3. DOCUMENTATION serves as a
permanent record of client information
and care.
REPORTING takes place when two or
more people share information about
client care, either face to face or by
telephone
4. Documentation as
Communication
Documentation is defined as written
evidence of:
• The interactions between and among health
professionals, clients, their families, and
health care organizations.
• The administration of tests, procedures,
treatments, and client education.
• The results or client’s response to these
diagnostic tests and interventions.
5. PURPOSES OF
CLIENT’S RECORD
CHART
1.1. Communication.Communication. Provides efficient and effectiveProvides efficient and effective
method of sharing information.method of sharing information.
2.2. Legal Documentation.Legal Documentation. It is admissible as evidenceIt is admissible as evidence
in a court of law.in a court of law.
3.3. Research.Research. Provides valuable health-related data forProvides valuable health-related data for
research.research.
4.4. Statistics.Statistics. Provides statistical information that canProvides statistical information that can
be utilized for planning people’s future needs.be utilized for planning people’s future needs.
5.5. Education.Education. Serves as an educational tool forServes as an educational tool for
students in health discipline.students in health discipline.
6. 6.6. Audit & Quality Assurance.Audit & Quality Assurance. Monitors the qualityMonitors the quality
of care received by the client and the competenceof care received by the client and the competence
of health care givers.of health care givers.
7.7. Planning Client Care.Planning Client Care. Provides data which theProvides data which the
entire health team uses to plan care for the client.entire health team uses to plan care for the client.
8.8. Reimbursement.Reimbursement. Provides the basis for decisionsProvides the basis for decisions
regarding care to be provided and subsequentregarding care to be provided and subsequent
reimbursement to the agency, to cover health-reimbursement to the agency, to cover health-
related expenses.related expenses.
7. Types of Medical Records
Components of medical record:-
Patient identification & demographic data
Present complains
Informed consent for treatment & procedure
Admission nursing history
Family history
Physical examination finding
Medical history
Tentative history
Medical diagnosis
Therapeutic order
Treatment given
Medical progress notes
Supportive care given
Reports of diagnosis studies
Final diagnosis
Patient education
Summary of operative procedures
Discharge plan and summary
Any specific instructions
8. Types of Nursing Records
Admission nursing assessment
Nursing care plan
Kardexes
Pertinent information about patient
Medication with date of order & time of administration
Daily treatment & procedures
Flow chart
Graphic record (TPRBP)
Fluid balance record
Medication
Skin assessment record
Progress notes
9. Legal and Practice Standards
Informed consent means that the client
understands the reasons and risks of the
proposed intervention.
Witnessing confirms that the person who
signs the consent is competent.
10. Elements of Effective
Documentation
Use of Common Vocabulary
Legibility
Abbreviations and Symbols
Organization
Accuracy
Documenting a Medication Error
Confidentiality
Factual
Complete
Current
Organized
11. Elements of Effective
Documentation
Use of Common Vocabulary
• Improves communication and lessens the
chance of misunderstanding between
members of the health team.
12. Elements of Effective
Documentation
Legibility
• Print if necessary.
• Do not erase or obliterate writing.
• State the reason for the error.
• Sign and date the correction.
13. Concepts of Nursing-NUR 123
Elements of Effective
Documentation
Correcting a documentation error
14. Elements of Effective
Documentation
Abbreviations and Symbols
• Always refer to the facility’s approved listing.
• Avoid abbreviations that can be
misunderstood.
15. Elements of Effective
Documentation
Organization
• Start every entry with the date and time.
• Chart in chronological order.
• Chart medications immediately after
administration.
• Sign your name after each entry.
16. Elements of Effective
Documentation
Accuracy
• Use descriptive terms to chart exactly what
was observed or done.
• Use correct spelling and grammar.
• Write complete sentences.
17. Elements of Effective
Documentation
Documenting a Medication Error
• Document in the nurses’ progress notes:
- Name and dosage of the medication
- Name of the practitioner who was notified of the error
- Time of the notification
- Nursing interventions or medical treatment
- Client’s response to treatment
18. Elements of Effective
Documentation
Confidentiality
• The nurse is responsible for protecting the
privacy and confidentiality of client
interactions, assessments, and care.c
19. Factual:-
• A factual record contains descriptive,
objective information about what a nurse
sees, hears, feels & smells.
• An objective description is the result of
direct observation & measurement.
Elements of Effective
Documentation
20. Elements of Effective
Documentation
Complete:-
• The information within a recorded entry or a
record must be complete, containing
appropriate and essential information.
21. Current:-
• Timely entries are essential in a patient’s
ongoing care. Delays in documentation
leads to unsafe patient care.
• Health organizations use military time to
avoid misinterpretation of AM & PM.
Elements of Effective
Documentation
22. Current
• Following activities should enter timely :-
Vital signs,
Pain assessment,
Administration of medication & treatment,
Preparation for diagnostic test or surgery,
Change in patient’s status & who notified,
Admission, transfer, discharge or death of
the patient,
Patient’s response to treatment
23. Organized:-
• Communicate information in a logical order.
• It is effective when notes are concise, clear,
& to the point
Elements of Effective
Documentation
25. Types of records
Patient clinical records
Individual staff records
Ward records
Administrative records with educational
value
26. Common ward records
Patient clinical records
Staff attendance record
Staff leave record
Staff patient assignment record
Student attendance and patient assignment record
Ward indent record
Ward inventory record
Equipment maintenance record
Ward incidence record
Infection surveillance record
Ward quality indicator record
Ward diet supply record
Emergency drug and crash card record
Patient admission/discharge/shift record
27. 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
28. Methods of Documentation
Narrative Charting (TRADITIONAL CLIENT
RECORD)
• Describes the client’s status, interventions and treatments;
response to treatments is in story format.
• Narrative charting is now being replaced by other formats.
• Five Basic components of a
Traditional Client Record
Admission sheet
Physician’s order sheet
Medical history
Nurse’s notes
Special records and reports (referrals, X-ray, reports, laboratory findings,
report of surgery, anesthesia record, flow sheets, vital signs, I&O,
29. Methods of Documentation
Source-Oriented Charting
• Each person or department makes notations in a separate
section/s of the client’s chart.
• Narrative recording by each member (source) of the health
care team on separate records.
• Most Traditional
• Different disciplines chart on separate forms
• Each reader must consult various parts of the record to get
a complete picture
• Records become bulky
• For example the admission department has an admission
sheet, nurses use the nurses’ notes, physicians have a
physician notes, etc….
30. Methods of Documentation
Problem-Oriented Medical Record( POMR) /Nurse’s
or narrative notes (SOAPIE format)
• Uses a structured, logical format called S.O.A.P.
S- SUBJECTIVE. WHAT PT TELLS YOU.
0 – OBJECTIVE. WHAT YOU OBSERVE, SEE.
A – ASSESSMENT. WHAT YOU THINK IS GOING ON BASED ON YOUR DATA.
P – PLAN. WHAT YOU ARE GOING TO DO.
CAN ADD TO BETTER REFLECT NURSING PROCESS
I – INTERVENTION (SPECIFIC INTERVENTIONS IMPLEMENTED)
E – EVALUATION. PT RESPONSE TO INTERVENTIONS.
R – REVISION. CHANGES IN TREATMENT.
Uses flow sheets to record routine care.
SOAP entries are usually made at least every 24 hours on any unresolved problem.
31. Methods of Documentation
PIE Charting
• P: Problem statement
• I: Intervention
• E: Evaluation
Example:
• P: Patient reports pain at surgical incision as 7/10 on 0 to 10 scale
• I : Given morphine 1mg IV at 23:35.
• E : Patient reports pain as 1/10 at 23:55.
32. Methods of Documentation
Focus Charting (DAR)
• 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 (Date & Time, Focus, Progress note)
DATA – SUBJECTIVE OR OBJECTIVE THAT SUPPORTS THE
FOCUS (CONCERN)
ACTION – NURSING INTERVENTION
RESPONSE – PT. RESPONSE TO INTERVENTION
Ex:
D – COMPLAINING OF PAIN AT INCISION SITE , PS: 7/10
A – REPOSITIONED FOR COMFORT. DEMEROL 50MG IM GIVEN.
R – STATES A DECREASE IN PAIN, “FEELS MUCH BETTER.”
33. Example of focus charting
Date & Time Focus: Progress notes:
09.Sep.2013 Acute pain related to surgical incision D: Patient reports pain as 7/10 on 0 to 10 scale.
A: Given morphine 1mg IV at 2335.
R: Patient reports pain as 1/10 at 2355.
34. Methods of Documentation
Charting by Exception (CBE)
• The nurse documents only deviations from
pre-established norms (document only
abnormal or significant findings).
• Avoids lengthy, repetitive notes.
35. Methods of Documentation
Computerized
Documentation
• Increases the quality of
documentation and save time.
• Increases legibility and accuracy.
• Facilitates statistical analysis of
data.
36. Methods of Documentation
Case Management Process
• A methodology for organizing client care
through an illness, using a critical pathway.
• A critical pathway is a multidisciplinary plan
or tool that specifies assessments,
interventions, treatments and outcomes of
health related problems a cross a time line.
37. Forms for Recording Data
Kardex
Flow Sheets
Nurses’ Progress Notes
Discharge Summary
38. Forms for Recording Data
The Kardex is used as a reference throughout
the shift and during change-of-shift reports.
• Client data (e.g name, age, admission date, allergy)
• Medical diagnoses and nursing diagnoses
• Medical orders, list of medications
• Activities, diagnostic tests, or specific data on the pt.
39. Provides a concise method of organizing andProvides a concise method of organizing and
recording data about a client, making informationrecording data about a client, making information
readily accessible to all members of the health team.readily accessible to all members of the health team.
It is a series of flip cards usually kept in portable fileIt is a series of flip cards usually kept in portable file
It is a way to ensure continuity of care from one shiftIt is a way to ensure continuity of care from one shift
to another and from one day to the next.to another and from one day to the next.
It is a tool for change – of – shift report. ButIt is a tool for change – of – shift report. But
endorsement is not simply reciting content of kardex.endorsement is not simply reciting content of kardex.
Health care needs of the client is still primary basis forHealth care needs of the client is still primary basis for
endorsement.endorsement.
40. Usually include the following data:Usually include the following data:
• Personal dataPersonal data
• Basic needsBasic needs
• AllergiesAllergies
• Diagnostic testsDiagnostic tests
• Daily nursing proceduresDaily nursing procedures
• Medications and intravenous (IV) therapy, bloodMedications and intravenous (IV) therapy, blood
transfusionstransfusions
• Treatments like oxygen therapy, steam inhalation,Treatments like oxygen therapy, steam inhalation,
suctioning, change of dressings, mechanical ventilation.suctioning, change of dressings, mechanical ventilation.
Entries usually written in pencil. This implies the kardex isEntries usually written in pencil. This implies the kardex is
for planning and communication purpose only.for planning and communication purpose only.
41. Forms for Recording Data
Flow Sheets
The information on flow sheets can be formatted to
meet the specific needs of the client.
(e.g.: graphic sheets for vital signs, intake & output
record, skin assessment record).
Nurses’ Progress Notes
Used to document the client’s condition, problems
and complaints, interventions, responses,
achievement of outcomes.
42. 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.
44. Reporting
Verbal communication of data regarding the
client’s health status, needs, treatments,
outcomes, and responses
Reporting is based on the nursing process.
46. Reporting
Summary / Hand-Off Reports
Commonly occur at change of shift (or when client care
is transfers to another health care provider).
Walking Rounds Reports
Occur in the client’s room
Include Nursing, physician, interdisciplinary team.
Incident or Occurrence Reports
Used to document any unusual occurrence or accident
in the delivery of client care.
47. Reporting
Telephone Reports and Orders
• Provide clear accurate and concise information
• The nurse documents telephone report by including
the following information:
- when the call was made
- who made the call/report
- who was called
- to whom information was given
- what information was given
- what information was received
48. Only RN’s may receive telephone
orders
The order need to be verified by
reporting it clearly and precisely.
The order should be countersigned
by the physician who made the order
within the prescribed period of time
(within 24 hours)
50. GENERAL
DOCUMENTATION
GUIDELINES
* Ensure that you have the correct client record or chart.
* Document as soon as the client encounter is concluded to ensure
accurate recall of data.
* Date and time of each entry.
* Sign each entry with your full legal name and with your
professional credentials.
* Do not leave space in between entries.
* If an error is made while documenting, use a single line to cross out
the error, then date, time and sign the correction
* Never change another person’s entry even if it is incorrect
* Use quotation marks to indicate direct client responses.
* Document in chronological order
* Use permanent ink
* Document all telephone calls that you received that are related to
client’s case.
51. Minimizing legal liability through
effective record keeping
Date & time
Timing
Legibility
Permanence
Correct spelling
Signature
Accuracy
Sequence
Appropriateness
Completeness
Conciseness
Accepted terminology
24 Hour
Time
52. CORRECTING ERRORS
IF YOU SPILL SOMETHING ON THE CHART, DO NOT
DISCARD NOTES. RECOPY, PUT ORIGINAL AND COPIED
SHEETS IN CHART. WRITE “COPIED” ON COPY.
DO NOT SCRIBBLE OUT CHARTING.
AVOID USING “ERROR” OR “WRONG PATIENT” WHEN
MAKING CORRECTION.
FOLLOW YOUR FACILITIES POLICY.
DO NOT ALTER CHARTING, IT IS A LEGAL DOCUMENT.
*Correct errors by drawing a single horizontal line
*through the error
*Write the word error above the line, then sign
*your signature
*No ink eradication, erasures or use of occlusive materials.
54. Questions
1. Document is a………. evidence.
2. Use of Common Vocabulary Improves communication and lessens
the chance of ………… between members of the health team.
3. Chart should be done in ……….. order.
4. TRADITIONAL CLIENT RECORD also called……………………….
5. Start every entry with……….
6. What is SOAPIE elaborate.
7. Health organizations use…….. time to avoid misinterpretation.
8. What is DAR
9. What is CBE
10. Kardex is a series of ………… usually kept in portable fileseries of ………… usually kept in portable file
55. ANSWERS
1. Written
2. Misunderstanding
3. Chronological
4. Narrative Charting
5. Date and time
6. S- subjective, 0 – OBJECTIVE, A – ASSESSMENT, P – PLAN, I – INTERVENTION, E –
EVALUATION, R – REVISION.
7. Military
8. Data , action , response
9. Charting by Exception
10.10. Flip cardsFlip cards