Lesson 7 - Recording and Documentation

Discussion

Informal oral exchange to identify and resolve issues

Report

Oral, written, or digital communication to convey information

Record (Chart/Client Record)

Formal legal document providing evidence of care

Recording/Charting/Documenting

The process of entering data into client records

Restrict access

Ethical codes and legal responsibility

Policies and procedures to ensure privacy and confidentiality

Security for Computerized Records

Passwords required and should not be shared

Never leave the computer terminal unattended after logging on

Do not leave client information displayed

Shared all unneeded computer-generated worksheets

Know the facility’s policy and procedure for correcting an entry error

Follow agency procedures for documenting sensitive material

Firewalls

11 ways of Maintaining Confidentiality of Records

Communication

Planning client care

Auditing health agencies

Research

Education

Reimbursement

Legal documentation

Health care analysis

8 purposes of client record

Source-Oriented Record

Problem-oriented medical record

PIE Model (Problems, Interventions, Evaluation)

Focus Charting

Charting by Exception (CBE)

Computerized Documentation

Case Management

7 types of documentation systems

Source-Oriented Records

Traditional client record

Each discipline makes notations in a separate section

Information about a particular problem distributed throughout the record

Narrative charting used

Admission Sheet: Demographic, allergies

Initial Nursing Assessment: Nsg Hx and PE

Medical History and Physical Examination: PMHx FMHx, HPI

Physician’s Order Form: Medical orders for medications, treatments

Physician’s progress notes: Medical observations, treatments, client progress

Nurse’s notes; Pertinent assessment of client Specific nursing care including teaching and client’s responses

Medication record: Name, dosage, route, date of regularly administered medications

Name or initals of individual administering the medication

Special flow sheets VS Sheet: Fluid balance record, skin assessment

Diagnostic reports: Lab and Diagnostic reports

Consultation Records

Client discharge plan and referral summary

11 Components of the Source-Oriented Record

Narrative Charting

• A traditional form of documentation in source-oriented records of written notes that describe routine care, normal findings, and client problems

• There is no strict order, but entries are often recorded chronologically

• Although less common today, narrative charting is still used alongside modern systems like charting by exception or focus charting for describing abnormal findings

Problem-oriented Medical Records (POMR)

• Data arranged according to client problem

• Four Components of POMR:

  • Database

  • Problem List

  • Plan of Care

  • Progress Notes

• Health team contributes to the problem list, plan of care, and progress notes for each problem

• Database

• Problem List

• Plan of Care

• Progress Notes

Four Components of POMR

Subjective Data (S)

• Information obtained from what tje client says. In relation to the problem.

  “I feel lightheaded and nauseous.”

Objective Data (O)

• Measurable and observable information collected through assessment

• Includes vital signs, laboratory results, imaging findings, and physical exam results

• Example: BP 88/60 mmHg, HR 110 bgm, pale skin.

Assessment (A)

• Interpretation of subjective and objective data

• During the initial assessment, the problem list is created

• In subsequent notes, this section describes progress and condition

• Example: Hypotension secondary to dehydration

Plan (P)

• The care plan to address the identified problem

• Includes treatment, interventions, and follow-ups

• Example: Administer IV fluids, reassess BP in 30 minutes

SOAPIE

SOAP that adds Interventions and Evaluations

Interventions (I)

• Actions performed by the caregiver.

• Example: Administered *1L normal saline IV bolus.)

Evaluation (E)

• Client’s response to interventions

• Example: BP improved to 100/70 mmHg, dizziness resolved

SOAPIER

SOAPIE that adds Revision

Revision (R)

• Adjustments to the care plan based on evaluation

• Continue IV fluids at maintenance rate; monitor BP hourly.

AP(Assessment & Plan)

• Combines subjective and objective data into the assessment

APIE/APIER

• Includes interventions, evaluation, and revision but eliminates separate subjective/objective sections

PIE Documentation

• Groups information into 3 categories:

• Problem, Interventions, Evaluation

• Consists of client assessment, flow sheet, and progress notes

Flow Sheet Overview

• Uses specific assessment criteria (e.g., human needs, health patterns).

• Time intervals vary from minutes to months.

Problems (PIE documentation)

• Identified based on client assessment

• Often written using nursing diagnosis

• If no approved diagnosis exists, a problem statement is formulated with:

  1. Client’s response

  2. Probable causes

  3. Manifested characteristics

Interventions (PIE documentation)

• Actions taken by the nurse to address the problem.

• Recorded with a corresponding problem number

Evaluation (PIE documentation)

• Assesses effectiveness of interventions

• Determines whether modifications are needed

Focus Charting

• Focus on client concerns and strengths

• Holistic perspective of client and client’s needs

• Nursing process framework for the progress notes

• Uses three columns:

  1. Date/TIme

  2. Focus: The Focus can be a condition, nursing diagnosis, behavior, symptom, acute change, or client strength

  3. Progress notes:

Data

Action

Response

3 progress notes follow the DAR format:

Data (Focus Charting)

Observations of client status and behaviors (subjective & objective data, flow sheet info)

Action (Focus Charting)

Nursing interventions, planning, and any care plan adjustments

Response (Focus Charting)

Client’s reaction to nursing and medical care.

Charting by Exception (CBE)

• A documentation system in which only abnormal or significant findings or exceptions to norms are recorded

  • Saves time by reducing unnecessary documentation and highlighting significant client changes

  • May pose legal risks due to incomplete records, and some nurses feel uneasy about the “not charted, not done” concern

Flow Sheets

Standards of Nursing Care

Bedside Access to Chart Forms

Key Elements of CBE

Flow Sheets

Used to record vital signs, assessments, and risk evaluations in a structured format

Standards of Nursing Care

Routine care is documented by reference to pre-set standards, with only deviations fully described in nursing notes

Bedside Access to Chart Forms

Flow sheets are kept at the bedside for immediate recording, eliminating transcription delays.

Recorded

A documentation system in which only abnormal or significant findings or exception to norms are ___

• saves time by reducing unnecessary documentation and highlighting significant client changes

• May pose legal risks due to incomplete records, and some nurses feel uneasy about the “not charted, not done” concern.

Computerized Documentation

• EHR integrate all client information into one system

• Developed to manage volume of information

• Use of computers to store the client’s database, new data, crete and revise care plans and document client’s progress

• Information easily retrieved.

• Possible to transmit information from one care setting to another

Case Management Model

• Focuses on quality, cost-effective care within a set timeframe.

• Critical pathways outline expected outcomes and interventions for specific client groups.

• CBE is often used, requirinf documentation only when goals are unmet (variance)

• Variance refers to deviations from the expected care plan, requiring documentation of cause and action taken.

Uses of CBE

• Documentation of variance include:

  1. Actions taken to correct the situation

  2. Justify the actions taken

• Documenting the Nursing Process

Admission Nursing Assessment

A comprehensive assessment is conducted upon admission and documented based on health patterns, body systems, or healthcare settings, with updates recorded in flow sheets or progress notes.

Nursing Care Plans

Required by the Joint Commission, care plans can be traditional (individualized) or standardized (Institution-based but customizable) and must include assessments, interventions, and expected outcomes.

Kardexes

A quick-reference record for healthcare professionals that contains essential client information, including medications, treatments, and care needs, and may be temporary or permanent.

Kardex

Flow Sheets

Concise records that track various aspects of patient care, such as vital signs (graphic record), fluid balance (intake/output), medications (MAR), and skin integrity (assessment records)

Progress Notes

Used to document client status, interventions, and responses, following the institution’s preferred format.

Nursing Discharge & Referral Summaries

These summaries ensure continuity or care by documenting the client’s condition, ongoing needs, treatments, restrictions, support systems, and follow-up care in clear, understandable language.

Date and Time

• Essential for legal and clinical accuracy to track interventions and patient progress

• Must be documented with each entry using either

• 12-hour format (e.g., 0900, 1515) to avoid confusion

• Never pre-record entries before performing care

Timing

• Follow the healthcare facility’s documentation frequency policy

• Adjust documentation based on the patient’s condition (e.g., unstable vital signs require more frequent recording)

• Document immediately after providing care or making an assessment.

Legibility

Entries must be clear and readable to prevent misinterpretation

Permanence

• Use dark ink for written records to ensure clarity and prevent alterations

• Corrections in EHRs must follow the software’s tracking and correction policies

Accepted Terminology

• Use standardized medical abbreviations to prevent errors

• Avoid ambiguous abbreviations that may have multiple meanings.

Correct Spelling

• Spelling errors can lead to serious medical mistakes, especially with medication names (e.g., Fosamax vs. Flomax)

Signature and Identification

• Each entry must be signed with the nurse’s full name and credentials (e.g., “Jane Doe, RN”).

Accuracy

• The patient’s full name and ID must appear on each page of the medical record

• Verify the correct chart before making an entry

• Document only objective facts, avoiding assumptions or opinions.

Correcting Errors

• Do not erase, use correction fluids, or overwrite mistakes

• To correct a handwritten mistake:

• Draw a single line through the error

• Write “error” above it, initial, and date the correction

Sequence

• Record events in the order they occur (e.g., assessment → interventions → patient response).

Appropriateness

• Only document information relevant to patient care.

Conciseness

• Entries should be brief but complete to save time while maintaining clarity. Omit the patient’s name in each entry (it is assumd from the record).

Legal Prudence

Accurate and complete documentation protects the nurse, patient, and facility in legal cases.

Example of Proper Documentation in a Fall Incident:

1100 - Patient complained of dizziness. Raised side rails and instructed patient to stay in bed.

1130 - Found patient on the floor. Patient stated, “I climbed out of bed all by myself.” Assisted back to bed. BP 100/60, HR 90, RR 24

1135 - Physician Dr. Nadem notified. Signed: Rs Woo, RN

• Chart a change in a client’s condition and show that follow-up actions were taken

• Read the nurse’s notes prior to care to determine if there has been a change in the client’s condition

• Be timely. A late entry is better than no entry; however, the longer the period of time between actual care and charting, the greater the supicion

• Use objective, specific, and factual descriptions

• Correct charting erors.

• Chart all teaching

• Record the client’s actual words by putting quotes around the words

• Chart the client’s response to interventions

• Review your notes - are they clear and do they reflect what you want to say?

Do’s for Practice Guidelines: Documentation

• Leave a blank space for a colleague to chart later

• Chart in advance of the event (e.g., procedure, medication).

• Use vague terms (e.g., “appears to be comfortable,” “had a good night”).

• Chart for someone else

• Record “patient” or “client” because it is their chart

• Alter a record even if requested by a superior or a primary care provider.

• Record assumptions or words reflecting bias (e.g., “complainer,” “disagreeable”).

Don’t for Practice Guidelines: Documentation

Guidelines for Reporting Client Data

Reporting is essential in healthcare to ensure effective communication of patient information among healthcare professionals.

A well-structed report should be:

• Concise - Contain only relevant details.

• Accurate - Based on factual data and observations.

• Timely - Delivered promptyl to maintain continuity of care.

• Organized - Presented logically to facilitate understanding.

• Change-of-shift report

• Telephone reports

• Care plan conference

• Nursing rounds

types of reporting

Handoff Communication (Change-of-shift report)

• It is a process of sharing client care information

• A standardized approach is critical for client safety during transitions of care

• Healthcare institutions must define the elements of handoff communication to prevent adverse outcomes.

• Every hospital and healthcare system must implement a standardized approach to handoff communication

Handoff occurs at multiple levels in healthcare settings, such as:

• Nurse to nurse/ Nurse to physician/ Physician to physician/ Other healthcare providers

Change-of-Shift Report Process

• The report is given to all nurses on the next shift

• Face-to-face communication allows the incoming nurse to:

  • Ask questions

  • Gain confidence in client care

• Incoming and departing nurses establish care priorities for the next hours

• Reviewing checklists and medical records ensures a smooth transition

• Report content includes: Client problems and interventions for client care

Methods of Change-of-Shift Reporting

• Written

• Oral (face-to-face or audiotape recording)

• Face-to-face bedside reporting allows the oncoming nurse to:

  • Meet the client and family

  • Ask questions and address concerns

  • Involve the client in their care

A designated room

The nurses’ station

At the client’s bedside

Face-to-face reports can also occur in

• I PASS the BATON

• I-SBAR

• PACE

• Five-P’s

Standardized Handoff Communication Tools

I PASS the BATON

Introduction, Patient, Assessnent, Situation, Safety Concerns, Background, Actions, TIming, Ownership, Next

I-SBAR

Introduction, Situation, Background, Assessnebt, Recommendation

PACE

Patient/Problem, Assessment/Actions, Continuing (treatments)/Changes, Evaluation

Five-P’s

Patient, Plan, Purpose, Problem, Precautions, Physician (assigned to coordinate)

Key Elements for Effective Handoff Communication

The communication should include the following":

• Up-to-date information

• Interactive communication allowing for questions between the giver and receiver of client information

• Method for verifying the information (e.g., repeat-back, readback techniques)

• Minimal interruptions

• Opportunity for receiver of information to review relevant client data (e.g., previous care and treatment),

Guidelines for Change-of-Shift report

• Follow a particular order

• Provide basic identifying information

• For new clients provide the reason for admission or medical diagnosis/es, surgery, diagnostic tests and therapies in the past 24 hours

• Significant changes in client’s condition

• Provide exact information

• Report client’s need for emotional support

• Include current nurse and physical-prescribed orders

• Provide a summary of newly admitted clients, including diagnosis, age, general condition, plan of therapy, and significant information about the client’s support people

• Report on clients who have been transferred or discharged

• Clearly state priorities of care and care due after the shift begins

• Be concise

Telephone reports

Health professionals frequent;y report client information via telephone.

• Nurses inform primary care providers about changes in a client’s condition

• A radiologist may report x-ray results

• A nurse may report to another nurse regarding a transferred client

Guidelines for Receiving a Telephone Report

• Document date and time

• Record the name of person giving the information

• Record the subject of the information received

• Repeat information to ensure accuracy

• Sign the notation

• The individual receiving the information should repeat it back to the sender to ensure accuracy

Guideliens for Giving a Telephone Report

• Be concise and accurate

• When giving a telephone report to a primary care provider, it is important that the nurse to be concise and accurate. The SBAR communication tool is often used for telephone

• Have chart ready to give any further information needed

• Document the date, time. and content of the call

SBAR communication tool

Telephone and Verbal Orders

• Primary care providers may order therapy (e.g., medication) by telephone or verbally (face-to-face).

• Most agencies have specific policies regarding these orders

• Many agencies allow only registered nurses (RNs) to take these orders

• Many acute care hospitals require the provider to sign the order within 24 hours as per policy.

While receiving the order:

• Write the complete order on the physician’s order form.

• Read it back to the primary care provider to ensure accuracy

Clarify any ambiguous, unusual, or controindicated orders, such as:

• Abnormally high medication dosafes

• Orders that contradict the client’s condition

The primary care provider must verbally acknowledge the read-back of the order

Indicate on the physician’s order form it is a Telephone Order (TO) or Verbal Order (VO)

Care Plan Conference

• A meeting where nurses discuss solutions to a client’s problems, such as coping difficulties or lack of progress

• Other health professiona;s, like social workers or dietitians, may provide expertise

• Effective conferences require, nonjudgemental acceptance, and active lsitening

• Nurses visit clients bedised to gather information, allow client input, and evaluate care

• The assigned nurse gives a brief summary of the client’s needs and interventions

• Benefit include client participation and direct observation of the client and equipment

• Nurses should use simple language to ensure client understanding.