The document discusses guidelines for effective nursing documentation. It outlines content, timing, format, accountability, and confidentiality guidelines. It also discusses the purpose of client records for communication, planning care, auditing, research, education, reimbursement, and legal documentation. Finally, it describes different documentation systems like source-oriented records, problem-oriented records, nursing care plans, flow sheets, and computerized documentation.

1. DOCUMENTING and
REPORTING

2. Objectives:
At the end of the discussion, the learner will
be able to:
• List guidelines for effective documentation
• Discuss reasons for keeping clients record
• Explain how various forms in the client
record are used to documents steps of
nursing process
• Identify guidelines for effective recording
and reporting

3. Documenting Care
• Documentation is the written, legal
record of all pertinent interactions
with the patient.
• The Patient record is a compilation
of a patient’s health information

4. Guidelines for Effective Documentation
Content:
– enter information in a complete, accurate,
concise and factual manner
– Avoid generalizations such as “seems
comfortable today”
– Document in a legally prudent manner. Know and
adhere to professional standards
– Avoid the use of stereotypes or derogatory
terms when charting

5. Guidelines for Effective Documentation
Timing:
– chart in a timely manner
– Indicate in each entry the date and both
the time the entry was written and the
time of pertinent observations and
interventions
– Document nursing interventions as closely
as possible to the time of their execution
– Never document interventions before
carrying them out

6. Guidelines for Effective Documentation
Format:
– chart on the proper form as designated by
agency
– Print or write legibly in dark ink to ensure
permanence. Use correct grammar and
spelling. Use standard terminology.
– Chart nursing interventions chronologically
on consecutive lines. Never skip lines.
Draw a single line through blank spaces

7. Guidelines for Effective Documentation
Accountability:
– sign your first initial, last name and title to
each entry
– Do not use dittos, erasures or correcting fluid.
A single line should be drawn through an
incorrect entry and words
– “mistaken entry” or “error in charting” should
be printed above or beside the entry and
signed. The entry should then be rewritten
correctly
– Recognize that the patient’s record is
permanent

8. Guidelines for Effective Documentation
Confidentiality:
– observe patient’s moral and legal rights
– The student or graduate is bound by a
strict ethical code and legal
responsibility to hold all information in
confidence.
– Actual patient names and other
identifiers should not be used in written
or oral student reports

9. Ethical and Legal Consideration
• ANA code of ethics states:
– The nurse has a duty to maintain
confidentiality of all patient information
• The client’s record is protected legally as a
private record of the client’s care.

10. Ensuring Confidentiality of
computer records
• A personal password is required to enter and
sign off computer files.
• After logging on, never leave a computer
terminal unattended.
• Do not leave client information displayed on
the monitor where others may see it.
• Shred all unneeded computer-generated
worksheets.

11. • Follow the agency procedures for
documenting sensitive material, such
as diagnosis of AIDS.
• IT personnel must install firewall to
protect the server from authorized
access.

12. Purpose of clients
Records
– Communication
– Planning Client care
– Auditing Health Agencies
– Research
– Education
– Reimbursement Legal documentation
– Health Care Analysis

13. Definition of Terms
• Discussion
– An informal consideration of a subject by
two or more health care personnel to
identify a problem or establish strategies
to resolve a problem
• Report
– An oral, written or computer-based
communication intended to convey
information to others.

14. • Record
– A written or computer based.
– The process of making an entry on a
client record is called recording,
charting or documenting
• Clinical record or chart or client
record
– A formal, legal document that provides
evidence of a client’s care.

15. Methods of
Documentation

16. DOCUMENTATION
SYSTEMS
– Source- oriented Record
– Problem – Oriented Medical Record
– Problem Intervention Evaluation (PIE)
Model
– Focus Charting
– Charting by exception
– Computerized documentation
– Case Management

17. SOURCE ORIENTED RECORD
• One in which each healthcare group keeps
data on its own separate form
• Advantage: each discipline can easily find and
chart pertinent data
• Disadvantage: the data are fragmented
making it difficult to tract problems
chronologically with input from different
group of professionals

18. SOURCE ORIENTED RECORD
Progress notes written by nurses are
Narrative notes – it consist of written
notes that include the routine care, normal
findings and client’s problem

19. Problem-Oriented Medical Record (POMR)
• Also called as problem oriented
record (POR)
• Establish by Lawrence Weed in
1960’s
• The data are arranged according to
the problems the client has rather
than the source of information

20. Advantages of POMR
• It encourages collaboration
• Problem list in the front of the chart alerts
caregiver to the client’s needs and makes it
easier to track each status of the problem
• Progress notes clearly focus on patient’s
problem

21. Disadvantages of POMR
• Caregivers differ in their ability to use the
required charting format
• It takes constant vigilance to maintain an up-
to-date problem list
• It is somewhat inefficient because
assessments and interventions that apply to
more than one problem must be repeated

22. POMR 4 Basic Components
• Database – consist all information known
about the client when the client first enters
the health care agency.
• Includes nsg. Assessment , the physician’s
history , social and family data and family
data and result of the physical exam., and
baseline diagnostic test

23. POMR 4 Basic Components
• Problem List
– is derived form the data base
– It is usually kept in front of the chart and
serves as an index to the numbered entries
in the progress notes

24. • Plan of Care
– the initial list of orders or plan of care is
made with reference to the active
problems
– Care plans are generated by the person who
list the problems ex. Physician writes order or
medical care plans: nurses write nursing orders
of nursing care plan, the written plan is listed
under each problem in the progress notes

25. • Progress Notes
– is a chart entry made by all health
professional involves in a client’s care, they
all use the same type of sheet for notes
– Ex. SOAP format is frequently used,
SOAPIE, SOAPIER

26. SOAPIE or SOAPIER
• S- UBJECTIVE- What the clients says
• O-BJECTIVE – observation of nurse with the use of senses (
physical assessment, v/slab results, X-rays
• A- SSESSMENT– interpretation or conclusion drawn from S and O
data on initial assessment. Problem list is created from data base.
Statement of the problem
• P-LAN- care designed to resolve the problem, desired outcomes
criteria, Targets , SMART
• I- NTERVENTION – specific intertvention that actually performed
by the care giver. Includes treatment given
• E-VALUATION – responses to nursing intervention and medical
treatment
• R-EVISION – Reflect care plan modification suggested by the
evaluation. Changes may be made in desired outcomes.

27. PIE Model
• The plan of care is incorporated into
the progress notes in which problems
are identified by number
• 3 Categories:
– Problems
– Interventions
– Evaluation

28. PIE Model
• Advantage: it promotes continuity of
care
• Disadvantage: Nurses need to read all
the nursing notes to determine
problems and planned interventions
before initiating care

29. Focus charting
• Intended to make the client and the client
concerns and strengths the focus of care
• The focus maybe a condition, a nursing
diagnosis, a behavior, sign and symptom, an
acute change in client’s condition or a client’s
strength
• The progress notes are organized in: DAR
– D data
– A action
– R response

30. DATA is used alone when the purpose of the
note is to document assessment finding and
there is no flow sheet/ checklist for that
purpose.
D: “Mainit ang pakiramdam ko” Skin warm to
touch. Temperature is 39°C.
D – “Miss, masakit ang pinaglagyan ng IV ko.”
Check site of IV, found beginning signs of infiltration
D: “Sumasakit and dibdib ko”Midclavicular line; pain of
4/5 Radiating to jaw. Relieved by Rest. VS stable.

31. Begin the note with ACTION when the patient's
interaction beings with intervention or when including
data would be unnecessary repetition
A: Tepid sponge bath given. Encouraged toIncrease
fluid intake. Referred to (Dr. Tan. Paracetamol
500mg 1 tab. po given. May Aquino, RN
A: Patient instructed on the Actions and side effects
of Digoxin. Given digoxin information Card.
Discussion when He would call the physician About
the medicine. May Aquino , RN

32. A– Remove IV, change the whole system,
reinserted the new set aseptically into the
distal portion of basilic vein, left arm
anchored, splint applied, advised to call nurse
for any presence of pain . May Aquino, RN
A: Encourage to rest on bed. Medicated with
Isordil 5mgSL. May Aquino, RN

33. DATA and ACTION are recorded at
one hour, and RESPONSE is not
added until later, when the
patient outcome is evident.

34. RESPONSE is used alone to indicate a
care plan goal has been
accomplished.
R: “Pinagpawisan na ako.” Temperature is 38°C.
Tolerated 2 glasses of water . May Aquino, RN
R: Return demonstration of Radial pulse. “I understand
Purpose of medication.” May Aquino, RN
R: Resting in bed “Navawasan ang sakit ng dibdib ko.”
Rating of 2/5.
May Aquino, RN

35. Sample of FDAR
DATA/ TIME FOCUS DATA, ACTION, RESPONSE
3/2/17 Fever D: “Mainit ang pakiramdam ko” Skin warm to
7:00am touch. Temperature is 39°C.
A: Tepid sponge bath given. Encouraged to
Increase fluid intake. Referred to Dr. Tan.
Paracetamol 500mg 1 tab. po given. M.. Aquino, RN
8:00nn Fever R: “Pinagpawisan na ako.” Temperature is
38°C. Tolerated 2 glasses of water
A: Continue tepid sponge bath. Changed
Cloting. Will monitor temperative. M. Aquino, RN

36. ACTION AND RESPONSE
DATA/ TIME FOCUS DATA, ACTION, RESPONSE
3/2/17 Health A: Patient instructed on the
2:00 pm Teaching: Actions and side effects of
Digoxin Digoxin. Given digoxin information
Card. Discussion when
He would call the physician
About the medicine.
R: Return demonstration of
Radial pulse. “I understand
Purpose of medication.” M.
Aguino, RN.

37. DATA/ TIME FOCUS DATA, ACTION, RESPONSE
3/2/17 Chest pain D: “Sumasakit and dibdib ko”
10:00am Midclavicular line pain of 4/5
Radiating to jaw. Relieved by
Rest. VS stable.
A: Encourage to rest on bed.
Medicated with Isordil 5mg
SL. M. Aquino, RN
12nn Chest pain R: Resting in bed “Navawasan ang sakit ng
dibdib ko.” Rating of 2/5. M. Aquino, RN

38. Charting by Exception (CBE)
• Is a documentation system in which only
abnormal or significant findings or
exceptions to norms are recorded
• Example:
• Flow sheets- Vital signs graphic record,
I & O, Medication Sheet

39. Computerized Documentation
• Computerized clinical record system are
being developed as a way to manage the
huge volume of information required in
contemporary health care
• Nurse use computers to store the client’s
database, add new data, create & revise
care plans & document client progress

40. CASE MANAGEMENT
• Emphasizes quality, cost-effective care delivered
within the established length of stay.
• Uses multidisciplinary approach to planning and
documenting client care, using critical pathways
• These form identify the outcomes that certain
groups of clients are expected to achieve on each
day of care, along with the interventions
necessary for each day
• Incorporates graphics and flow sheet

41. • Progress notes typically use some
type of charting by exception
• Ex. If goals are met, no further
charting is required
• A goal that is not met is called
Variance

42. Documenting Nursing Activities
• Admission Nursing Assessment
• Nursing Care Plan
• Kardexes
• Flow Sheet
• Progress Notes
• Nursing Discharge/Referral
Summaries

43. Admission Nursing Assessment
• A comprehensive admission assessment
also referred to as an initial database,
nursing history or nursing assessment, is
completed when the client is admitted
to the nursing unit
• The nurse generally records ongoing
assessments or reassessments on flow
sheets or on progress notes.

44. Nursing Care Plans
2 types of NCP
1. Traditional care plan is written for
each client
– Varies from agency to agency according
to the needs of the client and the
department
– Most forms have 3 columns: nursing
diagnosis, expected outcomes, nursing
interventions

45. 2. Standardized Care Plan
– were develop to save documentation
time.
– Based on an institution’s standard of
practice, thereby helping to provide a
high quality of nursing care
– Individualized

46. Kardexes
• Concise method of organizing and
recording data about a client, making
information quickly accessible to all
health care professionals
• System consist of series of cards
kept in a portable index file or a
computer generated forms

47. DO’S OF DOCUMENTATION
1.DO read what other providers have written
before providing care and before charting your
care.
2.DO time and date all entries
3.DO write the time you put your pen on the
paper.

48. 4. Do record exactly what happens to
patient and care given.
5. DO be factual and complete
6. DO draw a single line through an
error. Mark this entry as “error” and sign
your initials

49. 7.DO use next available line to chart.
8.DO document patient’s current status and
response to medical care and treatments.
9.DO write legibly.
DO use ink.
Do use accepted chart forms.
10. Do use only approved abbreviations.

50. • Incident reports
– Also termed a variance or occurrence report
– Used to document the occurrence of anything
out of the ordinary that results in or has the
potential to result in harm to a patient,
employee or visitor
– These reports are for quality improvement and
should not be used for disciplinary action
against staff members

51. Thanks and God Bless
You!