Documentation
the act of making a written record
recording; charting
clear, comprehensive yet concise, complete, correct
Written, electronic, or both
By 2024, push to all electronic
Medical, now refer to as health record
20.6%
% of time spent by RN’s in the workday documenting & reviewing the e-health record
Documenting throughout ADPIE
Why Is Documentation Important?
- For education & research
- Enhance team communication
- Continuity of care
- Quality improvement (chart audits)
Why Is Documentation Important? cont’d
- Monitor patient outcomes over time
- Is a legal record
- Identify standards of care
- Helps with reimbursement & utilization review
Need For Standardized Language
- Make nursing visible
- Support nursing research
- Provides standardized terminology for use in EHR systems
- Helps in transition to electronic systems
NANDA-I
NIC & NOC
GE Healthcare Epic Meditech Siemens Healthcare Cerner
- Source-oriented vs problem-oriented record systems
- Charting by exception
- Expensive
- Frequent updates → downtime
- Lack of integration between units/departments
- Paper records (familiarity)
Document Using The Nursing Process
Assessment
- Chart signs and symptoms that may indicate actual or potential client problems. At initial, document comprehensive data about all client symptoms
Document Using The Nursing Process cont’d
Diagnosis
- After analyzing assessment data, document your clinical nursing judgment about the client’s response to actual or potential health conditions or needs
Document Using The Nursing Process cont’d
Planning Outcomes/Interventions
- Document measurable and achievable short and long-term plan of care with goals directed at preventing, minimizing, or resolving identified client problems/issues
Document Using The Nursing Process cont’d
Implementation
- After plan of care in effect, record specific interventions used
Document Using The Nursing Process cont’d
Evaluation
- Document client responses to nursing care; chart whether plan of care was effective in preventing, minimizing or resolving the identified problems; modify plan as needed
Formats For Nursing Progress Notes
?
Organizes info according to the client problems
Eliminates the need for a separate care plan
Does not enhance holistic care
Nursing-focused rather than medical-focused
Doesn’t document in planning portion of nursing process
Problem-Intervention-Evaluation (PIE)
?
Used with source-oriented and problem-oriented charting
Useful when trying to demonstrate a timeline of events (i.e. cardiac arrest)
Can result in lengthy notes
Clinicians may not read (focus on EHR)
Story of client’s experience in order it happens
Narrative
?
Only exceptions to norm or significant info
Is based on the charting by exception model
Fact documentation
?
View from client perspective
Concern can be nursing diagnosis, sign or symptoms, client behaviors, a special need, acute change in condition, or a significant event
Data-Action-Response (DAR)
Data [Assessment]
Action [Planning/Implementation]
Response [Evaluation]
Holistic
Lack of common problem list may lead to inconsistent labeling of the focus of notes; thus causes difficulty in tracking client progress
Focus charting
?
Subjective data, Objective data, Assessment (inferences/conclusions), Plan, Interventions, Evaluation, Revision
Can be inefficient and ineffective
Shifts focus from client to illness
Problem list, initial plan, progress notes, discharge summary
SOAP/SOAPIE/SOAP(IER)
Joint Commission’s List of “Do Not Use” Abbreviations
See W&T Volume II
Ch 18 p. 183 - Common Healthcare Abbreviations
Ch 26 p. 499 - Medical Abbreviations
Forms Used To Document Nursing Care
Nursing Admissions Data Forms
Discharge Summary
Flowsheets
Checklists
Intake and Output (I&O)
Medication Administration Records (MAR)
Medication Administration Records (MAR)
Ensure your documentation includes the following details…
- Scheduled, Unscheduled, Continuous Infusion, PRN, STAT, one time dose
- Injection type & site
- Assessments required before administration
- Drug allergies
- Delayed administration
- Omitted medications/patient refusal
Guidelines For Paper Charting
- Maintain confidentiality
- Ensure you have the correct forms before beginning to write
- Check that forms are clearly marked with client name and medical record number
- Write legibly and with black ink
Guidelines For Paper Charting cont’d
- Do not leave blank lines in narrative notes
- Draw a line through incorrect charting and initial it
- Sign all documentation with your first name, last name, and professional credentials
- Do not write shorthand or use your own abbreviations - approved abbreviations only
Guidelines For Electronic Documentation
- Ensure you are in the proper client record by verifying name and medical record number
- Complete and sign documentation as soon as possible
- If you make an error, you can change it - but note there is always a digital footprint of this
- If the system is not working, utilize paper records
Guidelines For Electronic Documentation cont’d
NEVER ACCESS CLIENT RECORDS THAT YOU HAVE NO PROFESSIONAL REASON TO VIEW
Never document care given by others
Document only what you did
Incident Reports
- Formal record of an unusual occurrence or accident
- Used to analyze the event and identify quality improvement areas to prevent future occurrence
Incident Reports cont’d
- Incident reports are not part of the client health record and should not be referenced in nursing notes or other sections of the health record
- Report all errors, including near misses, even if no adverse effect on the client
Events Requiring an Occurrence Report
- Patient fall or other injury
- Medication error
- Incorrect implementation of a prescribed treatment
- Needlestick injury or other injury to staff
- Loss of patient belongings
- Injury of a visitor
- Unsafe staffing situation
- Lack of availability of essential patient care supplies
- Inadequate response to emergency situation
Reporting
oral communication about a client’s status
handoff
Handoff Report Types
?
- Time-consuming
- Does not permit oncoming nurse to ask questions about the client
- Purpose is for outgoing nurse to continue to provide care while oncoming nurse receives report
- Updates may not be included
Audio-recorded report
?
- Outgoing and oncoming nurse(s)
- Encouraged to give at bedside, including the patient (bedside report)
- Can be given outside of client room, in conference rooms, etc.
- Most common
face-to-face oral report
