Lesson 3 Documentation & Reporting

Documentation

Written or electronic legal record of all pertinent interactions with patient including data related to assessing, diagnosing, planning, implementing, and evaluating

Documentation purposes

Facilitates quality evidence-based patient care, serves as financial and legal record, helps in clinical research, and supports decision analysis

Characteristics of effective documentation

Consistent with professional and agency standards, complete, accurate, concise, factual, organized and timely, legally prudent, and confidential

Elements of documentation

Include content, timing, format, accountability, and confidentiality

24-hour cycle clock

Military time system used for documenting times to eliminate AM/PM confusion and ensure accuracy

Confidential patient information

All information about patients including written, spoken, or computer-saved data such as name, address, phone, reason for illness, treatments, and past health conditions

Potential breaches in patient confidentiality

Include displaying information on public screens, sending confidential emails via public networks, sharing printers among units, discarding patient information in trash, holding overheard conversations, and faxing to unauthorized persons

Patient rights regarding health information

Right to see and copy health record, update health record, get list of disclosures, request restrictions on uses or disclosures, and choose how to receive health information

Verbal order policy

Must be given directly by physician or nurse practitioner to registered professional nurse or pharmacist, recorded with VO initials, read back to verify accuracy, dated and timed, and should be limited to urgent situations

Physician or NP review of verbal orders

Must review orders for accuracy, sign with name, title, and pager number, and date and note time orders signed

Computerized documentation (EHRs)

Electronic health records providing digital method for documenting patient care

Source-oriented records

Documentation organized by data source with progress notes and narrative notes

Problem-oriented medical records

Documentation system focusing on patient problems with SOAP note format

SOAP notes

Documentation format including Subjective data, Objective data, Assessment, and Plan

PIE charting

Documentation format addressing Problem, Intervention, and Evaluation

Focus charting

Documentation method organizing information around patient concerns or focus areas

Charting by exception

Documentation method recording only abnormal or significant findings, assuming normal findings unless otherwise noted

Initial nursing assessment

Comprehensive baseline evaluation documented at time of patient admission

Care plan and patient care summary

Documentation of nursing diagnoses, goals, interventions, and patient progress

Critical collaborative pathways

Standardized interdisciplinary plans outlining expected patient progression and outcomes

Progress notes

Ongoing documentation of patient status, interventions, and responses to treatment

Flow sheets and graphic records

Standardized forms for documenting routine assessments, vital signs, and repetitive data

Medication administration record

Documentation of all medications given including dose, route, time, and nurse signature

Acuity record

Documentation of patient care complexity and nursing resource requirements

Discharge and transfer summary

Documentation of patient status, teaching provided, and care requirements at time of discharge or transfer

Medicare requirements for home health care

Patient must be homebound needing skilled nursing care, have good rehabilitation potential or be dying, status not stabilized, and making progress in expected outcomes

Change of shift/hand-off report

Communication between nurses at shift change including patient identification, health status, current orders, abnormal occurrences, unfilled orders, and patient/family concerns

ISBARR hand-off communication

Structured format including Identity/Introduction, Situation, Background, Assessment, Recommendation, and Read back of orders/response

Telephone/telemedicine report guidelines

Identify yourself and patient, report concisely the condition change and actions taken, provide current vital signs, have patient record available, and document time, date, communication, and physician response

Transfer and discharge reports

Communication of patient status and care requirements when moving between units or leaving facility

Incident/variance reports

Documentation of unusual occurrences or deviations from standard care for quality improvement and risk management

Nursing care conferences

Interdisciplinary team meetings to discuss patient care planning and coordination

Nursing care rounds

Systematic patient visits by nursing staff to assess status and provide care

Purposeful rounding

Structured patient visits addressing specific needs at scheduled intervals

C-I-CARE with PRESENCE

Opening key words including Connect, Introduce, Communicate, Ask, Respond, and Exit with full presence throughout interaction

Connect

Greet patient warmly, make eye contact, and introduce yourself and your role

Introduce

Explain what you're going to do and why, setting expectations for the interaction

Communicate

Share information clearly, listen actively, and encourage questions and concerns

Ask

Invite patient input, ask about preferences, and assess understanding and needs

Respond

Address questions and concerns promptly, provide reassurance and support

Exit

Summarize interaction, confirm next steps, thank patient, and ensure comfort before leaving

PRESENCE

Being fully present, attentive, and focused on patient throughout entire interaction, demonstrating genuine caring through body language, tone, and undivided attention

Four Ps in nursing: Pain

Assess and manage patient's pain level regularly to ensure comfort and adequate analgesia

Four Ps in nursing: Potty

Address toileting needs and assist with bathroom use, bedpan, or urinal to prevent incontinence and falls

Four Ps in nursing: Position

Reposition patient regularly for comfort, pressure injury prevention, and optimal body alignment

Four Ps in nursing: Proximity

Ensure essential items are within reach including call light, water, tissues, and phone while maintaining safe organized environment

Environmental assessment during rounding

Evaluation of patient room safety, organization, and adequacy of supplies

"Is there anything else I can do for you?"

Key phrase asked during rounding while stating "I have time" to address additional needs

Documentation of purposeful rounding

Recording completion of scheduled rounds, tasks accomplished, and patient responses