Documentation Lecture PPT -E1

8/31/26 FOR EXAM 1

Legally

If it wasn’t documented, it wasn’t done.

Ethically

If it wasn’t done, don’t document it.

What is documentation?

Anything that is entered into a patient’s chart

“EHR” “Patient record” “Patient chart”

Identify the purpose of the patient record

-permanent, legal documentation - acute stay as well as Hx

-decreases errors (when done correctly)

-collaboration

-legal evidence

-evaluation of patient outcomes

Describe measures to maintain confidentiality of patient information

-maintaining privacy of written patient information

-paper charts

EHR: private login, traceable, do not leave patient info on screen, protect printed items, log off when done

Legal and ethical implications of nursing documentation

-concise

-facts, not opinionated, not vague

-accurate

-complete, demonstrates completion of Nursing Process

-current, includes time of event

-organized

-grammar/spelling

Charting Formats + Special Reports

1) Charting by Exception: EHR

2) Narrative

3) SOAP/SOAPE/SOAPIE

4) PIE

Charting by Exception: EHR

-document only if abnormal

-eliminates redundancy

-checkboxes - flowsheet form

-narrative notes used ONLY when there is an exception to the checkbox options

Narrative Charting

-story like format, but concise

-no extraneous words

-approved abbreviations

-can be used as a single way to document or to augment CBE/EHR documentation

When is narrative charting useful

to describe procedures and emergency situations when so much is happening at one time that documenting it in CBE format is not reasonable

SOAP/SOAPE/SOAPIE documentation format

Subjective, Objective, Assessment, Plan (Evaluation, Intervention")

PIE charting format

Problem, Intervention, Evaluation

Rules for handwritten documentation

-No erasing, no white out, no scratching out

-Black ink ONLY

-leave no blank line spaces between entries, put a LINE

-begin entry w/ date + time

-end with signature + title

-indicate late entires

Some facilities require documentation every (q) ? hours

2

What do I document?

-Assessment findings → subjective + objective

-Nursing actions → what did you do about it?

-Patients response to nurse actions → tolerance

-Additional plans/communication/follow up

-Evaluation of pt. progress

-Any changes in assessment findings

Types of Special Documentation

1) Routine shift scales

2) Against medical advice (AMA)

3) Restraint flowsheet

4) Incident / adverse event reporting

Routine Shift Scales (Special Documentation)

A form of documentation used to record patient assessments and vital signs at specific intervals during a nursing shift, ensuring consistent monitoring of patient status.

EX) Braden, Morse, GCS, etc.

AMA: Against Medical Advice (Special Documentation)

Documentation of a patient's decision to leave a healthcare facility or refuse treatment contrary to medical advice, acknowledging the risks involved.

-thorough documentation of measures taken, communication w/ pt and provider, patient education

Restraint Flowsheet (Special Documentation)

Documents in one place care delivered regarding restraints and the concerns that surround it

-Alternatives tried before restraints

-Reason for restraints

-Assessments

Assessments used for a Restraint Flowsheet

-type of restraint in place

-which extremities are restrained

-basic human needs are assessed q 2 hrs + prn

(toilet, drink, food, ROM, neurovascular checks)

Incident/Adverse Event Reporting (Special Documentation)

An event outside the normal routine of the unit occurs that could cause or does harm to a guest, pt., employee, etc.

*actual or potential (near miss) injury/harm

-error, fall, injury, accident

Completing an adverse/incident report accurately

-actual or potential (near miss)

-for facility quality improvement (QI) purposes

**completely separate from pt. chart

True or False: You should refer to an incident report in a patient’s chart after an incident occurred.

False! NEVER refer to an incident report in a patients chart

Your patients slips on water in the hall and falls. What do you do 1st, 2nd, 3rd?

1st: Check the patient's condition and provide assistance.
2nd: Report the incident to the appropriate personnel.
3rd: Complete an incident report following facility protocol.