Documentation in Nursing Care

Documentation in Nursing Care

Definition of Documentation

• Documentation: The act of recording pertinent medical information in a patient’s medical record, which may be done in the following ways:

  • Handwritten on a paper chart.

  • Keyboarded into an Electronic Health Record (EHR).

Purpose of Documentation

• Continuity of Care: Nurses document ongoing accounts of pertinent patient data 24 hours a day, which provides members of the health-care team with a more complete picture of each patient.

• Permanent Record of Care: Serves as an enduring account of the patient's conditions and treatments.

• Accountability: Motivates continual internal assessment and evaluation of the care that is delivered.

• Legal Record: A recognized and necessary form of written evidence in legal contexts.

Principles of Documentation

• "Not Charted, Not Done": The belief that if something is not charted, then it was not done. Documentation is recognized as written evidence of care.

Ownership of Medical Records

• Medical Record Ownership: The original written or computerized medical record is the property of the hospital or facility, but all information within the chart belongs to the patient.

• HIPAA Compliance: Patients are guaranteed by the Health Insurance Portability and Accountability Act (HIPAA) the right to view and obtain a copy of their medical record.

Confidentiality of Documentation

• Confidentiality: The maintenance of privacy by not sharing privileged or entrusted information with third parties.

  • Consequences of Violations: Violations can lead to litigation and cause unintended hardship.

• Access Control: All medical records must be protected to ensure that no unauthorized individuals have access. Only health-care providers directly involved in the patient’s care should have access.

Various Uses of Documentation Forms

• Report Form:

  • Often referred to as “pocket brains.”

  • Used to document report received at the beginning of each shift and to make additional notes throughout the shift as events occur.

• Incident Report: Document occurrences that are out of the ordinary. Must be objective and should include the incident and actions taken.

  • Reasons for Incident Reports Include:

  • Medication errors.

  • Patient injuries.

  • Visitor or employee injuries.

  • Conditions that constitute a safety hazard.

  • Failure of a health-care provider to respond to emergencies or to perform ordered care.

  • Loss of patient’s personal belongings.

  • Lack of availability of vital patient care supplies or equipment.

• Care Plan:

  • Documents patient’s problems, interventions, effectiveness of each intervention, and revisions made as the patient's condition changes.

• Patient Chart or Medical Record:

  • Important to avoid shortcuts, use only approved abbreviations, and emphasize being accurate and objective.

Clicker Question Example

• Question: Which type of documentation form is used to record out-of-the-ordinary occurrences?

  • Options: Care plan, Incident report, Report form, Medical record

  • Correct Answer: B. Incident report; also known as difference reports that should include only objective information.

Types of Medical Records

• Source-oriented Records: Organized by the source of information:

  • Nurse’s notes.

  • Health-care provider's progress notes.

  • Vital signs.

  • Rehabilitation therapy information.

  • Medication administration records (MAR).

  • Laboratory results.

  • X-ray results.

• Problem-oriented Records: Organized around patient-specific issues:

  • Database includes patient history.

  • Problem list.

  • Plan of care.

  • Progress notes.

  • Encourages collaboration among health-care providers.

Clicker Question 2 Example

• Question: What information would be included in a problem-oriented health record?

  • Options: Patient’s vital signs, The plan of care, A laboratory result, Nurse’s notes

  • Correct Answer: B. The plan of care, which is a defining feature of problem-oriented records.

Data to Document

• Essential data to document includes:

  • Physical and emotional assessments.

  • Nutrition details.

  • Hygiene practices.

  • Activity level data.

  • Physician visits documentation.

  • Elimination patterns.

  • All nursing care and interventions, including patient teaching and discharge teachings.

  • Patient's response to each intervention.

  • All patient complaints.

  • Safety issues identified.

  • Laboratory tests, x-rays, and other diagnostic testing results documented.

Methods of Recording Patient Information

• Narrative Charting:

  • Provides a chronological and continuous description of the patient's experiences during their hospital stay including:

  • Complaints.

  • Problems encountered.

  • Assessment findings.

  • Activities conducted.

  • Treatments received.

  • Nursing care provided.

  • Evaluations of the effectiveness of nursing interventions.

Documenting Patient Care

• Important aspects to document include:

  • The teaching needs of the patient.

  • Specific information taught to the patient.

  • Methods used for teaching.

  • Effectiveness of teaching efforts documented.

Electronic Health Record (EHR)

• Definition: A record of an individual’s lifetime health information that is easily updated and transferable.

• Benefits of EHR Documentation:

  • Reduces errors in patient care.

  • Emphasizes patient needs and problems.

  • Enhances communication among all health-care staff involved in patient care.

• EHR Documentation Includes:

  • Patient interactions with the health-care system.

  • Tests, appointments, and medications documented over time.

  • Records of signs and symptoms, diseases, immunizations, allergies.

• Protecting Confidentiality of the EHR:

  • Requires a login ID and password.

  • Breaches are subject to civil and criminal penalties.

• Learning to Use the EHR: Provides additional research possibilities and information for the health-care community, as well as aiding in continuing education efforts.

Long-term Care Documentation

• Documentation Frequency: Different than in acute care settings, often utilizing paper charts.

• Use of Kardex: Commonly used for maintaining patient records in long-term care settings.

Guidelines for Paper Documentation

• Best practices for paper documentation include:

  • Use black or blue ink.

  • Write neatly and legibly.

  • Sign each entry for accountability.

  • Include date and time with each entry.

  • Follow chronological order of entries.

  • Make entries in a timely manner.

  • Be succinct to ensure clarity.

• Additional Guidelines:

  • Proper use of punctuation.

  • Avoid leaving blank lines in documentation.

  • Use continuation notes when necessary.

  • Correct mistaken entries properly.

  • Ensure medical record integrity is maintained.

Long-term Care Admission Documentation and Required Assessments

• Must compete an admission assessment document to meet Medicare and Medicaid requirements:

  • Minimum Data Set (MDS): For resident assessment and care screening as mandated by the Omnibus Budget Reconciliation Act (OBRA).

  • Weekly assessment data documentation.

  • Medication Administration Records (MAR).

Home Health Documentation

• Criteria must be met for admitting a patient to home health care:

  • OASIS: Outcome and Assessment Information Set, serves as a regulation and audit tool by state health department and Medicare.

Five Documentation Mistakes That Carry Increased Risk of Malpractice

• Common errors in documentation that can lead to legal issues include:

  • Failure to document assessment findings accurately.

  • Failure to document medications administered.

  • Failure to document pertinent health history effectively.

  • Documenting on the wrong chart or Medication Administration Record (MAR).

  • Failure to accurately document physician’s orders.