Documentation and Charting Vocabulary (Nursing Notes)

Documentation in Nursing: Comprehensive Study Notes (Video Transcript)

• Why documentation matters

  • Documentation is a form of communication within the interprofessional healthcare team.
  • If it isn’t documented, it isn’t considered done; “if you didn't chart it, it didn't happen.”
  • Charting should be thorough and precise, as if you were talking to a jury; a year later, the chart is your evidence.
  • Documentation supports communication, legal protection, reimbursement, auditing, education, and research.
  • It helps prevent errors by preventing duplication of care (e.g., missing or duplicating PRN medications).
  • It provides a legal defense: accurate, timely, and complete entries protect providers and organizations.

• Objectives and core questions

  • Documentation equals communication; it’s how care is traced and understood by others.
  • Who uses the chart besides the primary nurse? Providers, outside reviewers, quality improvement teams, and auditors.
  • Documentation should be accurate, clear, timely, factual, comprehensive, readable, and organized.

• What can poor documentation cause?

  • Adverse events if information is missing or incorrect.
  • Inaccurate records can lead to improper care or missed interventions.
  • Hospitals may face reimbursement issues if conditions or care are not properly documented.

• Hospital-acquired conditions and nurse sensitivity

  • Hospitals track 11 hospital-acquired conditions (HACs) for reimbursement decisions by Centers for Medicare & Medicaid Services (CMS).
  • Four of these HACs are nurse-sensitive:
  • ext{Stage III and IV pressure injuries}
  • ext{Falls with injury}
  • ext{CAUTI (Catheter-Associated Urinary Tract Infection)}
  • ext{Central line infection (CLABSI)}
  • Nurses are responsible for preventing these conditions and documenting prevention efforts (turning, heel protection, catheter care, central line dressings).
  • Documentation should reflect both the action and the outcome to reduce liability and demonstrate adherence to standards of care.

• Examples of documentation in practice

  • Pressure injuries: document positioning, heel floating, skin condition, measurements, interventions.
  • Falls prevention: bed rails up, call light in reach, bed in low position, fall risk precautions.
  • CAUTI prevention: catheter care and maintenance; ensure proper timing and dressing changes.
  • Central lines: dressing changes, sterile technique, and infection prevention measures.
  • If a skin injury develops later, hospital pays if it wasn’t documented initially; baseline assessments on admission matter (e.g., skin assessment within 8 hours).
  • Prior documentation practices can affect reimbursement; e.g., missing initial skin assessment can reclassify a condition as hospital-acquired.

• Purpose of the healthcare record

  • Communication among the interprofessional team: nurses, therapists, physicians, nurse practitioners, respiratory therapists, etc.
  • Legal document and defense against legal claims.
  • Reimbursement: payers rely on documentation to determine payment.
  • Auditing and monitoring: quality improvement teams use charts to identify trends and gaps in care.
  • Education and research: de-identified data can be used for statistical analysis; patient identifiers must be removed for privacy.

• What the chart includes (typical components)

  • Patient identifiers and demographics; admission data; code status (e.g., ext{Full code} vs ext{DNR}); living will or power of attorney.
  • Admission data, past medical history, and diagnoses.
  • Care plan and evaluation of care; progress notes; physical assessment findings; diagnostics; patient education.
  • Operative procedures, discharge planning, and discharge summaries.
  • Discharge instructions, medications on discharge, follow-up appointments, and contact information.
  • Documentation of education provided (methods used and patient response).
  • Documentation of communications with providers (phone calls, orders, and follow-ups).

• Documentation guidelines and legal requirements

  • Do not document personal opinions or unverified judgments (e.g., avoid phrases like "the patient appears ill today").
  • Begin each entry with the date and time; end with your signature and credentials (e.g., ext{SN} for student nurse).
  • Protect your password; do not share it; never leave a chart open unattended.
  • Use only black ink for paper charting; do not use pencils or erasable ink; corrections must be made by drawing a single line through the error, marking "error", initialing, dating, and documenting the correct information.
  • If you must correct an entry, do not erase; use the above method to correct information.
  • Electronic documentation (EHR/EMR) offers readability, time stamps, and cross-provider accessibility; EHR is the lifetime record, while EMR is the record for a single admission.
  • Confidentiality and HIPAA: discuss patient information only with those involved in care; use restricted computer areas; avoid displaying screens in public areas; do not include patient identifiers in non-clinical settings unless necessary.
  • Access is traceable; attempts to access unrelated charts are a violation; be mindful of Fishbowl-room audits and random monitoring by hospitals.
  • Written consent may be required to release records; refer requests to medical records; access should be limited to information necessary to provide safe, effective care.
  • Only information needed to provide safe and effective care should be reviewed; charts are factual, descriptive, objective, and detailed.

• Confidentiality and privacy specifics

  • Discuss patient information only with involved care team; HIPAA guidelines apply.
  • Protect passwords; never share or leave computers unlocked for others to access behind you.
  • Do not include patient identifiers in clinical paperwork that could be accessed by non-care personnel; use restricted access areas for computer terminals.
  • When faxing, use a proper cover sheet and confirm the recipient’s number; do not remove charts from clinical sites; shred copies when appropriate.
  • Access to patient records is restricted; law and policy allow audits and tracing of who accessed which chart and when.

• Abbreviations and documentation practices

  • Abbreviations can cause miscommunication; use the Joint Commission-approved list of abbreviations and avoid commonly misinterpreted ones.
  • Some abbreviations to avoid include trailing zeros (e.g., write 1.0 not 1.), and any shorthand that could be misread.
  • A patient’s chart should contain clear, unambiguous entries; if there is doubt, spell out terms.
  • Many facilities provide a site-specific abbreviation list; always reference the agency’s standard list and doctor-provided lists.

• Documentation formats and tools

  • Flow sheets: graphic records organized by body systems; used for vital signs, intake/outtake, daily weights, oral intake, etc.; efficient for repetitive documentation; may use WDL (Within Defined Limits) or WNL (Within Normal Limits) for quick charting; allows documentation by exception.
  • Note (progress notes): a structured entry that may resemble SOAP or PIE formats; components include Subjective (S) data, Objective (O) data, Assessment (A) and Plan (P).
  • Subnote: provider-specific notes that illustrate a diagnosis-based plan and actions such as medication adjustments and patient education; example provided for hypertension.
  • Narrative notes: free-text, story-like entries commonly used on paper and in electronic formats; should be clear, concise, and logically organized with objective data and dated entries; include interventions and plans and the date/time and signature.
  • Admission nursing history form: baseline information collected on admission; standard for establishing a baseline for ongoing care.
  • Patient care summary: organizes recent vital signs, orders, and care status; used for handoffs.
  • Care plans: standardized plans tied to diagnoses but adjustable for individual patient needs; used to guide ongoing care.
  • Discharge summary form: initiated on admission to plan for discharge; includes medications on discharge, follow-up care, community resources, and emergency contact information.
  • Communication with providers: document all calls and orders with time, caller/receiver, content, and any follow-up; read-back is required for telephone and verbal orders to minimize miscommunication; cosign occurs for orders.
  • Telephone/verbal orders: should be used only when necessary (emergency or urgent need); some agencies require a second person to listen and read-back; read-back is mandatory; after entry, orders must be cosigned by the provider.
  • Incident reports: not part of the patient’s permanent chart; used for organizational improvement (patient incidents and staff events); do not reference the incident report within the medical record; document patient response and actions taken in the chart.
  • Nursing informatics: integrates nursing science with computer science to manage data, information, and knowledge; helps apply clinical judgment to technology; identifies technology-related challenges and supports improved delivery of care; roles include optimizing devices, scanners, mobile computers, and barcode administration.

• Timekeeping and documentation timing

  • Military time is standard in nursing notes; format is four-digit time without colons (e.g., 1022 for 10:22, 2300 for 23:00, 0000 for midnight).
  • Documentation should occur as soon as possible after events (e.g., vital signs, pain, medication administration, and treatment).
  • Time references should be precise to help track trends and assess response to interventions.

• Hypothetical/illustrative scenarios mentioned

  • Suppose a patient has a PRN pain medication order; a nurse before you forgot to administer it; you must check if it has been given and document to prevent an adverse event.
  • When communicating with a provider by phone, clearly identify the patient (name, room number, and diagnosis) to ensure the right chart is updated and the right patient is treated.
  • If an error occurs in charting, fix using the approved correction method (line through, write "error", initials, date, and corrected information).
  • When a provider gives a telephone or verbal order, read it back, document it, and await cosignature; if the order is unclear, insist on clarification.

• Demonstration prompt (application of guidelines)

  • Demonstrate documenting a patient’s situation using a SOAP approach (S, O, A, P), ensuring objective data, measured findings, and a clear plan; include patient education, method of delivery, patient response, and any follow-up actions.

• Practical takeaway for exam preparation

  • Always document comprehensively and accurately; follow facility policies for frequency (e.g., head-to-toe assessments, focused assessments, vital signs), and align with policy-driven expectations.
  • Use the correct format for times, avoid ambiguous language, and maintain professional, factual language.
  • Be mindful of confidentiality and legal implications; practice with mock cases to become proficient at reading back orders and documenting clearly.
  • Understand the differences between EHR and EMR and how they affect information accessibility and continuity of care.

• Quick-reference highlights (recap)

  • Key reasons to document: communication, legal protection, reimbursement, auditing, education, research.
  • Nurse-sensitive HACs: Stage III/IV pressure injuries, falls with injuries, CAUTI, and central line infection (CLABSI).
  • Documentation components: admission data, care plan, progress notes, assessments, diagnostics, education, discharge planning.
  • Formats to know: flow sheets, notes (SOAP/PIE), subnotes, narrative notes.
  • For accuracy: start entries with date/time, sign with credentials, protect passwords, correct errors properly.
  • Acknowledge the ethical and legal obligation to maintain confidentiality; comply with HIPAA and facility policies.
  • Incident reports are for quality improvement and do not appear in the patient’s chart.
  • Nursing informatics supports efficient, safe care by integrating technology and nursing judgment.

• Foundational connections

  • Builds on prior lessons about assessment and documentation as a core nursing skill.
  • Connects to quality improvement concepts: how data in charts informs changes in practice to reduce HACs.
  • Real-world relevance: high-stakes environments require precise records for patient safety, billing, and legal protection.

• Common questions addressed

  • What should be documented? Assessment findings, problems, interventions, nursing diagnoses, evaluation of interventions, patient education, and discharge planning.
  • How often? Determined by facility policy, acuity, and unit guidelines; e.g., head-to-toe assessment once per shift; focused assessments every 2 hours in patient with higher acuity.
  • How to handle errors? Draw a line, mark "error", initial and date, and insert the correct information.
  • When to use abbreviations? Use approved lists; avoid nonstandard abbreviations per Joint Commission recommendations.
  • How to protect privacy? Discuss only with involved staff; use restricted access; de-identify data for research.

• Key terms to remember

  • ext{EMR} = Electronic Medical Record (single admission, digital record)
  • ext{EHR} = Electronic Health Record (lifetime, interoperable across providers)
  • ext{CAUTI} = Catheter-Associated Urinary Tract Infection
  • ext{CLABSI} = Central Line-Associated Bloodstream Infection
  • ext{DNR} = Do Not Resuscitate
  • ext{SN} = Student Nurse

• Risks and benefits emphasized for exam-ready understanding

  • Benefits of thorough documentation: safer patient care, clearer communication, defensible legal record, and proper reimbursement.
  • Risks of poor documentation: miscommunication, duplicated or omitted care, reduced patient safety, and financial penalties for HACs.

• Final reminder

  • Documentation is a professional responsibility that underpins patient safety and quality of care; practice with the formats highlighted, adhere to timing and confidentiality standards, and apply the 24-hour clock for clarity and consistency.

• Note: All references to specific tables and examples (e.g., Table 26.1, Table 26.2) are drawn from the course materials cited in the transcript (e.g., table 26.1 for corrections; table 26.2 for time documentation).