WEEK 9: DOCUMENTATION

Documentation

Involve all written and electronic entries reflecting all aspects of patient care communicated, planned, recommended or given to that patient 

Guidelines for Good Documentation

Factual, Accurate, Current, Organized, Complete

Documentation

Involve all written and electronic entries reflecting all aspects of patient care communicated, planned, recommended or given to that patient 

Guidelines for Good Documentation

Factual, Accurate, Current, Organized, Complete

Methods of Documentation

Narrative charting, Source oriented charting, Problem oriented charting, PIE charting, Focus charting, Charting by exception, Computerized documentation

Narrative Charting

Describe the client status, intervention, treatments and response to treatments in story like format

Sources Oriented Charting

Narrative recording by each member of health care team on separate records

Problem Oriented Charting

Uses structured logical format called SOAP (Subjective, Objective, assessment, Plan)

Pie Chart

Problem, Implementation, Evaluation 

Focused Charting

Method of identifying and organizing the narrative documentation of all client concerns. Uses columnar format within the progress notes progress notes are organized into Data, Action and Response

Computerized Documentation

• Increase quality of documentation and save time

• Increase legibility and accuracy

• Facilitate statistical analysis of data

Document Forms

Kardex, Flow sheets, Nurse's progress notes, Discharge summary

Kardex

Is a concise method of organizing and recording data about a client, making information quickly accessible to all health professionals. It contains-Client information, list of medical diagnosis on priority, allergies, list of daily treatments, procedures and measurement of vital signs, procedure order such as X-ray and lab tests.

Flow Sheets

A simple form that gathers all important data regarding a patient's condition includes graphic records, medication administration records, etc.

Nurses Progress Notes

Is the notes made by nurses provided information about the progress a client is making towards achieving desired outcome.

Discharge Summary

Is completed when the patient is being discharged and referred to home. It includes client instructions about medication, diet, food-drug interaction, etc.

Significance of Documentation

Patient Safety, Legal and Ethical Considerations, Quality of Care

Patient Safety

• Accurate documentation as a means to prevent errors and ensure continuity of care (Bastable, 2023).

• Case examples where poor documentation led to negative patient outcomes.

Patient Safety

A nurse must document a patient’s allergy to a specific medication. If this information is omitted, the patient might be inadvertently given that medication, leading to a severe allergic reaction. Accurate records help prevent such incidents.

Legal and Ethical Considerations

• Nursing documentation as a legal record

• Ethical responsibilities associated with maintaining confidentiality and integrity of documentation.

Legal and Ethical Considerations

A nurse fails to document a patient’s fall. In a lawsuit, the lack of documentation can lead to questions about the nurse's accountability. Proper documentation is essential to demonstrate the care and actions taken. 

Quality of Care

• Importance of thorough documentation in evaluating the quality of care and outcomes.

• Reference to health promotion strategies and their documentation 

Quality of Care

A review of patient charts shows that detailed post-operative care documentation helps identify trends, such as delayed recovery due to insufficient pain management. These insights can improve protocols and enhance overall patient outcomes.

Key Components of Effective Documentation

Clarity and Conciseness, Timeliness, Completeness and Accuracy, Subjective and Objective Data, Description of Care

Clarity and Conciseness

• Writing in a clear, objective manner. 

• Avoiding jargon and ensuring accessibility for all healthcare team members

Clarity and Conciseness

Instead of saying, “The patient looks bad,” a nurse should document, “The patient appears pale, diaphoretic, and reports 8/10 pain in the left chest area.” This provides clear and specific information. 

Timeliness

• Documenting care in real-time or as soon as possible. 

• Impact of delays on patient care and memory recall.

Timeliness

A nurse captures medication administration in the electronic health record (EHR) immediately after giving it, ensuring that the information is current and that other healthcare members can provide appropriate care based on the latest data.

Completeness and Accuracy

• Fully detailing assessments, interventions, and evaluations.

• Utilizing standardized nursing terminologies and abbreviations appropriately.

Completeness and Accuracy

When transferring a patient to a different unit, the nurse includes all necessary information such as allergies, current medications, and recent lab results. This comprehensive transfer report reduces the likelihood of miscommunication.

Subjective and Objective Data

Importance of both types of data in providing a comprehensive view of patient health.

Subjective and Objective Data

The nurse documents the patient’s report of pain level (subjective) alongside vital signs and lab results (objective) to provide a comprehensive view of the patient’s condition. This combination supports clinical decision-making.

Description of Care

How to document patient education effectively, including patient understanding and follow-up.

Description of Care

After providing education to a diabetic patient about managing their blood sugar levels, the nurse documents, “The patient verbalized understanding of the importance of carbohydrate counting and was able to demonstrate the use of the glucose meter, with a follow-up appointment scheduled in one week.” 

Legal and Ethical Considerations

Understanding Legal Implications and Ethical Practices

Understanding Legal Implications

• Legal standards that govern documentation 

• Consequences of incomplete or inaccurate documentation.

Understanding Legal Implications

 A hospital is sued for malpractice due to mismanaged care. The court reviews the nursing documentation, which highlights the nurse’s adherence to protocols and standards, ultimately demonstrating due diligence and legal protection for the nurse

Ethical Practices

• The obligation to maintain patient privacy and confidentiality.

• Reporting and documenting adverse events or near misses transparently.

Ethical Practices

A nurse discovers a coworker has made unauthorized alterations to patient records. The ethical response requires the nurse to document the discrepancy (without tampering with the original records) and report the incident per facility protocol, ensuring accountability.

Teaching and Learning Principles applied to Documentation Skills

Adult Learning Theories and Simulation and Role-Playing

Adult Learning Theories

• Incorporating principles from Bastable (2023) on how adults learn best. 

• Engaging students in active learning strategies that reinforce documentation practices.

Adult Learning Theories

When teaching documentation skills, a facilitator can encourage nursing students to discuss their prior experiences with documentation, creating a learner-centered environment where students share and learn from each other. 

Simulation and Role-Playing

• Techniques for practicing documentation through simulations or role-playing scenarios.

• Encouraging peer feedback and reflection on documentation practices.

Simulation and Role-Playing

Organize a simulation where students must document a patient’s care during a mock shift. Afterward, students review each other's documentation for clarity and completeness, fostering peer-to-peer critique and learning. 

Importance of Documentation

Communication, Legal Compliance, and Quality Improvement

Communication

Documentation acts as a vital tool for interdisciplinary communication, ensuring all healthcare providers are informed about patient care plans and progress.

Communication

During a shift change, a nurse documents a patient’s vital signs, medication administration, and symptoms of pain. This ensures the incoming nurse can seamlessly continue care without missing critical information

Legal Compliance

Accurate records provide legal protection for nurses and institutions, demonstrating adherence to professional standards.

Legal Compliance

A nurse documents a patient’s refusal of treatment, including the reason and the actions taken to address their concerns. This protects the nurse legally if the patient’s condition worsens. 

Quality Improvement

Well-maintained documentation supports evidence-based practice and improves patient outcomes

Quality Improvement

Analysis of nursing notes reveals that patients with pressure ulcers received inconsistent repositioning. This leads to policy changes to improve care. 

Principles of Effective Documentation

Accuracy, Completeness, Timeliness, Confidentiality 

Accuracy

Ensure all entries are factual, specific, and free from bias.

Accuracy

A nurse records exact details of a wound assessment, including size, depth, and color, avoiding subjective terms like “severe” or “minor”.

Completeness

Include all relevant details about assessments, interventions, and patient responses. 

Completeness

A discharge summary includes all relevant details such as medications prescribed, follow-up appointments, and patient education provided

Timeliness

Document promptly to maintain reliability and avoid errors. 

Timeliness

After giving medication to the patient, the nurse immediately documented and signed what she administered.

Confidentiality

Adhere to ethical standards by protecting patient privacy. 

Confidentiality

A nurse ensures that electronic health records are accessed only by authorized personnel and avoids discussing patient details in public areas. 

Barriers to Effective Documentation

Time Constraints, Lack of Training, Technological Challenges, Environmental Factors

Time Constraints

Nurses often face limited time due to high workloads.

Time Constraints

A busy emergency department nurse struggles to document every detail due to high patient volume. 

Lack of Training

Inadequate education on proper documentation techniques can lead to errors.

Lack of Training

Nurse struggles to navigate the hospital software, leading to incomplete and inaccurate documentation of a patient's medication administration. 

Technology Challenges

Difficulty adapting to electronic health record systems. 

Technology Challenges

nurse unfamiliar with an electronic health record system makes errors in charting. 

Environmental Factors

Negative workplace environments may hinder accurate record-keeping

Environmental Factors

Prolonged exposure to such a stressful environment has led the nurse to experience burnout, further reducing her attention to documentation accuracy. 

Strategies for Overcoming Barriers

Education and Training, Time Management, Technology Support, Team Collaboration

Education and Training

Incorporate documentation skills into nursing curricula using case studies and simulations. 

Education and Training

Nursing students practice documentation using simulated scenarios to build confidence in recording accurate and detailed notes.

Time Management

Develop efficient workflows that integrate documentation into daily routines.

Time Management

At the start of her shift, the nurse reviews her patients’ charts and creates a prioritized to-do list. She allocates specific time blocks for documentation after completing rounds for each patient. 

Technology Support

Provide training on electronic health record systems.

Technology Support

A hospital provides training on new electronic health record systems and offers IT support during implementation.

Team Collaboration

Foster a supportive environment that values accurate record-keeping

Team Collaboration

At the end of her shift, the primary nurse consolidates all documentation and verbally updates the incoming nurse during handoff. She highlights key points from her notes, such as pain levels and any adverse reactions to medications.