Documentation/SBAR

Documentation

Written or printed material that becomes part of the client's permanent medical record; it must be accurate, comprehensive, and communicate data clearly.

Purpose of documentation

Communicates with the health care team, fulfills legal and accreditation requirements, supports reimbursement, and allows research and continuity of care.

Patient medical record

Confidential, permanent, legal documentation containing demographics, consents, history, progress notes, orders, diagnostics, and discharge information.

Electronic Health Record (EHR)

Longitudinal electronic record of patient health information generated by encounters across settings; improves safety and communication.

Advantages of EHR

Improves patient safety, streamlines workflow, generates complete encounter records, and supports quality management and evidence-based decisions.

Clinical Information Systems (CIS)

Electronic systems for entering, storing, and monitoring clinical data such as orders, labs, radiology, and vital signs.

Nurse responsibility with CIS

Review and approve automatically imported data to ensure accuracy and accountability.

HIPAA

Health Insurance Portability and Accountability Act of 1996; protects patient privacy and regulates electronic data use.

Confidentiality

Nurses are ethically and legally obligated to keep patient information private and share only with authorized team members.

Authentication

Process verifying that the person accessing patient data is authorized to do so.

Authorization

Level of access granted based on role and patient care need.

Audit

Review of who has accessed patient data to ensure compliance with privacy policies.

Hand-off reports

Oral, written, or electronic transfer of information to another care provider (e.g., shift change, transfers, or physician reports).

SBARR communication

Situation, Background, Assessment, Recommendation, Read Back; ensures concise, factual communication among providers.

Consultation

Formal advice from one health-care professional (often a specialist) to another about patient care.

Referral

Arrangement for services by another provider or specialist; may require insurance approval.

Factual documentation

Objective data of what you see, hear, smell, and feel, plus quoted patient statements for subjective data.

Accurate documentation

Use exact measurements, approved abbreviations, and avoid irrelevant details.

Complete documentation

Includes all essential information about assessment, interventions, and responses.

Concise documentation

Clear, brief, and easy to understand.

Current documentation

Document events as soon as possible after they occur and note the exact time.

Organized documentation

Logical order such as assessment, intervention, and patient response.

Signature requirements

Each entry must be signed with date, time, and credentials; EHRs often apply automatically.

Paper charting rules

Use black ink, write legibly, no blanks, correct errors with one line and initials, never erase or use white-out.

Safety in documentation

Incomplete or inaccurate charting can delay or lead to inappropriate care; standardize abbreviations and symbols.

Follow-up documentation

If a problem is charted, document interventions, reassessment, and outcomes (e.g., vital signs after giving medication).

Source-oriented record

Chart organized by discipline (nursing, social work, respiratory therapy).

Problem-oriented medical record (POMR)

Chart organized by patient problems; includes database, problem list, care plan, and progress notes.

Charting by exception (CBE)

Only abnormal findings or deviations are documented; normals defined by institution.

Narrative charting

Story-like format describing events in chronological order; useful in emergencies.

Telephone orders

Orders given by a provider over the phone; must be entered and co-signed promptly.

Verbal orders

Orders given face-to-face in urgent situations; discouraged except when necessary.

Incident or adverse event

Unexpected occurrence such as falls or errors; documented objectively but report kept separate from medical record.

Progress notes

Document patient progress; may follow SOAP, SOAPIE, or PIE formats.

SOAP format

Subjective, Objective, Assessment, Plan.

SOAPIE format

Subjective, Objective, Assessment, Plan, Intervention, Evaluation.

PIE format

Problem, Intervention, Evaluation.

Flow sheets

Used to record frequent or routine data such as vital signs, intake/output, or pain scores; trends changes over time.

Critical or clinical pathways

EBP-based care plans outlining key interventions and expected outcomes within time frames for specific diagnoses.

Acuity records

Used to determine nursing care hours and staffing needs based on patient complexity.

Discharge summary

Includes medications, activity limits, teaching, follow-up appointments, and warning signs to report.

Home care documentation

Must meet Medicare standards for reimbursement; requires detailed notes.

Long-term care documentation

Must meet federal and accrediting-body standards for reimbursement and quality.

Information technology in nursing

Includes EHRs, bar-code scanning, computerized order entry, wireless networks, and biometric log-ins to improve safety.

Interprofessional collaboration

Teamwork among multiple health disciplines and patients to deliver high-quality care.

Benefits of interprofessional collaboration

Reduces medical errors, shortens hospital stays, improves outcomes, and builds trust.

Sentinel events

Serious unexpected events often caused by poor communication; account for over half of preventable adverse events.

SBARR purpose

Provides a structured, efficient method for communicating critical information to promote safe patient care.