1. Documentation and Reporting
Chapter 16
Documentation and Reporting

2. 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.
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3. Documentation as Communication
The medical record serves as a legal document for recording all client activities by health care practitioners.
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4. Documentation as Communication
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
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5. Documentation as Communication
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.
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6. Documentation as Communication
Critical thinking skills, judgments, and evaluation must be clearly communicated through proper documentation.
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7. Purposes of Health Care Documentation
Professional Responsibility and Accountability
Communication
Education
Research
Legal and Practice Standards
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8. Purposes of Health Care Documentation
Recording provides written evidence of what was done for the client, the client’s response, and any revisions made in the care plan.
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9. Purposes of Health Care Documentation
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.
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10. Purposes of Health Care Documentation
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.
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11. Purposes of Health Care Documentation
Research
Researchers rely heavily on medical records as a source of clinical data.
Documentation can validate the need for research.
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12. Purposes of Health Care Documentation
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.
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13. Legal and Practice Standards
Informed Consent
Advance Directives
American Nurses Association (ANA) Standards of Care
State Nurse Practice Acts
Joint Commission on Accreditation of Health Care Organizations (JCAHO)
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14. Legal and Practice Standards
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.
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15. Legal and Practice Standards
An advance directive allows the client to participate in end-of-life decisions.
The Patient Self-Determination Act of 1990 requires health care facilities to document whether the client has such a directive.
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16. Legal and Practice Standards
American Nurses Association Standards of Care make explicit the role of data collection and documentation in nursing practice.
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17. Legal and Practice Standards
State Nurse Practice Acts have established guidelines to ensure safe practice.
Require evidence of compliance through documentation.
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18. Legal and Practice Standards
The Joint Commission on Accreditation of Health Care Organizations (JCAHO) requires documentation of compliance with its standards of care requirements.
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19. Purposes of Health Care Documentation
Reimbursement
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.
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20. Purposes of Health Care Documentation
Reimbursement
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.
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21. Purposes of Health Care Documentation
Reimbursement
Consolidated Omnibus Budget (COBRA) Reconciliation Act
Any COBRA client receiving care in an emergency room must be stabilized before being transferred to another facility.
Facilities in violation of COBRA laws are fined and may lose their eligibility for Medicare and Medicaid funding.
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22. Principles of Effective Documentation
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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23. Elements of Effective Documentation
Use of Common Vocabulary
Legibility
Abbreviations and Symbols
Organization
Accuracy
Documenting a Medication Error
Confidentiality
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24. Elements of Effective Documentation
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.
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25. Elements of Effective Documentation
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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26. Elements of Effective Documentation
Correcting a documentation error
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27. Elements of Effective Documentation
Abbreviations and Symbols
Always refer to the facility’s approved listing.
Avoid abbreviations that can be misunderstood.
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28. Elements of Effective Documentation
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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29. Elements of Effective Documentation
Charting a late entry
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30. Elements of Effective Documentation
Charting a prn medication
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31. Elements of Effective Documentation
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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32. Elements of Effective Documentation
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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33. Elements of Effective Documentation
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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34. Methods of Documentation
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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35. Methods of Documentation
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.
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36. Methods of Documentation
Source-Oriented Charting
Narrative recording by each member (source) of the health care team on separate records.
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37. Methods of Documentation
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
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38. Problem-Oriented Charting (POMR)
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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39. Problem-Oriented Charting (POMR)
SOAPIE and SOAPIER refer to formats that add:
I: Intervention
E: Evaluation
R: Revision
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40. Problem-Oriented Charting (POMR)
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41. Methods of Documentation
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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42. Methods of Documentation
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43. Methods of Documentation
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.
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44. Methods of Documentation
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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45. Methods of Documentation
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).
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46. Methods of Documentation
Computerized Documentation
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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47. Methods of Documentation
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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48. Methods of Documentation
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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49. Forms for Recording Data
Kardex
Flow Sheets
Nurses’ Progress Notes
Discharge Summary
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50. Forms for Recording Data
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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51. 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.
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52. Forms for Recording Data
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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53. Forms for Recording Data
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
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54. Trends in Documentation
Standardized data bases are required to ensure accuracy and precision in nursing information systems.
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55. Trends in Documentation
Nursing Minimum Data Set (NMDS)
Nursing Diagnoses (Taxonomy II)
Nursing Intervention Classification (NIC)
Nursing Outcomes Classification (NOC)
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56. Reporting
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
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57. Reporting
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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58. Reporting Summary Reports Walking Rounds Telephone Reports and Orders
Incident Reports
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59. Summary Reports
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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60. Walking Rounds Nursing, physician, interdisciplinary
Occur in the client’s room and include the client
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61. 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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62. Documenting a Telephone Order
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63. Incident Reports
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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