DOCUMENTATION

AND REPORTING

NUR 152-Nursing
Theory & Science I
Fall 2016

REASONS FOR
DOCUMENTATION AND
Facilitate communication
REPORTING
Promote good nursing care and continuity of care
Meet professional and legal standards (Quality of Care)
Planning/Evaluation of Outcomes
Education and Research
Reimbursement and Utilization Review/Accrediting Agencies
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DOCUMENTATION
The act of recording patient status and care in written
or electronic form
Creating a record of assessments and care
Oral communication is reporting
Care is provided in chronological order

Clear, concise, comprehensive and accurate

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PATIENT RECORD
Legal documentation of patients healthcare
experience
Confidential & permanent
Available to all members of healthcare team

DOCUMENTATION
SYSTEMS
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MAIN DOCUMENTATION
SYSTEMS
Source-oriented- Each discipline
records findings separately
Problem-oriented- Organized
around patient problems
Charting by Exception- Only
significant findings or exceptions
charted

SOURCE-ORIENTED
DOCUMENTATION
Each discipline charts separately
Variety of sections
Advantage:

Data usually easy to find

Disadvantage:

Data scattered; may lead to

fragmentation

COMPONENTS OF
SOURCE ORIENTED
RECORD
Admission data

Laboratory data

Advance directives

Nurses notes

H&P

Graphic data

Physicians orders

Rehabilitation & therapy

notes

Progress notes
Diagnostic studies

Discharge planning

PROBLEM-ORIENTED
DOCUMENTATION
Organized around patient problems
No separate sections for disciplines
Advantage:

Allows greater collaboration and easy to

monitor client progress since each
problem is identified
Disadvantage:

Requires cooperation & diligence to

maintain the problem database
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COMPONENTS OF
PROBLEM ORIENTED
RECORD
Database

Problem list
Plan of care
Progress notes

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CHARTING BY EXCEPTION
Chart only significant findings or exceptions to norms
Streamlines charting and saves time
Uses preprinted forms and checklists
Abnormals documented in narrative note

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CBE
Advantages:
Reduces charting time and repetitive
charting
Easier to read & understand
Highlights variations from expected POC

Disadvantages:
Inadvertent omissions
Assumes care has been done
Fragments care into tasks
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NURSES NOTES
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COMMON TYPES OF
NURSES NOTES
Narrative
PIE
SOAP
Focus
FACT

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NARRATIVE CHARTING
Used with both source & problem-oriented documentation
Story of care in chronological format
Tracks patients changing status & progress towards goals
Can be lengthy and disorganized
Clear, concise and accurate
Begin with Report received

End with Report given

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NARRATIVE CHARTING
EXAMPLE
8/30/14 1100-Pt arrived to floor from PACU
in bed. VSS-refer to flow sheet. Drowsy,
but easily arouses to verbal stimuli.
Oriented x3. PERRLA. O2 at 2L via NC. Sat
98%. Abd dsg CDI. No BS noted. Denies
N/V. Foley intact and draining clear yellow
urine. Reports pain 2/10 to abd/incision.
Denies need for pain meds at present.
---------------------------------------George White,
RN---------------16

FOCUS CHARTING
Highlights the patients concerns, problems, or
strengths in 3 columns:

Column 1: Time and date

Column 2: Focus or problem being
addressed
Column 3: Charting in a DAR format
(Data, Action, Response)

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FOCUS CHARTING
Advantages

Holistic
Disadvantages

Lack of common problem list

Inconsistency in labeling focus of notes

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FOCUS CHARTING
EXAMPLE
8/30/15
1100

8/30/15
1130

Focus:
Post-op
Pain

D: Pt states I feel like my stomach is being

ripped open. It hurts so bad. Reports pain 10/10.
BP 142/92, P 98. Pt lying in bed, moaning and
guarding abdomen
A: Medicated with Morphine 4mgIV per MAR

R: Pt resting quietly in bed. Reports pain to

abd /incision now 3/10. Denies need for further
intervention at this time. --------------------George
White, RN

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PIE CHARTING
Problemobtained from admission data
Interventionincludes assessment
Evaluationclient response

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FORMS FOR
DOCUMENTATION
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DOCUMENTATION FORMS
Admission database
Flowsheets
Graphic records
Medication records (MAR)
Progress notes

Kardex or Pt care
summary
Care plans
D/C summary
Incident reports

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ADMISSION DATABASE
Record of baseline data:
Chief complaint or reason for admission
Physical assessment data
Vital signs
Allergy information
Current meds
ADL status & D/C planning info/ needs
Data about support system & contact
info
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FLOWSHEETS & GRAPHIC

RECORDS
Record routine aspects of care
Document assessments
Track response to care
Graphic records - vital signs, I & O
Allow one to quickly see patterns of change

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MEDICATION
ADMINISTRATION
RECORD (MAR)

Comprehensive list of all ordered medications

Information on allergies
Documents scheduled/routine, infusions, single-orders,
PRN, STAT, or omitted doses
Documents any meds refused

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PROGRESS NOTES
Used to communicate nursing assessments,
interventions carried out, and the impact of these
interventions on outcomes
Separate from physicians progress notes

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PROGRESS NOTES
INCLUDE:
Assessments before & after administration of PRN
medications
Information reported to HCP & providers response
Patient teaching & D/C planning
Pertinent data collected while providing care

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CARE PLANS
Documents specifying nursing actions
necessary for the care of a specific
patient
Map out:
Problems
Outcomes
Interventions
Treatments
Evaluations
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D/C SUMMARY
Last entry in paper chart; started at any point during
the patients stay and revised throughout their
hospitalization
Completed when

Pt transferred to another unit

Pt transferred to another facility
Discharged home

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DISCHARGE SUMMARY
INCLUDES:
Time of departure and method of
transportation
Individual(s) accompanying patient at
discharge
Patient condition at discharge
Teaching conducted and
handouts/informational matter provided
Discharge instructions
Follow-up appointments or referrals given
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COMPLETING AN
INCIDENT REPORT
Include:

Date, Time, & Place of the Incident

Name of person(s) involved
Name of any witnesses
Facts about what happened
Consequences to the person involved
Your response to the incident
(assessment/care)
Full name of provider notified
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COMPLETING AN
INCIDENT REPORT
Avoid

Heresay
Your opinion or who is at fault
Assumptions about what caused the
incident or any circumstances you did not
observe
Suggestions as to how this could have
been prevented
Filing the report in the medical record
Documenting in the Medical Record that
an incident report was completed
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ELECTRONIC
MEDICAL RECORDS
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ELECTRONIC HEALTH
RECORD/ELECTRONIC
MEDICAL RECORD
Records recorded via computer
Typically combine source-oriented & problem-oriented
styles

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ADVANTAGES OF
EHR/EMR
Enhanced communication & collaboration
Improved access to information
Saves time
Embedded protocols
Improved quality of care
Privacy and security

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DISADVANTAGES OF
EHR/EMR
Expensive
Downtime
Difficulties associated with change
Lack of integration between departments

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COMPUTERIZED
CHARTING REMINDERS
Dont leave data displayed on a screen where others
can see it
Follow protocol for correcting mistaken entries
Allows log out when leaving computer
Never share your password with anyone

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DOCUMENTATION
GUIDELINES
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GUIDELINES FOR
DOCUMENTATION
Factual
Objective vs Subjective terms
No vague terms

Accurate
Exact measurements
Abbreviations
Spelling
Date, time, signature
Full Name, SN, SCC
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MILITARY TIME

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GUIDELINES FOR
DOCUMENTATION
(CONT.)
Complete

Contains appropriate and essential

information

Current
Timely entries are essential
Increases accuracy and decreases
unnecessary duplication

Organized
Communicates information in a logical order
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COMMON CHARTING
ERRORS
Failing to record meds given
Failing to record nursing actions
Failing to record changes in patient condition
Transcribing orders incorrectly
Illegible/Incomplete documentation
Wrong medical record used
Failing to document a response to an intervention

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HIGH RISK SITUATIONS

Anticoagulant therapy
Blood transfusions & identifiers
Change in condition and early recognition
Contacting a provider
Critical lab results
Medication reconcilitation
Safety, including patient and family involvement

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HIGH RISK SITUATIONS,

CONTD.
Sedation/Anesthesia monitoring
Restraints
Suicide Prevention
Skin Care (Foleys, Surgical Sites, Central Lines)
Infection Control
Patient Falls
Chain of Command

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EXAMPLES OF ITEMS TO
INCLUDE IN CHARTING
Head-to-toe assessment
Response to
interventions
Pain evaluation
Bleeding/unusual
discharge
Sleep, hygiene, and
ADLs

Safety measures
Teaching
needs/teaching
done
Psychosocial and
spiritual needs
Discharge planning
needs

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DOCUMENTATION DOS
Make sure you have the
correct chart before
beginning
documentation

Be accurate, objective,
and nonjudgmental

Write legibly

Include all aspects of

care

Chart patient care at the

time you provide it
Be familiar with facility
forms
Chart in the required
format

Provide details

Use black ink for

written documentation
Date, time, and sign all
notes

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DOCUMENTATION
SHOULD BE:
F: Factual
A: Accurate
C: Complete
T: Timely

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FACTUAL
Only info you see, hear, collect through your senses
Describe behavior, do not label

Ex. Pt seemed confused vs Pt found

at gift shop, stated he was in Dallas
Avoid bias
Be specific

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ACCURATE
Quantify when possible
Identify who gave care
Accurately double check math calcs
Not Documented = Not Done!

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COMPLETE
Include any condition change, patient response
Chain of command
Communication with patient/family
Do not leave blanks

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TIMELY
Date/Time are CRITICAL when determining a timely
response to a patients needs
Try not to leave documentation until the end of the
shift
Do not document in advance = falsifying

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DOCUMENTATION
DONTS
Use subjective terms
Chart about a s/s
without charting what
you did about it
Alter a patients
record-THIS IS A
CRIMINAL OFFENSE

Use abbreviations
that arent widely
accepted
Chart ahead of the
current time
Chart that you have
filled out an incident
report
Leave blank lines
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WHAT IF I MESS UP?

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COMMUNICATING WITH
SBAR
Situation
What is happening at the present time?

Background
What are the circumstances leading up to the
situation?

Assessment
What do I think the problem is?

Recommendation
What should we do to correct the problem?

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HANDOFF REPORT/ORAL
REPORT
Name, age, room #
Diagnosis
Relevant past medical hx (PMH)
Treatments received
Upcoming tests, surgeries, or treatments
Restrictions
Plan of Care
Significant assessment findings

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SOME QUESTIONS
Which of the following findings would the nurse note
when assessing a client with a stage 1 pressure ulcer?
1. Redness noted (measurements included)
2. Deep pink, red, or mottled skin noted
(measurements of area included)
3. Subcutaneous damage noted
4. Damage to the muscle or possible bone involvement
noted

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A nurse administers an incorrect dose of a medication

to a client. Which is the primary purpose of
documenting this event in an Incident Report?

1. Record the event for future litigation

2. Provide a basis for designing new policies
3. Prevent similar situations from happening in the
future
4. Ensure accountability for the cause of the incident

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A nurse completes an incident report after a witnessed

patient fall. Which is the purpose of this report?
1. Ensure that all parties have an opportunity to
document what happened
2. Help establish who is responsible for the incident
3. Make data available for quality-control analysis
4. Document the incident on the patients chart

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