Fundamentals: Documentation

CHARTING

C - Communication

H - Health Reimbursement

A - Audit

R - Research

T - Teaching

I - Information Technology

N - Negligence and Malpractice Lawsuits

G - General purposes of the healthcare team

What are the purposes of the medical record?

Subjective Data

Nurses should document this data with direct quotes, within quotation marks, or summarize and identify the information as the client’s statement.

It should be supported by objective data so charting is as descriptive as possible.

Objective Data

It should be descriptive and should include what the nurse sees, hears, feels, and smells. Document without derogatory words, judgments, or opinions. Document the client’s behavior accurately. Instead of writing “client is agitated,” write “client pacing back and forth in the room, yelling loudly.

• Begin each entry with the date and time.

• Record entries legibly, in non-erasable black ink, and do not leave blank spaces in the nurses’ notes.

• Do not use correction fluid, erase, scratch out, or blacken out errors in the medical record. Make corrections promptly, following the facility’s procedure for error correction.

• Sign all documentation as the facility requires, generally with name and title.

• Documentation should reflect assessments, interventions, and evaluations, not personal opinions or criticism about client or other health care professionals’ care.

What are the legal guidelines of documentation?

Flow Charts

It show trends in vital signs, blood glucose levels, pain level, and other frequent assessments.

Source-oriented Record

It is a traditional client record. Each person or department makes notations in a separate section or sections of the client’s chart.

Narrative Documentation

Records information as a sequence of events in a story-like manner.

Charting by Exception

It uses standardized forms that identify norms and allows selective documentation of deviations from those norms.

Problem-oriented Medical Record

They are organized by problem or diagnosis and consist of a database, problem list, care plan, and progress notes. Examples include SOAP, PIE, and DAR or focus charting.

1. SOAP (subjective data, objective data, assessment, plan)

2. PIE (Problem, Intervention, Evaluation)

3. DAR (Data, Action, Response)

Examples of Problem-Oriented Medical Record

The Privacy Rule requires that nurses protect all written and verbal communication about clients. Components of the Privacy Rule include the following:

• Only health care team members directly responsible for a client’s care can access that client’s record. Nurses cannot share information with other clients or staff not caring for the client.

• Clients have a right to read and obtain a copy of their medical record.

• Nurses cannot photocopy any part of a medical record except for authorized exchange of documents between facilities and providers.

• Staff must keep medical records in a secure area to prevent inappropriate access to the information. They cannot use public display boards to list client names and diagnoses.

• Electronic records are password-protected. The public cannot view them. Staff must use only their own

What does the RA 10173 or Data Privacy Act said according to the nurses’ responsibility in confidentiality?

10-25 years

Medical records should be kept by the facility for how many years?

RA 4226 or the Hospital Licensure Act

What republic act requires facilities to keep medical records for a duration of time?