Lesson 2 Documentation & Reporting
Nursing Documentation & Reporting
Overview of Documentation
Documentation in nursing refers to the act of creating a written or electronic legal record that captures all pertinent interactions with a patient. This record includes vital data related to the patient's assessment, diagnosis, planning, implementation, and evaluation. The primary functions of documentation are to facilitate quality, evidence-based patient care, serve as a financial and legal record, assist in clinical research, and support decision analysis.
Characteristics of Effective Documentation
Effective documentation possesses certain key characteristics:
Consistent with professional and agency standards: Adhering to established guidelines and rules within the healthcare profession and institution
Complete: All necessary information must be fully captured.
Accurate: Information must be free of errors to ensure patient safety and effective communication.
Concise: Documentation should be clear and to the point, avoiding unnecessary details.
Factual: Entries must reflect actual events and observations, without assumptions.
Organized and Timely: Information should be documented in an orderly manner and without delay to remain relevant.
Legally Prudent: Documentation needs to protect both the patient and the healthcare provider legally.
Confidential: Patient information must be securely protected and only shared with authorized personnel.
Elements of Documentation
Documentation consists of several critical elements, including:
Content: The specific information that is recorded about the patient’s case.
Timing: When the documentation is performed, which is crucial for accurate records.
Format: The way information is presented (e.g., electronic systems, forms).
Accountability: Acknowledgment of who documented the information and their role in care.
Confidentiality: Ensuring that all patient information remains private and secure.
Using the 24-hour Cycle Military Clock for Documenting Times
Documentation of times should utilize the military clock format (24-hour format) to avoid ambiguity. It includes times like:
1200 (Noon)
2400 (Midnight)
Other hourly notations will include increments from 0100 to 2300, such as 1700 (5 PM).
Confidentiality of Patient Information
Confidential information about patients encompasses all aspects of their health records, which include:
Identifying information such as name, address, phone number, fax number, and Social Security number.
Medical reasons for the person’s condition.
Treatments received by the patient.
Historical health conditions.
Potential Breaches in Patient Confidentiality
There are several actions that can lead to breaches of patient confidentiality, which healthcare providers should avoid:
Displaying patient information on a public screen.
Sending confidential email communications over public networks.
Sharing printers among different units that may compromise confidentiality.
Discarding printed copies of patient information improperly.
Conducting conversations in public spaces where they can be overheard.
Faxing confidential information to unauthorized recipients.
Sending messages containing confidential information that can be intercepted via pagers.
Patient Rights Regarding Health Records
Patients have specific rights concerning their health records, including:
The right to see and copy their health record.
The right to update their health record as necessary.
The right to request a list of disclosures made concerning their information.
The right to request restrictions on certain uses or disclosures of their health information.
The right to choose how to receive their health information.
Policy for Receiving Verbal Orders
Verbal orders in nursing should always conform to specific protocols:
Orders must be issued directly by a physician or nurse practitioner to a registered nurse (RN) or registered pharmacist.
The orders should be recorded in the patient's medical record with the notation “VO” (verbal order).
The nurse must read back the order to verify its accuracy.
It’s important to date and time-stamp the orders as issued.
The verbal order should include the name of the physician or nurse practitioner issuing it, followed by the RN's name and initials.
Verbal orders should mainly be utilized in urgent situations only.
Policy for Physician or Nurse Practitioner Review of Verbal Orders
The review process of verbal orders includes the following steps:
Confirming the accuracy of the orders.
Signing the orders, annotating their name, title, and pager number.
Documenting the date and time of signature to maintain a clear record.
Methods of Documentation
Various methodologies exist for documenting patient care, including but not limited to:
Computerized documentation/Electronic Health Records (EHRs)
Source-Oriented Records
Progress notes and narrative notes
Problem-Oriented Medical Records
SOAP notes (Subjective, Objective, Assessment, Plan)
PIE charting (Problem, Intervention, Evaluation)
Focus charting
Charting by exception.
Sample Focus Patient Care Note
An example of a patient's care note might include the following details:
Date/Time: 7/11/25 0915
High Risk Data: "Patient crying when I entered room; confided that she is afraid to go home because her injuries are the result of her husband's battery, which she had not previously wanted anyone to know."
Action Taken: "Attending notified and discharge cancelled; Abuse network called with patient's permission and they are sending a counselor this afternoon to talk with her."
Signed by the nurse: C. Taylor, RN
Further entries might consist of:
Date/Time: 1000
Pain Data: "Patient complaining of pain in right rib area."
Action Taken: "Tylenol 3 administered as ordered."
Signed by the nurse: C. Taylor, RN
This structured and detailed documentation is crucial in ensuring patient care is effective and properly communicated.
Formats for Nursing Documentation
Institutional norms dictate specific formats that must be adhered to, including:
Initial Nursing Assessment: A comprehensive baseline evaluation of the patient upon admission.
Care Plan: Document outlining the nursing interventions and patient goals.
Patient Care Summary: Summary of the care provided over a specified timeframe.
Critical Collaborative Pathways: Pathways that standardize care for specific diagnoses.
Progress Notes: Ongoing documentation of patient status and care outcomes.
Flow Sheets and Graphic Records: Visual representations of key metrics.
Medication Administration Record (MAR): Detailed record of medications given.
Acuity Record: Documentation of patient acuity to help determine staffing needs.
Discharge and Transfer Summary: Information conveyed at the patient's discharge or transfer to another facility.
Home Health Care Documentation: Records intended for home healthcare services.
Long-Term Care Documentation: Specific requirements and documentation formats for long-term care facilities.
Medicare Requirements for Home Health Care
For home health care eligibility based on Medicare requirements, the following criteria must be satisfied:
The patient must be homebound, unable to leave home without considerable effort.
The patient requires skilled nursing care.
The patient shows reasonable potential for rehabilitation or is experiencing a life-threatening condition.
The patient's health status must not be stabilized, indicating continued care is necessary.
The patient is expected to make progress toward achieving outlined care outcomes.
Reporting Care or Requesting Action
Effective reporting protocols ensure safe patient care, such as:
Change of Shift/Handoff Report: Essential transition communication between shifts.
ISBARR: A standardized method for communication involving Identification, Situation, Background, Assessment, Recommendation, and Read-back.
Telephone/Telemedicine Reporting: Communication through voice or video calls.
Transfer and Discharge Reports: Comments regarding patient transitions to different care environments.
Reports to Family Members or Significant Others: Communicating pertinent information to loved ones.
Incident/Variance Reports: Documentation and reporting of any unexpected events.
Hand-off Communication/ISBARR
The ISBARR framework for handoff communication consists of:
Identity/Introduction: Identify yourself and your role.
Situation: Clearly articulate the current situation.
Background: Provide relevant patient history.
Assessment: Share your assessment of the patient condition.
Recommendation: Offer suggestions for the next steps in care.
Read-back of Orders/Response: Confirm orders or responses to ensure accuracy.
Change of Shift/Hand-off Reports
These reports should include:
Basic identifiable information about each patient, including name, room number, bed designation, diagnosis, and attending and consulting physicians.
An appraisal of each patient’s current health status.
Current orders, particularly any new or modified orders.
Reports of abnormal occurrences during the previous shift.
Any unfilled orders that need to be continued onto the next shift.
Patient or family queries, concerns, or needs.
Details regarding any ongoing transfers or discharges.
Telephone/Telemedicine Reports
The approach to telephone or telemedicine reporting should involve:
Identifying yourself and the patient while referencing your relationship.
Accurately and concisely reporting changes in the patient’s condition.
Presenting vital signs and clinical manifestations relevant to the discussion.
Having the patient's medical record available for responsive dialogue.
Documenting the time, date of the call, exchanged information, and physician response coherently and accurately.
Conferring about Care
In nursing, conferring about patient care may include:
Consultations and Referrals: Engaging with other healthcare professionals for specialized advice.
Nursing and Interdisciplinary Team Care Conferences: Collaborative meetings to discuss patient care strategies.
Nursing Care Rounds: Systematic evaluations of patient progress within a care setting.
Purposeful Rounding: Intentional rounds to assess and attend to patient needs effectively.
Eight Behaviors of Purposeful Rounding
Purposeful rounding is guided by eight specific behaviors:
Use Opening Key Words (C-I-CARE) with PRESENCE: Establish a consistent opening during rounds.
Accomplish Scheduled Tasks: Complete scheduled duties efficiently.
Address Four Ps: Pain, Position, Potty, and Possessions to cover essential patient needs.
Address Additional Personal Needs: Attend to further requests or questions from patients.
Conduct Environmental Assessment: Check the patient’s environment for safety and comfort.
Ask “Is there anything else I can do for you?”: Reinforce patient-centered care by offering additional assistance.
Tell the Patient When You Will Be Back: Reassure patients about follow-up.
Document the Rounds: Properly record the findings and actions taken during rounds for legal and procedural consistency.