Documentation &

Informatics

1
What is Documentation?
2

 Any thing written or printed within a client record

 Provides written evidence of quality of client
care provided
 Written evidence of client’s response to
diagnostic tests and interventions
 Record or chart is a permanent, legal,
comprehensive account of client’s health status
 Reports are oral, written, or audiotape
exchanges of information between care-givers
Confidentiality

 Nurses are legally and ethically obligated to keep client information

confidential.
 Nurses are responsible for protecting records from all unauthorized
readers.
 HIPAA act requires that disclosure or requests regarding health
information are limited to the minimum neccessary – need to know only.
 What structured data elements do you need to provide you job function?
 Standards
 The Joint Commission requires each client have an assessment:
 Physical, psychosocial, environment, self-care, client education, and discharge
planning needs
 Requires documentation within context of nursing process including teaching & d/c
planning
 Evaluation of outcomes
 Federal and state regulations, state statutes, standards of care, and
accreditation agencies set nursing documentation standards.
 Nurses must document in accordance with standard of care & facility’s policy.
 Multidisciplinary Communication Within the Health
Care Team
 Records or chart:
 Confidential permanent legal document
 Reports:
 Oral, written, audiotaped exchange of information
 SBAR:
 Situation
 Background
 Assessment
 Recommendations
 Consultations:
 A professional caregiver providing formal advice to another caregiver
 Referrals:
 Arrangement for services by another care provider
6
Purpose of Records
Documentation
 Communication
 Legal documentation
 Financial reimbursement
 Education
 Research
 Auditing and monitoring
 7 Guidelines for charting
1. Be sure that client’s name and medical record
number are on each page of the chart
2. Date and sign each entry
3. Chart relevant and appropriate data
4. Avoid use of negative terms to describe client’s
behavior
5. Do not write about other staff members
6. Record facts clearly and accurately
7. Omit unnecessary words or vague terms
8. Use only standard abbreviations
8 Guidelines for charting cont’d

 Use black ink

 Write legibly, briefly and neatly
 Use correct grammer, spelling and punctuation
 Sign each entry with your name and title
 Never skip a line or leave a line blank
 Correct errors by drawing a line through the entry, don’t erase or
use ‘white-out’
 Chart information as soon as possible
9 Quality Documentation and
Reporting
 Factual
 Accurate
 Complete
 Timely
 Organized
10 Military Time Only
Methods of Recording

 Narrative:
 The traditional method
 Story like format, time consuming., replaced by other formats
 Problem-Oriented Medical Record (POMR):
 Database
 Problem list
 Nursing care plan
 Progress note
 Methods of Recording:
Progress Notes
 SOAP:
 Subjective, objective, assessment, plan
 SOAPIE:
 Subjective, objective, assessment, plan, intervention, evaluation
 PIE:
 Problem, intervention, evaluation
 Focus Charting (DAR):
 Data, action, response

 BOX 26-2 for examples of each

Methods of Reporting

 Source records:
 A separate section for each discipline
 Charting by exception (CBE):
 Focuses on documenting deviations
 Case management plan and critical pathways:
 Incorporates a multidisciplinary approach to care
 Review Care Map for Pneumonia: Fig 26-3 pg 395 & 396
14 Common Recording Keeping
Forms
 Admission assessment or nursing history forms
 Flow sheets and Graphic records
 Kardex or client care summary
 Acuity Records
 Standardized care plan
 Discharge summary form
Home Care Documentation

 Medicare has specific guidelines for establishing eligibility for home

care.
 Documentation is the quality control and justification for reimbursement
from Medicare, Medicaid, or private insurance.
 Nurses need to document all their services for payment.
Long-Term Health Care Documentation

 Governmental agencies are instrumental in determining the standards and

policies for documentation.
 The Omnibus Budget Reconciliation Act of 1987 includes Medicare and
Medicaid legislation for long-term care documentation.
 RAI: Resident Assessment Instrument
 The department of health in states governs the frequency of written
nursing records.
Reporting

 Change of shift
 Table 26-4
 Telephone reports
 Verbal )VO) or telephone orders (TO)
 Box 26-8
 Transfer reports
 Incident reports
 Computerized Documentation
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 Software programs allow nurses to enter assessment data.

 Computers generate nursing care plans and document care.
 A complete computer-based patient care record (CPCR) is not without legal risks
 Stores and retrieves client data fast and easily
 Uses standardized nursing care plans
 Charting is always legible
 Facilitates transmission of information from one care setting to another
 Improves communication through use of standard terminology
 19 Examples of Documentation

 “Pt. Requesting Demerol. Looks like he needs it.”

 Subjective: “Bitten by a snake. No movement, 17 in,. Multicolored, flat head.”
 “Pt. States she is vomiting. Will observe for truth.”
 “Two valium missing from stock. Supervisor notified that I didn’t do it.”
 Skin‑ somewhat pale but present
 Both the nurse and the patient reported passing
 flatus
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