accurate reflection of patient care, supporting continuity and
quality.
American Nurses Association (ANA) Principles: The ANA outlines six essential principles for nursing
documentation:
1. Characteristics: Documentation should be accessible, accurate, relevant, auditable, clear, concise,
comprehensive, thoughtful, timely, and aligned with the nursing process.
2. Education and Training: Nurses must be educated and trained in effective documentation practices.
3. Policies and Procedures: Organizations should have clear policies and procedures guiding
documentation.
4. Protection Systems: Measures must be in place to protect patient information.
5. Entries: Documentation entries should be timely and reflect the care provided.
6. Standardized Terminologies: Use of standardized language ensures consistency and clarity.
These principles guide nurses in creating high-quality documentation that reflects the nursing process and
supports effective communication among healthcare providers.
Importance of Accurate Documentation: Precise documentation is vital for several reasons:
 Patient Safety and Care Continuity: Accurate records ensure all healthcare team members are
informed about the patient's condition and treatment plan, reducing the risk of errors.
  Legal and Ethical Accountability: Comprehensive documentation serves as a legal record of the
care provided, protecting both patients and healthcare providers.
 Financial Reimbursement: In systems like the Centers for Medicare and Medicaid Services,
hospitals are reimbursed based on Diagnostic-Related Groups (DRGs). Proper documentation
supports the classification of hospital admissions into appropriate DRGs, affecting reimbursement
rates.
Adhering to these documentation standards and principles is essential for delivering high-quality, safe, and
efficient patient care.
4.The Medical Record
 The medical record is the legal documentation of care provided to a patient.
 In the event of litigation, the medical record is often the only available evidence of the event in
question.
 Medical record documentation should be based on fact, not opinions.
 Every entry in a medical record must include a date, time, and signature with credentials.
 Ethical practice dictates that nurses document only interventions that are performed.
 Medical record entries cannot be altered or obliterated.
5.Use of the Electronic Health Record
 The electronic health record (EHR) includes documentation over time from inpatient and outpatient
sources.
 Physicians, nurse practitioners, nurses, medical assistants, physician assistants, unlicensed assistive
personnel (UAP), social workers, and therapists may contribute to the EHR.
 Check the facility policy for documentation guidelines.
 Laboratory data and other test results are available in multiple care settings to facilitate making
decisions regarding patient care.
 In some circumstances, documentation of care including obtaining vital signs on stable patients and
assisting with activities of daily living may be delegated to the UAP.
 Registered nurses are responsible for reviewing documentation by UAP for all patients under their
care.
6. The transition to Electronic Health Records (EHRs) aimed to integrate advanced technology with built-in
safety and security features, ensuring compliance with the Health Insurance Portability and Accountability
Act (HIPAA). EHRs facilitate data sharing within healthcare systems, enhance continuity of care, support
research, and streamline reporting of required statistics. Benefits include reduced storage needs,
simultaneous multi-user access, easy duplication for sharing or backup, decreased medication errors, and
increased portability through wireless systems and handheld devices. Data entry methods encompass
keyboard input, voice dictation, light pens, and handwriting recognition systems, which can be converted
into text by computer programs.
7.The terms "electronic medical record" (EMR) and "electronic health record" (EHR) are often used
interchangeably, but they refer to different concepts. An EMR is a digital version of a patient's chart,
containing medical and treatment history from a single healthcare provider or facility. In contrast, an EHR is
a comprehensive, longitudinal record that aggregates health information across multiple providers and care
settings, offering a holistic view of a patient's health history.

FORMAT ELEMENTS
PIE Problem, intervention, evaluation
APIE Assessment, problem, intervention,
evaluation
SOAP Subjective date, objective data,
assessment,
plan
SOAPIE Subjective data, objective data,
assessment,
 plan, intervention, evaluation
SOAPIER Subjective data, objective data,
assessment,
plan, intervention, evaluation, revisions
to
plan
DAR Data, action, response
CBE Charting by exception

Here are sample nurse’s notes using the different documentation styles:

1. PIE Format (Problem, Intervention, Evaluation)

P: Patient reports pain at the surgical site, rated 7/10.

I: Administered prescribed analgesic and applied cold compress.

E: Patient reports pain reduction to 4/10 after 30 minutes.

2. APIE Format (Assessment, Problem, Intervention, Evaluation)

A: Patient appears anxious, heart rate elevated at 110 bpm.

P: Anxiety related to upcoming procedure.

I: Provided emotional support, explained procedure in detail, encouraged deep

breathing.

E: Patient verbalized understanding and appeared calmer, heart rate decreased to 90

bpm.

3. SOAP Format (Subjective, Objective, Assessment, Plan)

S: "I feel very weak and dizzy," patient states.

O: BP 88/60 mmHg, HR 102 bpm, pale skin.

A: Possible dehydration related to inadequate fluid intake.

P: Encourage oral fluids, monitor vitals closely, notify physician.

4. SOAPIE Format (SOAP + Intervention, Evaluation)

S: "I have a sharp pain in my abdomen," patient reports.

O: Guarding behavior, facial grimacing, abdomen tender upon palpation.

A: Acute abdominal pain, possible gastritis.

P: Administered prescribed antacid and advised patient to avoid spicy foods.

I: Provided warm compress, monitored response to medication.

E: Pain reduced to 3/10, patient more comfortable.

5. SOAPIER Format (SOAPIE + Revision)

S: "I feel short of breath," patient states.

O: RR 26/min, SpO2 88% on room air, audible wheezing.

A: Impaired gas exchange related to asthma exacerbation.

P: Administer nebulizer treatment and monitor response.

I: Administered albuterol via nebulizer.

E: SpO2 improved to 95%, RR decreased to 20/min.

R: Continue to monitor lung sounds and repeat nebulization as needed.

6. DAR Format (Data, Action, Response)

D: Patient reports nausea and dizziness after medication intake.

A: Assisted patient into a comfortable position, provided sips of water, and

administered prescribed antiemetic.

R: Nausea subsided within 30 minutes, patient reported feeling better.

7. CBE Format (Charting by Exception)

Assessment: Lungs clear, BP 120/80 mmHg, no complaints of pain.

Exception: Patient reports mild nausea after breakfast; provided antiemetic as

prescribed.

SBAR (Situation, Background, Assessment, Recommendation) is a structured

communication tool used by healthcare professionals to ensure clear and effective
communication, especially during hand-offs and critical situations. It enhances patient
safety by providing a standardized way to convey important information.

1. Situation (S) – Clearly state the current problem or reason for communication.
2. Background (B) – Provide relevant patient history or context.
3. Assessment (A) – Share clinical findings, observations, or concerns.
4. Recommendation (R) – Suggest next steps or actions needed.

Scenario: A nurse calls a physician about a patient with low blood pressure.

S: "Dr. Smith, this is Nurse Taylor from the ICU. I am calling about Mr. Johnson, a 68-
year-old patient whose blood pressure has dropped to 85/50 mmHg."
B: "He was admitted for sepsis two days ago and has been on IV antibiotics and fluids.
His blood pressure was stable earlier at 120/75 mmHg."

A: "His heart rate has increased to 110 bpm, and he appears pale and lethargic. Urine
output has also decreased in the last few hours."

R: "I recommend increasing his IV fluid rate and considering vasopressor support.
Would you like to assess him in person or order additional tests?"

This format ensures clear, concise, and effective communication, reducing errors and
improving patient care.

Verbal and Telephone Orders

Verbal and telephone orders are instructions given by a healthcare provider over the
phone or in person when immediate documentation is not possible. They are typically
used in urgent situations but should be minimized to reduce the risk of
miscommunication. Nurses receiving these orders must write them down, read them
back to confirm accuracy, and document them properly in the patient’s record. Most
facilities require the provider to sign the order within 24 hours to validate it.

Incident Reports

An incident report is a formal document used to record any unexpected or adverse

events in a healthcare setting, such as medication errors, falls, injuries, or equipment
failures. These reports help identify risks, improve patient safety, and prevent future
incidents. They should be factual, objective, and detailed but are not included in the
patient’s medical record to avoid legal complications. Instead, they are used for
internal quality improvement and risk management.