Documentation and recording communication with the healthcare team ensures quality of care and is required by regulatory agencies. It shows nursing actions, serves as a legal document, and involves summarizing activities, observations, and actions in an objective, non-judgmental manner through oral or written reports such as shift reports and reports to physicians. Various types of reports like change of shift reports, incident reports, and transfer reports must follow standards for documentation, including being legible, factual, complete, concise, timely, accurate, and organized according to guidelines in order to effectively communicate important patient information.

1. Documentation and RecordingCommunication with the Healthcare Team Subtitle

2. Document and ReportingEnsures quality of careRegulatory agencies require itMedicare reimbursement depends upon itShows nursing actionServes as a legal document

3. ReportingSummary of activities, observations, and actions performedObjective and non-judgmental

4. ReportsOral or writtenShift reportVerbal reports to physiciansMiscellaneousWritten lab reportsDietary reportsSocial workers notesPT, OT, Speech therapies

5. Types of ReportsChange of shiftOral, audiotape, roundsTelephoneTransferIncidentAny event not consistent with routine care of clientConcise, objectiveNot a part of the chartOral, audiotape, rounds

6. ConfidentialityLaw protects any information gained by exam, observation, conversation, or treatmentInformation not discussed or shared with anyone not directly involved in patient’s careNurses are legally and ethically obligated to keep patient information confidential

7. Medical RecordsPermanent written communicationsContinuing account of care statusDiscussion, discharge planning, conferences, consultationsAll caregivers can benefit from information and plan accordingly

8. Purpose of RecordsCommunicationFinancial billingEducationAssessmentResearchAuditing and monitoringLegal documentation

9. DocumentationAnything written or printed that is relied upon as a record of proof for authorized persons

10. Standards for DocumentationFederal regulations-Medicare and MedicaidState and Federal regulations – JCAHOProfessional standards – ANAFacility policies- charting techniques and responsibilities

11. LegibilityAll charting should be easy to readReduces errorsMay be used in court years after care given

12. FactualDescriptive, objective informationDecreases misinterpretationDo not use “seems”, “appears”, “apparently”, “good” “well”Subjective information is documented with client’s own words in quotationsNo opinions

13. Complete and ConciseThorough, exact, brief, and NO blah, blah, blah blahClear and succinctEliminate irrelevanceShort and to the point (long notes difficult to read)Too abbreviated gives impression of being hurried and incomplete

14. TimelinessDelay in reporting can result in serious omissions and delays in careLate entries may be interpreted as negligenceCertain things must be reported at time of occurrenceRoutine activities need not be charted immediately Military time usedNo leaving until important information recordedAvoids errors and duplication of care

15. AccurateReliable and preciseExact measurements when possibleUse only accepted abbreviationsSpell correctly

16. More accuracyNo charting for someone elseStudent’s notes are countersigned by person who assured care was givenDescriptive entries signed with full name and status (first initial, last name, and title)

17. Guidelines for Documentation and ReportingCertain abbreviations not acceptableAbbreviations used

18. OrganizationLogical format and orderChronological flow of events

19. Chart ComponentsData baseAssessment dataProblems listCare planProgress notesNarrativeFlow sheetsDischarge planning summaries

20. Documentation MethodsProblem oriented medical recordS.O.A.P. or S.O.A.P.I.RP.I.E.Source recordsCharting by exceptionFlow sheetsFocused chartingD.A.R.

21. Problem Oriented Medical RecordFocus on patient’s problemsFollows the nursing processOrganized by problems or diagnosesCoordinated care

22. Advantages of POMREasy to retrieve information and follow progressEasy to monitor for QA purposesSOAP notes establish structure that reflects what nurses do

23. PIE ChartingPIEDaily assessment data appears on flow sheetsContinuing problems documented dailyFocuses exclusively on single client problem

24. Source RecordsEach discipline has a separate section of the chart for recordingCan easily locate proper sectionExamples: admission sheet, physician's order sheet, history and physical, flow sheets, nurses notes, medication record

25. Charting by exceptionReduces repetitionClearly defined standards of practice and predetermined criteriaNurses documents only significant findings or exceptionsPreventive and wellness-focused functions not documented

26. Focus Charting - DAREasily understood and adaptable to most settingsReflects analysis and conclusionsDoes not indicate problem assessment

27. Standardized Care PlansPre-printed and established guidelines for clients with similar problemsImproved continuityLess time to documentInhibits unique or individualized therapies

28. Writing the Nursing Care PlanPrioritize problemsABC’sMaslowProblems perceived by patient

29. Formats5 columnsAssessment data or defining characteristicsDiagnosisGoals/outcomesInterventionsEvaluationConcept MapSame five components linked by rationalesBetter indicates process of critical thinking

30. Critical PathwaysDocumentation tool to integrate standards of care for multiple disciplinesList problems, key interventions, expected outcomes, expected timelinesAttempt to control and decrease length of stay

31. Discharge SummariesMultidisciplinary involvement is required by HCFAClient leaves hospital in timely manner with the necessary resourcesClient signs original for chart and takes copy home

32. KardexInformationMedicationIV’sTreatmentsDiagnostic proceduresAllergiesData Problem list

33. Computer DocumentationSaves time in storage and retrievalInformation is permanentVarious departments can coordinate informationCan be used at the bedside

34. Protocol ChartingNewest methodPrimary use in outpatient careWritten for use as a references or guide for careIndividualized, current, according to intended purpose