This document discusses various aspects of documentation in nursing. It defines documentation and explains its purposes, including professional responsibility, communication, education, research, legal and practice standards, quality assurance, reimbursement, and more. It also covers different documentation methods like narrative charting, problem-oriented charting, PIE charting, focus charting, charting by exception, and computerized documentation. Key elements of documentation like legibility, abbreviations, accuracy, and confidentiality are also addressed.

1. W.JOHNY WILBERT ,
M.Sc.(N)
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2.  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

3.  Written evidence of the interaction between and
among students, families, school staff, health care
professionals, regarding care, training,
consultation, student education, and the results or
response to the intervention.
 Written record of nursing process to deliver care.

4.  Professional Responsibility and Accountability
 Communication
 Education
 Research
 Legal and Practice Standards
 Quality assurance
 Statistics
 reimbursement
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5.  Professional Responsibility and
Accountability
 Recording documents compliance with professional practice
standards and accreditation criteria.
 Written records are a resource for review, audit,
reimbursement, and research.
 Documentation provides a written legal record to protect the
client, institution and practitioner.
 documentation is considered as an important criteria of an
profession.
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6.  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.
 The medical record serves as a legal document for recording
all client activities by health care practitioners.
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7.  Nurses rely on charting, records, and systems that
support the implementation of the nursing process.
 Systematic documentation is critical to presenting the
care administered by nurses in a logical fashion.
 Critical thinking skills, judgments, and evaluation must
be clearly communicated through proper documentation.
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8. Education
 Health care students use the medical record as a tool to learn
about disease processes, diagnoses, complications, and
interventions.
 Clinical rounds and case conferences rely heavily on
information contained in the medical record.
Research
 Researchers rely heavily on medical records as a source of
clinical data.
 Documentation can validate the need for research.

9. Legal and Practice Standards
In 80% to 85% of malpractice lawsuits
involving client care, the medical record is the
determining factor in providing proof of
significant events.
 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.
 Recording provide evidence of the care provided by the
nurses.

10.  Quality assurance
Documentation provide information about the care
provided during the time of audit.
 Statistics
Documentation provides information for formulation of
statistical report of the hospital.
Copyright 2004 by Delmar Learning, a division of Thomson
Learning, Inc. 16-10

11. Reimbursement(compensation)
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. Diagnosis-Related Groups (DRG)
 The medical record must provide documentation
that supports the DRG and appropriateness of care.
 If nurses fail to document the equipment or
procedures used daily, reimbursement to the facility
can be denied.

12.  Nursing notes must be logical, focused, and
relevant to care, and must represent each phase of
the nursing process.
 Nursing documentation based on the nursing
process facilitates effective care.
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13.  Use of Common Vocabulary
 Legibility
 Abbreviations and Symbols
 Organization
 Accuracy
 Documenting a Medication Error
 Confidentiality
 Timing
 Sequence
 completeness
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14.  Use of Common Vocabulary
Enhances the quality of documentation.
Supports the efforts of research.
 Improves communication and lessens the chance of
misunderstanding between members of the health
team.
 Legibility
Print if necessary.
Do not erase or obliterate writing.
Draw one line through an erroneous entry.
State the reason for the error.
Sign and date the correction.
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15. 16-15
Correcting a documentation error

16.  Abbreviations and Symbols
 Always refer to the facility’s approved listing.
 Avoid abbreviations that can be misunderstood.
 Organization
 Start every entry with the date and time.
 Chart in chronological order.
 Chart in a timely fashion to avoid omissions.
 Chart medications immediately after administration.
 Sign your name after each entry.
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17. 16-17
Charting a late entry

18.  Accuracy
 Use factual, descriptive terms to chart exactly what was
observed or done.
 Use correct spelling and grammar.
 Write complete sentences.
 Maintain continuity of care by recording with respect to notes
made on previous shifts.
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19.  Documenting a Medication Error
Chart the medication on the MAR.
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
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20.  Confidentiality
The nurse is responsible for protecting the
privacy and confidentiality of client
interactions, assessments, and care.
The client’s significant others, insurance
companies, or other parties not directly
involved in care provided by the health team
may not have access to clients’ records.
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21.  Timing
 The recording must be done on the particular time to
prevent error.
 Sequences
 The recording must be done in a continuous manner .
 Completeness
 The recording must be fully completed including the
sign.
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22.  Narrative Charting
 Source-Oriented Charting
 Problem-Oriented Charting
 PIE Charting
 Focus Charting
 Charting by Exception (CBE)
 Computerized Documentation
 Case Management with Critical Paths
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23.  Narrative Charting
 Describes the client’s status, interventions and treatments;
response to treatments is in story format.
 Narrative charting is now being replaced by other formats.
 Source-Oriented Charting
 Narrative recording by each member (source) of the health
care team on separate records.
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24.  Problem-Oriented Charting (POMR)
 Uses a structured, logical format called S.O.A.P.
 S: subjective data
 O: objective data
 A: assessment (conclusion stated in form of
nursing diagnoses or client problems)
 P: plan
 Uses flow sheets to record routine care.
 A discharge summary addresses each problem.
 SOAP entries are usually made at least every 24 hours
on any unresolved problem.
 SOAP was developed on a medical model.
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25.  SOAPIE and SOAPIER refer to formats that add:
 I: Intervention
 E: Evaluation
 R: Revision
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26.  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.
 PIE charting is a nursing model.
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27.  Focus Charting
 A method of identifying and organizing the narrative
documentation of all client concerns.
 Includes data, action, response.
 Uses a columnar format within the progress notes to
distinguish the entry from other recordings in the narrative
notes.
 Charting by Exception (CBE)
 The nurse documents only deviations from preestablished
norms.
 Avoids lengthy, repetitive notes.
 Enables the identification of trends in client status.
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28.  Computerized Documentation
 Increases the quality of documentation and save time.
 Increases legibility and accuracy.
 Enhances implementation of the nursing process. Enhances
the systematic approach to client care.
 Provides clear, decisive, and concise key words (standardized
nursing terminology).
 Provides access to other data, enhancing critical thinking.
 Information is quickly coordinated and integrated by other
departments.
 Facilitates statistical analysis of data.
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29.  Point-of-Care System
 A handheld portable computer is used for inputting and retrieving
client data at the bedside.
 Provides each health care practitioner with all pertinent client data
to ensure continuity of care without duplication.
 Provides crucial client information in a timely fashion.
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30.  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.
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31.  Kardex
 Flow Sheets
 Nurses’ Progress Notes
 Discharge Summary
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32.  The Kardex
 The Kardex is used as a reference throughout the
shift and during change-of-shift reports.
 Client data
 Medical diagnoses and nursing diagnoses
 Medical orders
 Activities
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33.  Forms for Recording Data
 Flow sheets reduce the redundancy of charting in the
nurses’ progress notes.
 The information on flow sheets can be formatted to meet
the specific needs of the client.
 Nurses’ progress notes are used to document the client’s
condition, problems and complaints, interventions,
responses, achievement of outcomes.
 Progress notes can be completely narrative or
incorporated into a standardized flow sheet.
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34.  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
 Trends in Documentation
 Standardized data bases are required to ensure accuracy and
precision in nursing information systems.
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35.  Verbal communication of data regarding the client’s health
status, needs, treatments, outcomes, and responses
 Summary of current critical information to facilitate clinical
decision making and continuity of client care
 Reporting is based on the nursing process, standards of care,
and legal and ethical principles.
 Reports require participation from everyone present.
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36.  Summary Reports
 Walking Rounds
 Telephone Reports and Orders
 Incident Reports
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37.  Commonly occur at change of shift (or when client
is transferred).
Assessment data
Primary medical and nursing diagnoses
Recent changes in condition,
adjustments in plan of care, and
progress toward expected outcomes
Client or family complaints
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38.  Walking Rounds
 Nursing, physician, interdisciplinary
 Occur in the client’s room and include the client
 Telephone Reports and Orders
 Report transfers, communicate referrals, obtain client
data, solve problems, 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.
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39.  Used to document any unusual occurrence or
accident in the delivery of client care.
 The incident report is not part of the medical
record, but it may be used later in litigation.
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40.  Trends in Charting
 Reduction in duplicate charting
 Bedside charting
 Multidisciplinary charting
 Clinical paths
 More uniformity in documentation
 Computerized documentation
 Fax machines
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41.  proper documentation will protect the nurse in
critical situation
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42.  THANK YOU
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