1. Documentation of Nursing Care
Chapter 7
Documentation of Nursing Care

2. Chapter 7
Lesson 7.1

3. Learning Objectives Theory Clinical Practice
Identify three purposes of documentation
Correlate nursing process with the process of charting
Discuss maintaining confidentiality of medical records
Compare and contrast 5 main methods of written documentation
Clinical Practice
Correctly make entries on a daily care flow sheet

4. Purposes of Documentation
Provides a written record of the history, treatment, care, and response of the patient while under the care of a health care provider
Is a guide for reimbursement of costs of care
May serve as evidence of care in a court of law
Shows the use of the nursing process
Provides data for quality assurance studies
Each person who provides care for the patient adds written documentation to the medical chart.
Insurers rely on documentation to determine actual length of stay, procedures performed, and diagnoses established, and to calculate charges due for reimbursement.
Each supply item used and each piece of equipment in service must be documented.

5. Purposes of Documentation
Is a legal record that can be used as evidence of events that occurred or treatments given
Contains observations by the nurses about the patient’s condition, care, and treatment delivered
Shows progress toward expected outcomes
Charts are also used for research data collection.
Documentation, also called charting, is used to track the application of the nursing process.
Documentation is also used for supervisory purposes to determine how staff members are performing.
Why is accurate documentation important?

6. Documentation and the Nursing Process
Written nursing care plan or interdisciplinary care plan is framework for documentation
Charting organized by nursing diagnosis or problem
Implementation of each intervention documented on flow sheet or in nursing notes
Evaluation statements placed in nurse’s notes and indicate progress toward the stated expected outcomes and goals
Standard areas of assessment are usually noted on flow sheets, and a written note is added if an abnormality exists.
Evaluation data must be documented showing that expected outcomes have been achieved before a nursing diagnosis is marked "resolved" or deleted from the nursing care plan.
What should happen when expected outcomes are not being met?

7. The Medical Record Contains data about patient’s stay in a facility
Only health care professionals directly caring for the patient, or those involved in research or teaching, should have access to the chart
Patient information should not be discussed with anyone not directly involved in the patient’s care
Each type of health care facility has a particular set of forms used to record information about patient care.
The medical record is a legal record, and its contents must be kept confidential.
The medical record can only be given out with the patient’s written consent.
The chart is the property of the health facility or agency, not the patient or physician, but patients do have a right to information contained in the chart under certain circumstances.

8. Methods of Documentation (Charting)
Source-oriented (narrative) charting
Problem-oriented medical record (POMR) charting
Focus charting
Charting by exception
Computer-assisted charting
Case management system charting
Whatever the method used, the nurse is required to chart the patient’s progress periodically during the shift, as defined by the organization.
Chart entries are either in notes or on the various flow sheets, which track routine assessments, treatments, and frequently given care.

9. Source-Oriented or Narrative Charting
Organized according to source of information
Separate forms for nurses, physicians, dietitians, and other health care professionals to document assessment findings and plan the patient's care
Narrative charting requires documentation of patient care in chronologic order
Narrative notes are phrases and sentences written without any standardized structure, content, or form in chronologic order—similar to a set of journal entries.
Assessments usually follow a body systems format.

10. Source-Oriented or Narrative Charting
Advantages
Information in chronologic order
Documents patient’s baseline condition for each shift
Indicates aspects of all steps of the nursing process
Disadvantages
Documents all findings: makes it difficult to separate pertinent from irrelevant information
Requires extensive charting time by the staff
Discourages physicians and other health team members from reading all parts of the chart
Because source-oriented charting encourages documentation of both normal and abnormal findings, it can be difficult to separate pertinent from irrelevant information.
Source-oriented charting is time consuming.
Entries are lengthy, which discourages a thorough reading.

11. Example of source-oriented (narrative charting)

12. Problem-Oriented Medical Record Charting (POMR)
Focuses on patient status rather than on medical or nursing care
Five basic parts: database, problem list, plan, progress notes, and discharge summary
POMR charting emphasizes the problem-solving approach to patient care and provides a method for communicating what, when, and how things are to be done in order to meet the needs of the patient.
It focuses on what, when, and how things are to be done to meet the needs of the patient.
The SOAP, SOAPIE, or SOAPIER format is used for progress notes.
Who developed the POMR?

13. Problem-Oriented Medical Record Charting (POMR)
Advantages
Documents care by focusing on patients’ problems
Promotes problem-solving approach to care
Improves continuity of care and communication by keeping relevant data all in one place
Allows easy auditing of patient records in evaluating staff performance or quality of patient care
Requires constant evaluation and revision of care plan
Reinforces application of the nursing process

14. Problem-Oriented Medical Record Charting (POMR)
Disadvantages
Results in loss of chronologic charting
More difficult to track trends in patient status
Fragments data because more flow sheets required

15. PIE Charting P—problem identification I—interventions E—evaluation
Follows the nursing process and uses nursing diagnoses while placing the plan of care within the nurses’ progress notes
The problems, teaching, and discharge needs are listed under the P of the PIE format.
Interventions performed are documented under I.
The outcomes of the interventions are evaluated and documented under E .

16. Example of PIE (problem, intervention, evaluation) charting

17. Chapter 7
Lesson 7.2

18. Learning Objectives Theory
Compare and contrast the five main methods of written documentation
List legal guidelines for recording on medical records
Relate the approved way to correct entries in medical records that were made in error

19. Learning Objectives Clinical Practice
Use a systematic way of charting to ensure that all pertinent information has been included
Document the characterization of a sign or symptoms in a sample charting situation
Apply the general charting guidelines in the clinical setting

20. Focus Charting
Directed at nursing diagnosis, patient problem, concern, sign, symptom, or event
Three components:
D: data, A: action, R: response (DAR) OR
D: data, A: action, E: evaluation (DAE)
Focus charting is similar to the POMR system but it substitutes focus for the problem, eliminating the negative connotation attached to “problem.”
What is the difference in focus charting and the POMR system?

21. Focus Charting Advantages Disadvantages
Compatible with the use of the nursing process
Shortens charting time: many flow sheets, checklists
Not limited to patient problems or nursing diagnoses
Disadvantages
If database insufficient, patient problems missed
Doesn’t adhere to charting with the focus on nursing diagnoses and expected outcomes

22. Example of focus charting

23. Charting by Exception
Based on the assumption that all standards of practice are carried out and met with a normal or expected response unless otherwise documented
A longhand note is written only when the standardized statement on the form is not met
The standards and protocols are integrated into flow sheets and forms, and the nurse needs only to document abnormal findings or responses correlated with the nursing diagnoses listed on the nursing care.
Why could this type of charting present some problems with legalities?

24. Charting by Exception Advantages Disadvantages
Highlights abnormal data and patient trends
Decreases narrative charting time
Eliminates duplication of charting
Disadvantages
Requires detailed protocols and standards
Requires staff to use unfamiliar methods of record keeping and recording
Nurses so used to not charting that important data sometimes omitted
This type of charting may present some problems when a chart is called into court, because only the abnormalities are documented in writing.

25. Computer-Assisted Charting
Electronic health record (EHR)
Computerized record of patient's history and care across all facilities and admissions
Computerized provider order entry (CPOE)
Provides efficient work flow
Automatically routs orders to appropriate clinical areas
The EHR is the type of record that is a goal for the future for every patient.
Systems are under design and study to accomplish this goal.
Security and confidentiality of records are still a major concern.
What is the Systematized Nomenclature of Medicine Clinical Terms?

26. Computer-Assisted Charting
Documentation done as interventions are performed using bedside computers
Variations depending on the system
Some produce flow sheets with nursing interventions and expected outcomes
Others use a POMR format to produce a prioritized problem list
This method is very cost-effective in terms of nursing time, because information is entered from the patient’s room—so no time need be spent trying to recall important details.
Some systems allow clinicians to select data from display screens to build the flow sheets and progress notes.

27. Computer-Assisted Charting
Advantages
Date and time of the notation automatically recorded
Notes always legible and easy to read
Quick communication among departments about patient needs
Many providers have access to patient’s information at one time
Can reduce documentation time
Electronic records can be retrieved very quickly
Reimbursement for services rendered is faster and complete
Can provide a complete record of the patient's medical history
Can reduce errors

28. Computer-Assisted Charting
Disadvantages
Sophisticated security system needed to prevent unauthorized personnel from accessing records
Initial costs are considerable
Implementation can take a long time
Significant cost and time to train staff to use the system
Computer downtime can create problems of input, access, transfer of information

29. Case Management System Charting
A method of organizing patient care through an episode of illness so clinical outcomes are achieved within an expected time frame and at a predictable cost
A clinical pathway or interdisciplinary care plan takes the place of the nursing care plan
Where is documentation of variances placed?
Ask the students which method of charting seems most logical? Why?

30. Accuracy in Charting
Be specific and definite in using words or phrases that convey the meaning you wish expressed
Words that have ambiguous meanings and slang should not be used in charting
Specific data about size, amounts, and other measurements provide a means for determining whether the condition is getting better, getting worse, or staying the same.
What abbreviations, acronyms, and symbols are too dangerous to be used?

31. Brevity in Charting Sentences not necessary
Articles (a, an, the) may be omitted
The word “patient” omitted when subject of sentence
Abbreviations, acronyms, symbols acceptable to the agency used to save time and space
Choose which behaviors and observations are noteworthy
In most agencies, if data are recorded on a flow sheet, they need not be documented again in the nurse's notes.
A rule of thumb is that if the behavior or finding is abnormal or a change from previous behavior or data, chart about it.

32. Legibility and Completeness in Charting
If writing not legible, misperceptions can occur
Completeness is more important than brevity (see Boxes 7-1 through 7-3 for charting guidelines)
Record information about the patient’s needs and problems and specify nursing care given for those needs or problems
What constitutes complete charting may vary among hospitals, extended-care facilities, and other health care agencies.
What is particularly important to document in home care?

33. The Kardex Not a part of the permanent medical record
A quick reference for current information about the patient and ordered treatments
Usually consists of a folded card for each patient in a holder that can be quickly flipped from one patient to another
Hospitals that have instituted a completely computerized patient care system may not have this type of Kardex anymore.
How may the Kardex be used by a unit secretary?

34. Information on the Kardex
Room number, patient name, age, sex, admitting diagnosis, physician’s name
Date of surgery
Type of diet ordered
Scheduled tests or procedures
Level of activity permitted
Notations on tubes, machines, other equipment in use
Nursing orders for assistive or comfort measures
List of medications prescribed by name
IV fluids ordered
The Kardex can be a tool to use as a reference when giving a report on your patients.