Documentation and Reporting Guidelines

Definition of Documentation

• Documentation: Any written or electronically generated information concerning a patient that documents their status, care, or services provided.

Purpose of Documentation in Patient Records

• Communication between health-care providers.

• Supports Quality Improvement efforts.

• Necessary for Research purposes.

• Aids in Reimbursement of care costs.

• Serves as Legal proof of health care provided.

• Demonstrates use of the nursing process.

• Helps meet legislative, regulatory, and credentialing requirements.

• Facilitates Diagnostic and Therapeutic Orders.

• Enhances Education for continued learning.

• Provides Historical Documentation of treatment.

Guidelines for Effective Documentation

• Format

  • ​correct patient record before documenting

  • Date/Time​

  • Record on the proper form or screen ​​

  • Use correct grammar and spelling (Appropriate Abbreviations)​

  • Record nursing interventions chronologically on consecutive lines

• Accountability

  • ​Sign your first initial, last name, and title to each entry ​

  • Draw a single line through an incorrect entry, and write the words “mistaken entry” or “error in charting”​

  • Patient record is permanent and must be complete

• Content

  • ​Enter information in a complete, accurate, concise, current and factual manner ​

  • Avoid generalization (Common average words) (Be specific and use objective data and put subjective in quotes)​

  • Avoid stereotypes or derogatory terms​

  • DO NOT copy and paste previous notes​

  • Note problems in an orderly, sequential manner

• Confidentiality

  • ​HIPAA Guidelines​

    • Patients have the moral and legal right to have their health records kept private​

    • Patient Rights- Able to get a copy of medical record​

  • Nursing student using patient records are bound professional and ethically to maintain privacy and confidentiality.

  • Breaches of Confidentiality:​

    • Sharing your password​

    • Discussing patient information in public areas​

    • Accessing records for patient you aren’t caring for​

    • Failing to log off​

    • Discarding patient information in trash cans (Put in shredding bin)

• Timing

  • Document nursing interventions as close to “real time” as possible​

  • NEVER document intervention before doing them​

  • Indicate date and time for EVERY entry​

    • Most facilities use military time (0100-2400)

Nursing Documentation Tools

• Initial Nursing Assessment - Document physical assessment findings

• Care Plan- Communicate patients problems, outcomes, progress, goals, etc.

• Patient Care Summary- Overview of certain information such as labs, medications, test results, etc.

• Flowsheets and Graphic Records- I/O, Vitals, restraints, where IV is, wound location

• Medication Administration Record (MAR)- Break down of dosages, routes, PRN/Dailys, etc.

• Discharge/Transfer Summary

• Home Health/Long-Term Care Documentation

• Progress Notes- Look at patient and how they are doing.

Methods of Documentation

Computerized Documentation/Electronic Health Records (EHR):

• Electronic Medical Records (EMRs): Digital versions of paper charts within hospitals.

• Electronic Health Records (EHRs): Comprehensive records from all clinicians involved in a patient's care; accessible to authorized clinicians. Even to outside specialists.

• Health Information Exchange (HIE): Allows health care providers to access and securely share a patients health information.

SOAP

• Progress Note Formats include:

• SOAP (IER):

  • S: Subjective (What the patient told you, past medical history, medications, allergies, and social history)

  • O: Objective (Vital signs, Physical assessment, Labs, or tests)

  • A: Assessment (Diagnosis based off of what our patient is experiencing)

  • P: Plan (What you are gonna do with your patient)

Methods of Documentation (Not Important)

• APIE Charting: Problem-Focused.

  • APIE Format:

  • A: Assessment

  • P: Problem

  • I: Intervention

  • E: Evaluation

• Focus Charting: Centered on patient concerns, using DAR Format:

  • D: Data

  • A: Action

  • R: Response

Effective Professional Communication: Reporting Care

• Report: Communication form for account of patient events.

• Hand-off Report: Transfer of patient-related information between caregivers.

• Miscommunication can cause adverse events

• SBAR: Structured communication format:

  • S: Situation (Objective data)

  • B: Background (Objective data)

  • A: Assessment (Subjective data)

  • R: Recommendation (Subjective data)

Types of Reports

• Change of Shift/Handoff Report: Transfer of care; includes baseline info for oncoming nurse.

  • When responsibility and accountability for the care of a patient is transferred from one nurse to another​

  • Provides baseline information for oncoming nurse

• Bedside Report: Focus on direct patient care during shift change.

  • Streamlined shift report done at the bedside​

  • Patient-centered focus

Conferring about Care

Consultations and Referrals​

• Consultations​

  • The process of inviting another professional to evaluate the patient and make recommendations to you about the patient’s treatment.

  • Usually specific with whatever patient is going to get done.​

• Referrals​

  • The process of sending or guiding the patient to another source for assistance.

Nursing and interdisciplinary Team Care Conferences​

• Nurses and other health care professionals frequently meet in groups to plan and discuss patient care​

Multidisciplinary Care Rounds​

• Commonly termed “Rounding”​

• Important mechanism for communication and coordination of care

• Helps nurses anticipate and address patient needs

Purposeful Rounding​

• Promotes patient safety​

• Is an evidenced –based intervention​

• Address 4 P’s​

  • Pain ​

  • Personal needs (toileting)​

  • Positioning- comfort​

  • Fall prevention- safety (near the patient, call bell, personal belongings, bed alarm on, bed down, 2-3 bed rails up, oxygen tubing on)​