Fundamentals of Nursing - Documentation

Documentation of Nursing Care

Purposes of Documentation

• Written record: Documentation serves as a comprehensive written account of patient care.
• Reimbursement of costs of care: Accurate documentation is essential for justifying and obtaining reimbursement for healthcare services.
• Evidence of care: It provides tangible evidence of the care provided to the patient.
• Shows the use of the nursing process: Documentation illustrates the application of the nursing process, including assessment, diagnosis, planning, implementation, and evaluation.
• Quality improvement: Documentation facilitates quality improvement initiatives by providing data for analysis and identifying areas for enhancement.
• Research: Medical records can be used for research purposes, contributing to the advancement of healthcare knowledge.
• Staff performance: Documentation can also be used to evaluate staff performance and identify areas for professional development.

The Medical Record

• Contains comprehensive data regarding a patient's stay within a healthcare facility.
• Addresses crucial aspects of Privacy-Confidentiality: Outlines who is authorized to access the patient's chart, ensuring adherence to privacy regulations and ethical standards.

Methods of Documentation

• Source Oriented
• Problem Oriented
• Focus
• Charting by exception
• Computer assisted
• Case management system (pathways)

Source-Oriented or Narrative Charting

• Organized according to the source of information.
• Utilizes separate forms for different healthcare disciplines.
• Narrative charting requires documentation of patient care in chronologic order.
• Advantages
• Disadvantages

Problem-Oriented Medical Record Charting (POMR)

• Focuses on patient status rather than on medical or nursing care.
• Five basic parts: database, problem list, plan, progress notes, and discharge summary
• Advantages
• Disadvantages

SOAP (IE) Documentation

• S - Subjective: Represents the subjective information provided by the patient, including their feelings, symptoms, and concerns.
• O - Objective: Encompasses the objective data gathered through observation, physical examination, and diagnostic tests.
• A - Assessment data: Involves the interpretation and analysis of the subjective and objective data to identify the patient's problems or needs.
• P - Plan: Outlines the plan of care developed to address the identified problems, including specific interventions and goals.
• I - Implementation: Specifies the actions taken to implement the plan of care.
• E - Evaluation: Describes the evaluation of the patient's response to the interventions and the progress toward achieving the goals.

Focus Charting

• Directed at nursing diagnosis, patient problem, concern, sign, symptom, or event.
• Three components:
  • D: data, A: action, R: response (DAR)
  • OR D: data, A: action, E: evaluation (DAE)
• Advantages & Disadvantages

Charting by Exception

• Based on the assumption that all standards of practice are carried out and met with a normal or expected response unless otherwise documented.
• A longhand note is written only when the standardized statement on the form is not met.
• Advantages & Disadvantages

Computer-Assisted Charting

• Electronic health record (EHR)
• Computerized provider order entry (CPOE)
• How to take a verbal order
• Documentation can be done immediately
• Use of flow sheets with nursing interventions and expected outcomes
• Others use a POMR format to produce a prioritized problem list
• Advantages
• Disadvantages

Characteristics of Documentation

• Factual
• Accurate
• Brevity
• Timely
• Complete
• Legible
• Spelling and Grammar

Factual

• Descriptive objective information about what the nurse observes
• NO vague terms
• Subjective data

Accurate

• Intake of $400$ml of water instead of adequate amount of water
• Use of exact measurement establishes accuracy
• COMPLETENESS is more important than brevity

Brevity in Charting

• Articles (a, an, the) may be omitted
• The word “patient” omitted when subject of sentence
• Sentences not necessary
• Abbreviations, acronyms, symbols acceptable to the agency
• Choose which behaviors and observations are noteworthy

Timely

• Date and time
• Military time
• Document when complete

Complete

• Condition change
• Patient’s responses especially unusual, undesired or ineffective response
• Communication with patient family
• Entries in all spaces on all relevant assessment form
• Do not leave blank areas

Legible

• Black ink, clear enough to be read, readable particularly handwriting
• Fixing errors in charting

Spelling and Grammar

• Misspelled words and poor grammar create a negative impression.
• Readers (lawyers and jurors) may infer that a person with poor spelling and grammar is uneducated and careless

Examples of errors found on nursing notes

• Fecal heart tone heard
• Patient observed to be seeping quietly
• Foley draining fowl smelling urine
• “IV infiltrated because nightshift forgot to check it”
• “Patient going into shock, could not reach Dr. Jones per usual”
• Physician Note, “Once again the lab forgot to draw the patient’s PTT this am”
• Physician Note “If the nurses would learn to read medication orders, we would have a lot fewer emergencies around here”
• “Patient received insufficient care today because nurse patient ratio was 1:7”
• Physician Note: “Patient fell due to lax nursing supervision”
• “Patient in extreme pain because previous nurse too busy to give pain meds”

Example Nurses' Notes

• Date & Time 03/21/11 0815
• S C/o nausea and severe abdominal pain of $7$ on $0-10$ scale.
• O Hypoactive bowel sounds RUQ, no bowel sounds heard in LUQ or lower quadrants. Abdomen firm, distended, and tender to touch. Flexes legs toward abdomen when abdomen touched. No bowel movement charted since admission. VS $148/92$, $100.6$° F, $114$, $24$.
• A Possible bowel obstruction. Monitor for continued change of status.
• P Notify doctor of change in status r/t abdominal pain. Monitor VS q hour. Prepare for further diagnostic studies and orders from physician.

Nursing Care Form

• (walking paper, Kardex etc.)
• Summary of client plan of care and status
• Medical diagnoses
• Nursing diagnoses
• Treatments
• Orders

Consent

• Legal document
• participation in decision making
• must know what the consent allows and be able to make a knowledgeable decision
• Informed consent
• Release