1. Documentation
PN 103

2. Purposes of Patient Records
Five Basic Purposes for Written Records
Written communication
Permanent record for accountability
Legal record of care
Teaching
Research and data collection

3. Purposes of Patient Records Purposes of Patient Records
Auditors
assess quality of care
Peer Review
appraisal by co-workers of equal status
Quality Assurance/Assessment/Improvement
audit in health care
evaluates services provided and the results achieved compared with accepted standards

4. Purposes of Patient Records Purposes of Patient Records
Diagnosis Related Groups (DRGs)
classifies patient by:
-age
-diagnosis
-surgical procedure
predicts the use of hospital resources
-length of stay
cost reimbursement rates for Medicare and Medicaid
and private insurance companies

6. Purposes of Patient Records
Nurse’s Notes
form on the patient’s chart
nurses record their observations, care given, and the patient’s responses
Institutions reimbursed by insurance companies or government programs only for the patient care documented

7. Purposes of Patient Records
Quality and accuracy
Spelling
Grammar
Punctuation
Good penmanship
Clear
Concise
Complete
Accurate.

8. Purposes of Patient Records
The nurse has primary responsibility for the initial admission nursing history, physical assessment, and development of the care plan based on the nursing diagnoses identified.

9. Charting Rules Basic Rules for Charting
All sheets should have the correct patient name, date, and time.
Approved abbreviations and medical terms.
Timely, specific, accurate, and complete.
Write legibly.
Follow rules of grammar and punctuation.
Fill all spaces; leave no empty lines
Chart consecutively, line by line
Do not indent left margin.
Chart after care is given, not before.

10. Charting Rules as soon and as often as possible.
your own care, observations, and teaching
- never chart for anyone else.
direct quotes when appropriate.
describe each item as you see it.
write only what you hear, see, feel, and smell.
Chart facts
-avoid judgmental terms and placing blame.

11. Charting Rules Sign each block of charting or entry
-full legal name and title.
What you observe, not opinions.
When the patient leaves a unit
-chart the time
-method of transportation on departure and return.
All ordered care as given
-or explain deviation.
Patient response to treatments
Response to analgesics/other medications.

12. Charting Rules Hard-pointed, permanent black ink pens
-no erasures or correcting fluids
If charting error is made
-draw one line through the faulty information
-mark error
-initial
-make the correct entry.
Note a late entry and then proceed with your notation.
Follow each institution’s policy and procedures

13. Charting Rules Avoid using generalized empty phrases
-“status unchanged”
-“ had a good day.”
If order is questioned, record that clarification was sought.

14. Common Medical Abbreviations and Terminology
A nurse needs some understanding and knowledge of common abbreviations and medical terms
Most facilities have a published list of generally accepted medical abbreviations and terms approved for use in charting.

15. Commonly Used Abbreviations
Abd Abdomen
ABO The main blood group system
ac Before meals
ad lib As desired
ADL Activities of daily living
Adm Admitted or admission
AM Morning
amb Ambulatory
amt Amount
approx Approximately
bid Twice daily
BM (bm) Bowel movement
BP Blood pressure
BRP Bathroom privileges
c– With
C Celsius (centigrade
CBC Complete blood count
c/o Complains of
DAT Diet as tolerated
Dc Discontinue
drsg Dressing
Dx Diagnosis
ECG (EKG) Electrocardiogram
F Fahrenheit
fld Fluid
GI Gastrointestinal
gtt Drop
h (hr) Hour
H2O Water
I&O Intake and output
IV Intravenous
(L) Left
LMP Last menstrual period

16. Commonly Used Abbreviations
MEDS Medications
mL Milliliter
mod Moderate
neg Negative
Ø None
# Number or pounds
NPO (NBM) Nothing by mouth
NS (N/S) Normal saline
O2 Oxygen
OD Right eye or overdose
OOB Out of bed
OS Left eye
p~ After
pc After meals
PE (PX) Physical examination
per By or through
PM Afternoon
po By mouth
postop Postoperatively
preop Preoperatively
prep Preparation
prn When necessary
qid Four times a day
(R) Right
s¯ Without
stat At once, immediately
tid Three times a day
TO Telephone order
TPR Temperature, pulse, respirations
VO Verbal order
VS Vital signs
WNL Within normal limits
WT Weight

17. Methods of Recording Traditional Chart
Divided into specific sections or blocks.
Specific sheets of information:
-admission sheet
-physician’s orders
-progress notes
-history and physical examination data
-nurse’s admission information
-care plan and nurse’s notes
-graphics
-laboratory and x-ray reports.

18. Methods of Recording Narrative charting Descriptive form
-basic patient need or problem data
-whether someone was contacted
-care and treatments provided
-patient’s response to treatment
Written in an abbreviated story form

20. Methods of Recording Problem-Oriented Medical Record
Scientific problem-solving system or method.
-database
-problem list
-care plan
-progress notes.

21. Methods of Recording Database Accumulated data
-history and physical examination
-diagnostic tests
Used to identify and prioritize the health problems on the master medical and other problem lists.

22. Methods of Recording Problem list
Active, inactive, potential, and resolved problems
-serve as the index for chart documentation.
A care plan with nursing diagnosis is developed for each problem by disciplines involved with the patient’s care.

23. Methods of Recording
SOAPIER is an acronym for seven different aspects of charting.
S – Subjective information
O – Objective information
A – Assessment
P – Plan
I – Intervention
E – Evaluation
R – Revision

25. Methods of Recording Focus Charting Format
Modified list of nursing diagnoses
-used as an index for nursing documentation.
Uses the nursing process
-positive concept of the patient’s needs rather than the
medical diagnoses and problems

26. Date/Hour
Focus
Progress Notes
5/20/201
08:00pm
Pain D:
Reports of sharp pain on the abdominal incision area with a pain scale of 8 out of 10
Facial grimacing
Guarding behavior
Restless and irritable A:
Administered Celecoxib 200mg IV
Encouraged deep breathing exercises and relaxation techniques
Kept patient comfortable and safe R:
Patient reports pain was relieved
The focus of this problem is pain. Notice the way how the D, A, and R are written.

27. Methods of Recording Data, Action and Response
Example: D – Facial grimacing, graded the pain as 7 in the scale of 1 to 10 with 10 as severe pain A – Given Oxycodone 5 mg po at 10:00. R – Rated pain as 2 and able to walk on her own

28. Basic Guidelines for Documentation
Charting by Exception
At the beginning of each shift pertinent data is charted
-physical assessments
-observations
-vital signs
-IV site and rate
During the shift
-additional treatments given or withheld
-changes in patient condition
-new concerns
Detailed flow sheets

30. Alternative Record-Keeping Forms
Variety of forms are used
-make medical record documentation
-easy
-quick
-comprehensive.
-eliminate the need to duplicate repeated data in
the nurse’s notes.
-unnecessary to chart a narrative
-medication
-bath
-vital signs

31. Methods of Recording Kardex/Rand Card system
-consolidates patient orders and care needs in a
centralized, concise way
Kept at the nursing station for quick reference

32. Methods of Recording Nursing Care Plan Preprinted guidelines
-patients with similar health problems
-meet the nursing needs of a patient
-based on nursing assessment and nursing diagnosis

34. Methods of Recording Incident Report
Any event not consistent with the routine care of a patient
-patient care was not consistent with facility or
national standards of expected care
Write:
-objective, observed information
-do not:
-admit liability
-give unnecessary details
-mention the incident report in the nurse’s notes

36. Methods of Recording
24-Hour Patient Care Records and Acuity Charting Forms
A system that accommodates a 24-hour period
-Consolidation of the nursing records
-Aids in the elimination of unnecessary record-keeping
forms
-More easily obtained with 24-hour notations:
-assessment information
-documentation of activities of daily living are

38. Methods of Recording Discharge Summary Forms
Patient's continued health after discharge.
-MD appointments
-equipment (oxygen, bath bench, etc.)
-Home Health follow-up
The summary should be concise and instructive.

40. Methods of Recording Clinical (Critical) Pathways
Managed care is a systematic approach
-a framework to target the coordination of medical
and nursing interventions
-staff from all disciplines
-develop integrated care plans
-projected length of stay for a specific case type
-pathways to monitor a patient’s progress and as a
documentation tool

41. PATHWAY: TOTAL HIP REPLACEMENT
DOS/Day 1
Respiratory Pain Management
Outcome:
• Verbalizes comfort or
tolerance of pain
Circle: V NV
Variance:
Key: V = Variance NV = No Variance
Signature: Initials:
• Verbalizes comfort with
pain control measures
Outcomes:
• Breath sounds clear to
auscultation
• Achieves 50% of volume
goal on incentive
spirometer
• Achieves 100% of volume
Days 2–3
Figure 15–8 ■ Excerpt from a critical pathway documentation form.

42. Home Health Care Documentation
Home health care reimbursement
-Medicare has specific guidelines for establishing
eligibility
50% of the nursing time is spent in documentation.
Documentation:
-quality control
-justification for reimbursement from Medicare,
Medicaid, or private insurance companies.
-unique problems
-need for different health providers to access the
medical record

43. Long-term Health Care Documentation
Omnibus Budget Reconciliation Act (OBRA) of 1987 regulated standards for:
-resident assessment
-individualized care plans
-qualifications for health care providers.
Each state’s Department of health for governs:
-frequency of written nursing records of residents in
long-term care facilities.
Long-term care documentation
-multidisciplinary approach (Nursing, Rehabilitation, Social Work,
Dietary, Activities)
-assessment
-planning process

44. Special Issues in Documentation
Record Ownership and Access
Original health care record/chart
-property of the institution or physician.
-patient usually does not have immediate access to
his/her full record.
Patients have gained access rights to their records in most states
-only if they follow the established policy of each facility.
A lawyer can gain access to a chart with the patient’s written permission.

45. Special Issues in Documentation
Confidentiality
Health care personnel
-respect the confidentiality of the patient’s record.
The Patient’s Bill of Rights and the law
-patient’s medical information will be kept private
-unless the information is needed in providing care
-patient gives permission for others to see it
The nurse:
-should not read a record unless there is a clinical reason
-hold the information regarding the patient in
confidence.