F. A.

Davis s Fundamentals of Nursing

Chapter 16: Documenting and Reporting

 Documentation: The act of recording client care in written form  Creating a written record of client care  Client record: A collection of material that serves as a legal record of the client's healthcare experience

F. A. Davis s Fundamentals of Nursing

Purpose of the Written Record

 Communication between providers  Educational tool: Snapshot of what is going on with the patient so that you can prepare to give safe care  Legal documentation of care  Quality assurance: Chart audits  Research  Reimbursement

F. A. Davis s Fundamentals of Nursing

Main Documentation Systems

Source-oriented:
 Disciplines charted separately; Variety of sections  Data scattered; may lead to fragmentation  May include: Admission data; Advanced directives (End-of-life care wishes); H&P; Dr.'s orders; Progress notes; Diagnostic studies (Lab results; XRays, etc.); Nurses' notes; Graphic sheet (V/S, I/O, BMs, weight, etc), Rehab & therapy notes (PT, OT, Resp Therapy), Discharge planning

F. A. Davis s Fundamentals of Nursing

Main Documentation Systems

Problem-oriented:
 Organized around client problems  Four components: Database, problem list, plan of care, and progress notes  Allows greater collaboration

F. A. Davis s Fundamentals of Nursing

Common Types of Charting

     Narrative SOAP PIE Focus Charting By Exception (CBE)

F. A. Davis s Fundamentals of Nursing

arrative Charting
 Can use with source- or problem-oriented system  Story of care in chronological format  Tracks the client s changing status  Can be lengthy and disorganized

F. A. Davis s Fundamentals of Nursing

SOAP Charting
    S for Subjective data O for Objective data A for Assessment P for Plan  Some Add IER
I for Intervention E for Evaluation R for Revision

F. A. Davis s Fundamentals of Nursing

PIE Charting
 P for Problem  I for Interventions  E for Evaluation  Used only in problem-oriented charting  Establishes an ongoing plan of care

F. A. Davis s Fundamentals of Nursing

Focus Charting
 Highlights the client s concerns, problems, or strengths  Occurs 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

F. A. Davis s Fundamentals of Nursing

ursing Documentation Forms: Admission Database

 Record of baseline data from which to monitor change  Helps forecast future needs

F. A. Davis s Fundamentals of Nursing

Admission Database
Chief complaint or reason for admission Physical assessment data Vital signs Allergy information Current medications ADL status and discharge planning information/ needs  Data about client support system and contact information
     

F. A. Davis s Fundamentals of Nursing

Flow Sheets
 Record routine aspects of care (hygiene, turning)  Document assessments; usually organized according to body systems  Track client response to care (wound care, pain, intravenous fluids)  Graphic records - used to record vital signs  Intake and output record

F. A. Davis s Fundamentals of Nursing

Medication Administration Records

 Comprehensive list of all ordered medications  Provides information on client s medication allergies  Documents scheduled/routine, PRN, STAT, or omitted doses
Additional explanation may be required for nonroutine or omitted medications

F. A. Davis s Fundamentals of Nursing

KARDEX or Client Care Summary

     Demographic data Medical diagnoses Allergies Diet/activity orders Safety precautions
continued

F. A. Davis s Fundamentals of Nursing

KARDEX or Client Care Summary

 Intravenous therapy orders  Ordered treatments (wound care, physical therapy), surgery, laboratory, and tests  A summary of medications ordered  Special instructions such as preferred intensity of care or isolation orders

F. A. Davis s Fundamentals of Nursing

Integrated Plans of Care (IPOC)

 A combined charting and care plan form  Maps out on a daily basis, from admission to discharge:
Client outcomes, interventions and treatments for a specific diagnosis or condition Laboratory work, diagnostic testing, medications, and therapies included in the pathway

F. A. Davis s Fundamentals of Nursing

Discharge Summary
 Time of departure and method of transportation  Name and relationship of person(s) accompanying client at discharge  Condition of client at discharge  Teaching conducted and handouts/informational matter provided to client  Discharge instructions (including medications, treatments, or activity)  Follow-up appointments or referrals given

F. A. Davis s Fundamentals of Nursing

Occurrence Events
 Also known as Incident reports  Closely follow each institution's procedure for how to report and document an Incident Report

F. A. Davis s Fundamentals of Nursing

Computerized Charting
 Confidentiality is important  Protect client confidentiality when doing/using the computer

F. A. Davis s Fundamentals of Nursing

Home Health-Care Documentation

 Home-bound status  Assessment highlighting changes in the client s condition  Interventions performed (wound care, teaching, etc.)  Client s response to interventions  Any interaction or teaching that you conducted with caregivers  Any interaction with the client s physician

F. A. Davis s Fundamentals of Nursing

Long-Term Care Documentation

 Minimum data set (MDS) for resident assessment and care screening must be completed within 4 days of admission and updated every 3 months

F. A. Davis s Fundamentals of Nursing

Long Term Care: Weekly Summary

 A summary of the client s condition  An evaluation of the client s ability to perform ADLs  The client s level of orientation and mood  Hydration and nutrition status  Response to medications  Any treatments provided  Safety measures used (e.g., bed rails)

F. A. Davis s Fundamentals of Nursing

Reporting
 Informing other caregivers about the client condition
Nurse to nurse; nurse to physician

 Passage of vital information related to the client s status/plan of care

F. A. Davis s Fundamentals of Nursing

Change-of-Shift Report
May be:
 Verbal  Through walking rounds  Taped report

F. A. Davis s Fundamentals of Nursing

Change-of-Shift Report
       

Client demographics and diagnoses Relevant medical history Significant assessment findings Treatments (e.g., wound care, breathing treatments) Upcoming diagnostics or procedures Restrictions (e.g., diet, activity, isolation) Plan of care for the client Concerns

F. A. Davis s Fundamentals of Nursing

Change-of-Shift Report
Keep It CUBAN:
    

Confidential Uninterrupted Brief Accurate Named Nurse

F. A. Davis s Fundamentals of Nursing

Transfer Reports
Your contact information Client demographics, diagnoses, reason for transfer Family contact information Summary of care Current status, including medications, treatments, and tubes in the client  Presence of wounds or open areas of the skin  Special directives, code status, preferred intensity of care, or isolation required  Always ask if the receiver has any questions
    

F. A. Davis s Fundamentals of Nursing

Verbal/Telephone Physician Orders

Verbal orders:
 Spoken to you; often during a client emergency  Should not be used as a routine means of communicating

Telephone orders:
 Received by phone and transcribed onto chart order sheet  Have an increased risk for errors

F. A. Davis s Fundamentals of Nursing

Telephone Orders
 Write the order only if you heard it yourself  Make sure the verbal orders make sense with the client s status  Repeat the order  Spell unfamiliar names; pronounce digits of numbers separately
continued

F. A. Davis s Fundamentals of Nursing

Telephone Orders
 Directly transcribe the order on the chart
Date/time Text TO followed by provider Your signature

s name

 Physicians must countersign within 24 hours

F. A. Davis s Fundamentals of Nursing

Documenting Client Care

 Be familiar with facility forms  Chart in the required format; use military time if required  Include all aspects of care  Be accurate, complete, and consistent

F. A. Davis s Fundamentals of Nursing

Documentation Do

s and Don

ts

 Be accurate and nonjudgmental  Adhere to the requirements for reimbursement  Provide details about the client s condition, nursing interventions provided, and client response  Document legibly and as soon as possible

F. A. Davis s Fundamentals of Nursing

Documentation Do

s and Don

ts

 Record significant events or changes in condition  Any attempts you have made to contact the primary care provider  Chart teaching performed  Chart use of restraints, including reason for use, type of restraints, and frequent checks of the client

F. A. Davis s Fundamentals of Nursing

Documentation Do

s and Don

ts

 Do not chart that you have filled out an occurrence report  Chart any client refusal of treatment or medication  Document any spiritual concerns expressed by the client and your interventions

F. A. Davis s Fundamentals of Nursing

Documentation Do

s and Don

ts

 Always use black or blue ink for handwritten notes  Date and time all notes  Avoid subjective terms  Use proper spelling and grammar  Use only authorized abbreviations  Document complete data about medications

F. A. Davis s Fundamentals of Nursing

Documentation Do

s and Don

ts

If a client refuses a medicine:

 Record on the medication administration record in narrative form; chart the reason given  Do not leave blank lines  If you make a mistake, draw a single line through the entry, and place your initials next to the change  Sign all your charting entries