RN Documentation
Key Terminology
Documentation: The act of recording patient status and care.
This reflects what care has been provided and is a legal record of that care.
Importance of Medical Records
Communication: Facilitates communication among health care providers.
Continuity of Care: Ensures that health care providers can plan care based on prior communications.
Quality Improvement: Supports chart auditing and assessment of health outcomes over time.
Legal Documentation: Medical records are admissible in court.
Professional Standards: Aligns with ANA nursing standards.
Reimbursement and Utilization Review: Assists facilities in obtaining reimbursements from insurers and evaluating service utilization.
Types of Documentation Systems in Nursing
Source-Oriented Medical Record (SOMR)
Description: Each discipline/department has separate sections for notations (e.g., nursing, physician orders).
Advantages: Organized and convenient for locating information.
Disadvantages: Information is scattered, making it difficult to gather comprehensive insights.
Narrative Charting: A written note that can include normal findings, care, problems, etc.
Problem-Oriented Medical Record (POMR)
Description: Information is organized by client problems.
Components:
Database: Includes nursing assessments, physician’s history, social/family data, and diagnostic tests.
Problem List: Continuously updated list of client problems, organized by identification.
Plan of Care: Orders for each problem identified, including nursing orders and care plans.
Progress Notes: Entries made by any professionals caring for the client, labeled by problem number.
Charting by Exception (CBE)
Description: A documentation system that highlights abnormal or significant findings.
Components:
Flow Sheets: Records vital signs, intake/output, daily assessments, etc.
Standards of Nursing Care: Minimum criteria for documentation outlined by the agency.
Advantages: Reduces time spent documenting.
Disadvantages: Risk of omissions and inconsistencies in documentation content.
Electronic Health Record (EHR)
Advantages: Improved communication, access to information, time savings, and quality of care.
Disadvantages: High costs, potential downtime, challenges with integration, and change management.
Paper Record
Advantages: Familiarity, fewer resources needed, no downtime, and lower costs.
Disadvantages: Delayed access, time-consuming to find information, higher risk of errors, and storage issues.
Nursing Progress Notes
Can be in paper or electronic formats.
Come in various formats including:
Narrative: Traditional method with chronological documentation of all findings and care.
PIE: Focus on problems, interventions, and evaluations.
SOAP/SOAPIER: Components include Subjective, Objective, Assessment, and Plan.
Focus Charting: Centers on client concerns and uses annotated sections for recording data.
DAR: Data, Action, Response documentation format.
SOAP Notes
Structure:
S: Subjective information (what patient reports).
O: Objective information (measured data).
A: Assessment (interpretation of data).
P: Plan (goals or care plan).
Example SOAP Note
Date: 09/04/24, Time: 1600
#3 Infection, risk for
S: “I feel like I am burning up, and I am shivering.”
O: Temp 103.3°F, shivering, tissue noted with purulent drainage.
A: Infectious process suspected, cultures pending.
P: Start antibiotic treatment with Keflex 500 mg tid.
Focus Charting
Focus: Addresses client concerns/problems and strengths with a three-column format:
Date & Time
Focus (nursing diagnosis, behavior, or symptoms)
Progress Note: Documenting data, actions, and responses.
Example Focus Note
Date/Hour: 09/04/24 1800
Focus: Infection
D: Temp 103.3°F, patient shivering.
A: Administered Acetaminophen 1000 mg PO.
R: Temp decreased to 100.4°F.
P: Continue monitoring every 4 hours.
What to Document
Interventions and progress toward goals.
Significant events or changes in condition.
Informed consent details and patient education.
Communication attempts with provider and against medical advice documentation.
Documentation Forms in Nursing
Patient Summary: Quick visual history and current data on patients.
Admission Data Forms: Completed during admission.
Discharge Summary: Details about clients at discharge, including medications and treatments.
Flow Sheets & Graphic Records: Used for documenting vital signs and intake/output.
Medication Administration Records (MAR): Track prescribed medications and administration details.
Guidelines for Documentation
Accuracy: Document in appropriate charts, present facts and observations.
Accepted Terminology: Use agency-approved terminologies (avoid "do not use" words).
Sequence: Document in the order events occur.
Legibility and Permanence: Use clear handwriting, preferably dark ink, to ensure readability.
Confidentiality: Adhere to HIPAA for patient information privacy.
Legal Aspects of Documentation
HIPAA: Legally protects PHI and establishes penalties for its violation.
Penalties: Range from $50,000 per violation to a maximum of $1.5 million depending on the tier of violation.
Reporting Requirements
Handoff Reporting: Use formal structures such as PACE or SBAR for communication.
Telephone Reports: Document all communications, including time, date, and details given to the receiver.
Verbal Orders: Must be documented and signed by the prescriber within 24 hours.
Ethical and Philosophical Implications
It is crucial to maintain the integrity and confidentiality of patient records.
Accurate documentation is essential for the safeguarding of legal rights for both the provider and the patient.
Case Scenarios
Example Case 1: Documenting chest pain episodes and interventions in a SOAP format.
Example Case 2: Crafting a focused note for a patient post-surgery on crutches, emphasizing safety education.
Conclusion
Effective nursing documentation is vital for delivery of quality care and legal protection.
Understanding different formats and their appropriate application is critical for nursing professionals.