Nursing Documentation and Reporting Notes

Objectives of Documentation and Reporting in Nursing

  • Use standard professional guidelines for effective nursing documentation.

  • Identify measures to protect confidential patient information.

  • Identify approved abbreviations and symbols used for documentation and distinguish these from error-prone abbreviations and symbols.

  • Describe the purposes of different types of patient health records.

  • Compare and contrast different methods of documentation, including:

    • Electronic Health Records (EHRs)

    • Source-oriented records

    • Problem-oriented medical records

    • PIE charting

    • Focus charting

    • Charting by exception

    • Case management model

  • Describe the purpose and correct use of various formats for nursing documentation, such as:

    • Nursing assessment

    • Nursing care plan

    • Critical/collaborative pathways

    • Progress notes

    • Flow sheets

    • Discharge summary

    • Home care documentation

  • Emphasize that documentation should be complete, accurate, current, and concise due to its legal status.

  • Describe the nurse's role in communication with other healthcare professionals through reporting.

Definition of Documentation

  • Documentation: A written or electronic legal record that encompasses all pertinent interactions with the patient.

    • Includes data related to:

    • Assessing

    • Diagnosing

    • Planning

    • Implementing

    • Evaluating

    • Facilitates quality, evidence-based patient care.

    • Serves as a financial and legal record.

    • Aids clinical research.

    • Supports decision analysis.

Characteristics of Effective Documentation

  • Must be:

    • Consistent with professional and agency standards

    • Complete

    • Accurate

    • Concise

    • Factual

    • Organized and timely

    • Legally prudent

    • Confidential

Elements of Documentation

  • Content: Information included in the documentation.

  • Timing: Timing of documentation, which must be timely to ensure accuracy.

  • Format: The structure of the documentation (e.g. SOAP, PIE, Focus).

  • Accountability: Responsibility for documentation entries.

  • Confidentiality: Protection of patient information.

Time Documentation Methods

  • Use of the 24-hour Military Clock for documenting times in nursing records.

Understanding Confidentiality

  • Confidential Information: All information related to a patient that includes but is not limited to:

    • Name, address, phone number, fax, social security number

    • Reason for illness

    • Treatment received

    • Past health conditions

Potential Breaches in Patient Confidentiality

  • Issues that can compromise confidentiality include:

    • Displaying information on public screens

    • Sending confidential emails via public networks

    • Sharing printers among units with differing functions

    • Discarding copies of patient information in unsecured locations

    • Holding conversations that can be overheard

    • Faxing confidential information to unauthorized individuals

    • Sending messages overheard on pagers

Patient Rights Relating to Documentation

  • Patients have the right to:

    • See and copy their health record

    • Update their health record

    • Get a list of disclosures

    • Request restrictions on certain uses or disclosures

    • Choose how to receive health information

Policy for Receiving Verbal Orders

  • Verbal Orders (VO) must:

    • Be given directly by a physician or nurse practitioner to a registered nurse or pharmacist.

    • Recorded in the medical record with the initials VO.

    • Be read back for accuracy verification.

    • Include date and time issued, along with the provider and nurse's information.

    • Be limited to urgent situations.

Policy for Review of Verbal Orders

  • Orders should be reviewed for accuracy and signed off by the issuing provider with:

    • Name, title, pager number, and date/time of signature.

Methods of Documentation

  • Computerized Documentation/EHRs: Offers traceability for all entries.

  • Source-Oriented Records: Contain progress notes and narrative entries.

  • SOAP Notes: Structure:

    • Subjective

    • Objective

    • Assessment

    • Plan

  • PIE Charting: Focuses on Problem, Intervention, Evaluation.

  • Focus Charting: Utilizes a format of Data, Action, Response.

  • Charting by Exception: Only significant findings are charted.

Example of SOAP Note

  • SOAP Note example for a patient named George Payne experiencing chest discomfort:

    • Subjective: George presents with right-sided chest discomfort rated at 3-4/10, relieved by heat or ibuprofen, worsened by lifting boxes

    • Objective: Vitals show BP 132/80, Temp 98.4 F, HR 80.

    • Assessment: Possible thoracic somatic dysfunction.

    • Plan: OMT and NSAIDs, with follow-up imaging/tests.

Focus Patient Care Note Example

  • A patient in distress due to domestic violence:

    • DATA: Patient crying, fears returning home.

    • ACTION: Attending notified, discharge cancelled, counseling services involved.

    • RESPONSE: Pain relief reported post-medication.

Formats for Nursing Documentation

  • Different formats include:

    • Initial nursing assessment

    • Care plans (patient care summaries)

    • Critical/collaborative pathways

    • Progress notes

    • Flow sheets and graphic records

    • Medication administration records

    • Long-term care documentation

    • Discharge and transfer summaries

    • Home health care documentation

Medicare Requirements for Home Health Care

  • Patients must:

    • Be homebound requiring skilled nursing

    • Show rehabilitation potential or be in significant decline

    • Exhibit changing or unstable conditions

    • Demonstrate progress towards care outcomes

RAI (Resident Assessment Instrument) Components

  • Minimum Data Set: Screening and assessment elements.

  • Triggers: Responses indicating needs for further assessment.

  • Resident Assessment Protocols: Identify care planning issues.

  • Utilization Guidelines: Direct how the RAI should be used.

Benefits of RAI

  • Individualized care for residents.

  • Enhanced communication among staff.

  • Increased family involvement in care.

  • Clearer documentation processes.

Reporting Care or Requesting Action

  • Types of Reports:

    • Change of Shift/Handoff Report

    • ISBARR (Identify, Situation, Background, Assessment, Recommendation, Response)

    • Telephone/Telemedicine Reports

    • Transfer/Discharge Reports

    • Reports to Family Members

    • Incident/Variance Reports

Change of Shift/Hand-off Reports

  • Must include:

    • Basic patient info (name, room, diagnosis).

    • Current health status and orders.

    • Abnormal occurrences.

    • Family needs and questions.

Bedside Shift Report Checklist

  • Engage with patient/family for hand-off discussions.

  • Conduct verbal SBAR report in understandable terms.

  • Perform focused assessment and ensure room safety.

  • Address patient needs and expectations for next shift.

Telephone/Telemedicine Reports

  • Identify self and patient relationship.

  • Concisely report patient condition change and actions taken.

  • Keep patient record on hand for accurate responses and record details of the call.

Purposeful Rounding in Nursing

  • Eight Behaviors of Purposeful Rounding:

    • Open with a greeting and review care plan.

    • Complete scheduled tasks.

    • Address pain and personal needs (toileting, positioning).

    • Assess the environment (IV pumps, alarms).

    • Always end by asking "Is there anything else I can do?"

    • Inform patients of your next visit times.

    • Document each round.

    • Focus on reducing anxiety and enhancing communication.