3. DEFINITION
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.
4. • DOCUMENTATION: It serves as a
permanent record of client information and
care.
• REPORTING: It takes place when two or
more people share information about client
care, either face to face or by telephone.
5. PURPOSES OF CLIENT’S
RECORD CHART
• Communication: Provides efficient and effective
method of sharing.
• Legal Documentation: Legal Documentation. It is
admissible as evidence. It is admissible as evidence
in a court of law.
• Research: Research Provides valuable health-related
data.
• Statistics: Provides statistical information that can
be utilized for planning people’s future needs.
• Education: Education Serves as an educational tool
for students in health discipline.
6. • Audit & Quality Assurance: Monitors the
quality of care received by the client and the
competence of health care givers.
• Planning Client Care: Provides data which the
entire health team uses to plan care for the
client.
• Reimbursement: Provides the basis for
decisions regarding care to be provided and
subsequent reimbursement to the agency, to
cover health-reimbursement to cover health-
related expenses.
7. TYPES OF MEDICAL
RECORDS/COMPONENTS
– 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 NURSES 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. LEGALAND 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. Use of Common Vocabulary
• Improves communication and lessens the
chance of misunderstanding between
members of the health team.
12. Legibility
• Print if necessary.
• Do not erase or obliterate writing.
• State the reason for the error.
• Sign and date the correction.
13. Abbreviations and Symbols
• Always refer to the facility’s approved listing.
• Avoid abbreviations that can be misunderstood
14. Organization
• Start every entry with the date and time.
• Chart in chronological order.
• Chart medications immediately after
administration.
• Sign your name after each entry
15. Accuracy
• Use descriptive terms to chart exactly what was
observed or done.
• Use correct spelling and grammar.
• Write complete sentences.
16. 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
17. Confidentiality
• The nurse is responsible for protecting the
privacy and confidentiality of client
interactions, assessments, and care.
18. 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
19. Complete
The information within a recorded entry or a
record must be complete, containing
appropriate and essential information.
20. 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.
• 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. TYPES OF RECORDS
Patient clinical records
Individual staff records
Ward records
Administrative records with educational value
Common ward records
24. 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
25. 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
26. 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
27. 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,
28. 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….
29. 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(SPECIFICINTERVENTIONS 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.
30. 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.
31. 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.”
• 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.
32. Charting by Exception (CBE)
– The nurse documents only deviations from pre-
established norms (document only abnormal or
significant findings).
– Avoids lengthy, repetitive notes.
33. Computerized Documentation
– Increases the quality of documentation and save
time.
– Increases legibility and accuracy.
– Facilitates statistical analysis of data.
34. 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.
35. Forms for Recording Data
• Kardex
• Flow Sheets
• Nurses’ Progress Notes
• Discharge Summary
36. • 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.
• Provides a concise method of organizing and recording data
about a client, making information readily accessible to all
members of the health team..
• It is a series of flip cards usually kept in portable .It is a way
to ensure continuity of care from one shift to another and
from one day to the next.to another.
• It is a tool for change – of – shift report But endorsement is
not simply reciting content of kardex. Health care needs of
the client is still primary basis endorsement.
37. Usually include the following data:
• Personal data
• Basic needs
• Allergies
• Diagnostic tests
• Daily nursing procedures
• Medications and intravenous (IV) therapy,
• Blood Medications and intravenous (IV) therapy, blood
transfusion
• Treatments like oxygen therapy, steam inhalation,
suctioning, change of dressings, mechanical ventilation
• Entries usually written in pencil. This implies the
kardex is for planning and communication purpose
only.
38. 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.
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.
39. REPORTING
• Verbal communication of data regarding the
client’s health status, needs, treatments,
outcomes, and responses
• Reporting is based on the nursing process.
41. 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.
42. 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
• 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)
43. 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.
44. 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
45. 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.
