Nursing Documentation and PHI/HIPAA – Study Notes

Learning Objectives/Outcomes

  • Describe the steps of Health Assessment.

  • Distinguish between subjective and objective data.

  • Identify the significance and process for validation of client data.

  • Describe the purpose, general guidelines, and rules for documenting assessment data.

  • Describe the nurse’s role with PHI/HIPAA.

Documentation Credibility

  • Documentation is essential for credibility:

  • No matter how skilled you are, poor nursing documentation will undermine your credibility if you are ever involved in a lawsuit.

Documentation Timing

  • Documentation requires careful timing for legal reasons and client safety.

  • Use the 24-hour cycle (Military Clock) for documenting times to avoid ambiguity.

Documentation Information

  • Documentation: Although healthcare organizations may use different systems/forms, all client records contain similar information.

Documentation Forms and Tools

  • Flow Sheets/Charts (with columns for dates, times, assessments, and interventions):

    • Physical Assessments

    • Specialty Assessments (e.g., Neuro, etc.)

    • Basic cares/ADLs/Nutrition

    • Vital signs

    • Use of special equipment

    • Treatments

    • IV therapy

    • Client teaching

  • Other documentation forms:

    • Medication Administration Record

    • Nursing Care Plan

    • Discharge summary: client’s status at admission and discharge; brief summary of care; interventions and education outcome; resolved problems and continuing need; referrals; client instructions

  • Forms for recording data include both EHR forms and written forms, varying per agency.

Types of Nursing Charting

  • Narrative Notes: A nursing narrative note provides clear, detailed information about the client, written in paragraph form, telling a story about the client, care provided, response to treatment, and any interventions or education.

  • Formats for narrative charting include DAR and SOAP.

  • Common charting formats:

    • DAR (Data, Action, Response)

    • SOAP (Subjective, Objective, Assessment, Plan)

DAR Note Details

  • D - Data: Describes the patient’s condition using subjective (what the patient says) and objective (what the nurse observes) information. Example: Patient states shortness of breath; respiratory rate is 22, with audible wheezing on auscultation of both lungs.

  • A - Action: Describes nursing interventions, including treatments, medication administration, patient education, and consultations with other healthcare professionals. Example: Administered two puffs of albuterol inhaler and elevated the head of the bed.

  • R - Response: Details the patient’s reaction to the action, assessing effectiveness and changes in condition. Example: Patient reports SOB resolved; wheezing no longer audible.

  • Types of Nursing Charting - DAR

SOAP Note Details

  • S (Subjective data): Patient reports throbbing pain in the lower right quadrant, pain level 7/10. Onset around 8:30 a.m. Ate about 25% of breakfast; up from bed twice to use the restroom.

  • O (Objective data): Patient is groaning, holding the right side, facial grimaces with movement. Vital signs: Temp 98.6°F, HR 78, RR 18, BP 124/79. Surgical incision site is intact, clean, and dry with no redness or drainage.

  • A (Assessment): Acute pain related to the surgical incision.

  • P (Plan): Administer prescribed pain medication; re-evaluate pain level and medication effectiveness within 15 minutes; encourage deep breathing and ambulation as tolerated.

  • SOAP Charting emphasizes synthesis of subjective and objective data to arrive at a nursing diagnosis and plan.

Charting by Exception (CBE)

  • Documents only items outside of the norm.

  • Takes less time to chart, allowing more time for other tasks.

  • Requires knowing what is considered “normal” for each client; standards/limits are defined by each organization and may not reflect every client’s baseline.

  • CBE can look different across environments due to different documentation tools.

  • Checklists and flow sheets are used (checkboxes).

  • Checklists/flow sheets provide a narrow snapshot (e.g., vital signs, weight) to spot metrics quickly.

  • CBE should complement, not replace, narrative charting.

Safe Documentation Guidelines

  • Do NOT let anyone use your password.

  • Always log off when you are done.

  • For incorrect data entries, use agency error protocols.

  • Do NOT leave client information displayed on computer monitors.

  • Do NOT leave printed documents visible.

  • Do NOT copy any part of the client’s record or take it home.

  • Do NOT use email to send protected client information.

  • Do NOT discuss clients in elevators, halls, or on social media; hospital monitors activity.

  • Do NOT disclose client information to visitors.

  • Do NOT look up anyone else’s test results, including your own!

  • Do NOT access another’s chart/EHR unless you are assigned to that client (this is monitored).

Legal and Practice Standards

  • Standards for nursing care are set by multiple bodies:

    • American Nurses Association (ANA) Standards of Care and Code of Ethics

    • Your state’s Nurse Practice Act

    • Agency policies and procedures

    • Federal regulators and other professional nursing organizations

    • These standards ensure safe, competent care for the public.

Verbal Communication of Data

  • Change of shift report: summary of client condition and current status of care from the off-going nurse to the oncoming nurse (including new or changed orders, IV fluids, PRN meds, tests/procedures, treatments, education, etc.).

    • Walking rounds; face-to-face; audiotaped SBAR (verbal communication of a client’s condition).

  • SBAR stands for Situation, Background, Assessment, Recommendation (verbal communication framework).

    • Communication pathways: Nurse to physician; Unit Nurse to Unit Nurse; Nurse to discharge facility nurse.