Chapter 16

Documentation and Reporting

Documentation as Communication 
Communication is a dynamic, continuous, and multidimensional process for sharing information.  Reporting and recording are the major communication techniques used by health care providers.

Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.

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Documentation as Communication 
The medical record serves as a legal document for recording all client activities by health care practitioners.

Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.

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Documentation as Communication  Documentation is defined as written evidence of: ‡ The interactions between and among health professionals. treatments. 16-4 . clients. a division of Thomson Learning. and health care organizations ‡ The administration of tests. Inc. and client education ‡ The results or client¶s response to these diagnostic tests and interventions Copyright 2004 by Delmar Learning. their families. procedures.

a division of Thomson Learning. 16-5 .Documentation as Communication  Nurses rely on charting. records.  Systematic documentation is critical to presenting the care administered by nurses in a logical fashion. and systems that support the implementation of the nursing process. Inc. Copyright 2004 by Delmar Learning.

Inc. Copyright 2004 by Delmar Learning. a division of Thomson Learning. judgments. 16-6 . and evaluation must be clearly communicated through proper documentation.Documentation as Communication  Critical thinking skills.

a division of Thomson Learning. Inc. 16-7 .Purposes of Health Care Documentation  Professional Responsibility and Accountability  Communication  Education  Research  Legal and Practice Standards Copyright 2004 by Delmar Learning.

16-8 . and any revisions made in the care plan.Purposes of Health Care Documentation  Recording provides written evidence of what was done for the client. Inc. the client¶s response. Copyright 2004 by Delmar Learning. a division of Thomson Learning.

 Documentation provides a written legal record to protect the client.  Written records are a resource for review.Purposes of Health Care Documentation  Recording documents compliance with professional practice standards and accreditation criteria. reimbursement. audit. a division of Thomson Learning. 16-9 . and research. Copyright 2004 by Delmar Learning. institution and practitioner. Inc.

complications.Purposes of Health Care Documentation  Education ‡ Health care students use the medical record as a tool to learn about disease processes. diagnoses. ‡ Clinical rounds and case conferences rely heavily on information contained in the medical record. Copyright 2004 by Delmar Learning. 16-10 . and interventions. Inc. a division of Thomson Learning.

‡ Documentation can validate the need for research. a division of Thomson Learning.Purposes of Health Care Documentation  Research ‡ Researchers rely heavily on medical records as a source of clinical data. 16-11 . Copyright 2004 by Delmar Learning. Inc.

Inc. a division of Thomson Learning. the medical record is the determining factor in providing proof of significant events. 16-12 .Purposes of Health Care Documentation  Legal and Practice Standards ‡ In 80% to 85% of malpractice lawsuits involving client care. Copyright 2004 by Delmar Learning.

16-13 . a division of Thomson Learning.Legal and Practice Standards  Informed Consent  Advance Directives  American Nurses Association (ANA) Standards of Care  State Nurse Practice Acts  Joint Commission on Accreditation of Health Care Organizations (JCAHO) Copyright 2004 by Delmar Learning. Inc.

16-14 . a division of Thomson Learning.  Witnessing confirms that the person who signs the consent is competent. Copyright 2004 by Delmar Learning. Inc.Legal and Practice Standards  Informed consent means that the client understands the reasons and risks of the proposed intervention.

 The Patient Self-Determination Act of 1990 requires health care facilities to document whether the client has such a directive. Copyright 2004 by Delmar Learning. 16-15 .Legal and Practice Standards  An advance directive allows the client to participate in end-of-life decisions. a division of Thomson Learning. Inc.

Legal and Practice Standards  American Nurses Association Standards of Care make explicit the role of data collection and documentation in nursing practice. a division of Thomson Learning. 16-16 . Inc. Copyright 2004 by Delmar Learning.

16-17 . a division of Thomson Learning. Copyright 2004 by Delmar Learning.Legal and Practice Standards  State Nurse Practice Acts have established guidelines to ensure safe practice.  Require evidence of compliance through documentation. Inc.

a division of Thomson Learning. 16-18 . Inc. Copyright 2004 by Delmar Learning.Legal and Practice Standards  The Joint Commission on Accreditation of Health Care Organizations (JCAHO) requires documentation of compliance with its standards of care requirements.

16-19 . Inc.Purposes of Health Care Documentation  Reimbursement ‡ Peer review organizations (PROs) are required by the federal government to monitor and evaluate care. ‡ Medical record documentation is the mechanism for the PRO review. Copyright 2004 by Delmar Learning. a division of Thomson Learning.

Copyright 2004 by Delmar Learning. Inc.If nurses fail to document the equipment or procedures used daily. .Purposes of Health Care Documentation  Reimbursement ‡ Diagnosis-Related Groups (DRG) .The medical record must provide documentation that supports the DRG and appropriateness of care. a division of Thomson Learning. reimbursement to the facility can be denied. 16-20 .

Facilities in violation of COBRA laws are fined and may lose their eligibility for Medicare and Medicaid funding. Copyright 2004 by Delmar Learning. 16-21 .Purposes of Health Care Documentation  Reimbursement ‡ Consolidated Omnibus Budget (COBRA) Reconciliation Act . a division of Thomson Learning. .Any COBRA client receiving care in an emergency room must be stabilized before being transferred to another facility. Inc.

and relevant to care. a division of Thomson Learning.Principles of Effective Documentation  Nursing notes must be logical. and must represent each phase of the nursing process. Copyright 2004 by Delmar Learning.  Nursing documentation based on the nursing process facilitates effective care. Inc. 16-22 . focused.

Elements of Effective Documentation        Use of Common Vocabulary Legibility Abbreviations and Symbols Organization Accuracy Documenting a Medication Error Confidentiality Copyright 2004 by Delmar Learning. 16-23 . a division of Thomson Learning. Inc.

‡ Supports the efforts of research. ‡ Improves communication and lessens the chance of misunderstanding between members of the health team. 16-24 . Copyright 2004 by Delmar Learning. a division of Thomson Learning. Inc.Elements of Effective Documentation  Use of Common Vocabulary ‡ Enhances the quality of documentation.

Draw one line through an erroneous entry.Elements of Effective Documentation  Legibility ‡ ‡ ‡ ‡ ‡ Print if necessary. Copyright 2004 by Delmar Learning. Do not erase or obliterate writing. a division of Thomson Learning. 16-25 . Inc. State the reason for the error. Sign and date the correction.

Elements of Effective Documentation Correcting a documentation error Copyright 2004 by Delmar Learning. 16-26 . Inc. a division of Thomson Learning.

Elements of Effective Documentation  Abbreviations and Symbols ‡ Always refer to the facility¶s approved listing. 16-27 . Inc. a division of Thomson Learning. ‡ Avoid abbreviations that can be misunderstood. Copyright 2004 by Delmar Learning.

Chart in a timely fashion to avoid omissions. Inc. ‡ Sign your name after each entry. 16-28 .Elements of Effective Documentation  Organization ‡ ‡ ‡ ‡ Start every entry with the date and time. Copyright 2004 by Delmar Learning. a division of Thomson Learning. Chart in chronological order. Chart medications immediately after administration.

a division of Thomson Learning. 16-29 . Inc.Elements of Effective Documentation Charting a late entry Copyright 2004 by Delmar Learning.

Elements of Effective Documentation  Charting a prn medication Copyright 2004 by Delmar Learning. a division of Thomson Learning. 16-30 . Inc.

descriptive terms to chart exactly what was observed or done. ‡ Write complete sentences. ‡ Use correct spelling and grammar. a division of Thomson Learning. 16-31 . Copyright 2004 by Delmar Learning. Inc.Elements of Effective Documentation  Accuracy ‡ Use factual. ‡ Maintain continuity of care by recording with respect to notes made on previous shifts.

Name and dosage of the medication . 16-32 .Client¶s response to treatment Copyright 2004 by Delmar Learning. a division of Thomson Learning.Elements of Effective Documentation  Documenting a Medication Error ‡ Chart the medication on the MAR.Name of the practitioner who was notified of the error .Time of the notification .Nursing interventions or medical treatment . ‡ Document in the nurses¶ progress notes: . Inc.

Elements of Effective Documentation  Confidentiality ‡ The nurse is responsible for protecting the privacy and confidentiality of client interactions. 16-33 . Inc. assessments. a division of Thomson Learning. and care. or other parties not directly involved in care provided by the health team may not have access to clients¶ records. insurance companies. Copyright 2004 by Delmar Learning. ‡ The client¶s significant others.

Methods of Documentation         Narrative Charting Source-Oriented Charting Problem-Oriented Charting PIE Charting Focus Charting Charting by Exception (CBE) Computerized Documentation Case Management with Critical Paths Copyright 2004 by Delmar Learning. 16-34 . a division of Thomson Learning. Inc.

a division of Thomson Learning. ‡ Narrative charting is now being replaced by other formats. interventions and treatments. response to treatments is in story format. Inc. Copyright 2004 by Delmar Learning. 16-35 .Methods of Documentation  Narrative Charting ‡ Describes the client¶s status.

a division of Thomson Learning. Inc. Copyright 2004 by Delmar Learning. 16-36 .Methods of Documentation  Source-Oriented Charting ‡ Narrative recording by each member (source) of the health care team on separate records.

O: objective data . .P: plan Copyright 2004 by Delmar Learning.A: assessment (conclusion stated in form of nursing diagnoses or client problems) . logical format called S. Inc.O.S: subjective data . a division of Thomson Learning. 16-37 .P.Methods of Documentation  Problem-Oriented Charting (POMR) ‡ Uses a structured.A.

Inc.  SOAP entries are usually made at least every 24 hours on any unresolved problem.  SOAP was developed on a medical model. Copyright 2004 by Delmar Learning.  A discharge summary addresses each problem. 16-38 .Problem-Oriented Charting (POMR)  Uses flow sheets to record routine care. a division of Thomson Learning.

Inc. a division of Thomson Learning.Problem-Oriented Charting (POMR)  SOAPIE and SOAPIER refer to formats that add: ‡ I: Intervention ‡ E: Evaluation ‡ R: Revision Copyright 2004 by Delmar Learning. 16-39 .

Inc.Problem-Oriented Charting (POMR) Copyright 2004 by Delmar Learning. 16-40 . a division of Thomson Learning.

16-41 . a division of Thomson Learning. Inc.Methods of Documentation  PIE Charting ‡ P: Problem ‡ I: Intervention ‡ E: Evaluation  Key components are assessment flow sheets and the nurses¶ progress notes with an integrated plan of care. Copyright 2004 by Delmar Learning.  PIE charting is a nursing model.

16-42 .Methods of Documentation Copyright 2004 by Delmar Learning. a division of Thomson Learning. Inc.

a division of Thomson Learning.Methods of Documentation  Focus Charting ‡ A method of identifying and organizing the narrative documentation of all client concerns. ‡ Uses a columnar format within the progress notes to distinguish the entry from other recordings in the narrative notes. 16-43 . Copyright 2004 by Delmar Learning. Inc. ‡ Includes data. response. action.

a division of Thomson Learning. Copyright 2004 by Delmar Learning. ‡ Enables the identification of trends in client status.Methods of Documentation  Charting by Exception (CBE) ‡ The nurse documents only deviations from preestablished norms. Inc. repetitive notes. 16-44 . ‡ Avoids lengthy.

Inc. ‡ Increases legibility and accuracy. decisive. Enhances the systematic approach to client care. ‡ Provides clear. Copyright 2004 by Delmar Learning. ‡ Enhances implementation of the nursing process.Methods of Documentation  Computerized Documentation ‡ Increases the quality of documentation and save time. and concise key words (standardized nursing terminology). 16-45 . a division of Thomson Learning.

a division of Thomson Learning. ‡ Information is quickly coordinated and integrated by other departments. enhancing critical thinking. 16-46 . Inc.Methods of Documentation  Computerized Documentation ‡ Provides access to other data. Copyright 2004 by Delmar Learning. ‡ Facilitates statistical analysis of data.

16-47 . ‡ Provides each health care practitioner with all pertinent client data to ensure continuity of care without duplication. a division of Thomson Learning. Copyright 2004 by Delmar Learning. ‡ Provides crucial client information in a timely fashion. Inc.Methods of Documentation  Point-of-Care System ‡ A handheld portable computer is used for inputting and retrieving client data at the bedside.

Methods of Documentation 
Case Management Process
‡ A methodology for organizing client care through an illness, using a critical pathway. ‡ A critical pathway is a monitoring and documentation tool used to ensure that interventions are performed on time and that client outcomes are achieved on time.

Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.

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Forms for Recording Data 
  
Kardex Flow Sheets Nurses¶ Progress Notes Discharge Summary

Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.

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Forms for Recording Data 
The Kardex is used as a reference throughout the shift and during changeof-shift reports.
‡ ‡ ‡ ‡ Client data Medical diagnoses and nursing diagnoses Medical orders Activities

Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.

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Copyright 2004 by Delmar Learning.  The information on flow sheets can be formatted to meet the specific needs of the client.Forms for Recording Data  Flow sheets reduce the redundancy of charting in the nurses¶ progress notes. a division of Thomson Learning. 16-51 . Inc.

16-52 .Forms for Recording Data  Nurses¶ progress notes are used to document the client¶s condition. achievement of outcomes. responses. Copyright 2004 by Delmar Learning.  Progress notes can be completely narrative or incorporated into a standardized flow sheet. problems and complaints. interventions. a division of Thomson Learning. Inc.

Inc.Forms for Recording Data  Discharge Summary ‡ ‡ ‡ ‡ ‡ ‡ Client¶s status at admission and discharge Brief summary of client¶s care Interventions and education outcomes Resolved problems and continuing need Referrals Client instructions Copyright 2004 by Delmar Learning. a division of Thomson Learning. 16-53 .

16-54 . a division of Thomson Learning. Copyright 2004 by Delmar Learning. Inc.Trends in Documentation  Standardized data bases are required to ensure accuracy and precision in nursing information systems.

a division of Thomson Learning. 16-55 . Inc.Trends in Documentation     Nursing Minimum Data Set (NMDS) Nursing Diagnoses (Taxonomy II) Nursing Intervention Classification (NIC) Nursing Outcomes Classification (NOC) Copyright 2004 by Delmar Learning.

Inc. and responses  Summary of current critical information to facilitate clinical decision making and continuity of client care Copyright 2004 by Delmar Learning. outcomes.Reporting  Verbal communication of data regarding the client¶s health status. 16-56 . needs. treatments. a division of Thomson Learning.

standards of care.Reporting  Reporting is based on the nursing process. Inc. and legal and ethical principles. a division of Thomson Learning.  Reports require participation from everyone present. Copyright 2004 by Delmar Learning. 16-57 .

Inc. a division of Thomson Learning. 16-58 .Reporting     Summary Reports Walking Rounds Telephone Reports and Orders Incident Reports Copyright 2004 by Delmar Learning.

and progress toward expected outcomes ‡ Client or family complaints Copyright 2004 by Delmar Learning. a division of Thomson Learning.Summary Reports  Commonly occur at change of shift (or when client is transferred). Inc. 16-59 . ‡ Assessment data ‡ Primary medical and nursing diagnoses ‡ Recent changes in condition. adjustments in plan of care.

16-60 .Walking Rounds  Nursing. interdisciplinary  Occur in the client¶s room and include the client Copyright 2004 by Delmar Learning. a division of Thomson Learning. Inc. physician.

Telephone Reports and Orders  Report transfers. obtain client data. communicate referrals. inform a physician and/or client¶s family members regarding a change in the client¶s condition.  Telephone orders are documented in the nurses¶ progress notes and the physician order sheet. solve problems. 16-61 . Copyright 2004 by Delmar Learning. Inc. a division of Thomson Learning.

16-62 . a division of Thomson Learning.Documenting a Telephone Order Copyright 2004 by Delmar Learning. Inc.

Inc. a division of Thomson Learning.  The incident report is not part of the medical record. but it may be used later in litigation. Copyright 2004 by Delmar Learning. 16-63 .Incident Reports  Used to document any unusual occurrence or accident in the delivery of client care.

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