Charting

Documentation and the Health Record

• Learning Objective: Discuss fundamental principles of documentation and the health record.

Purposes of Documentation

• Learning Objective: Describe purposes of documentation in the health record, including types of information found in common forms.

Documentation provides an electronic or written record of the history, treatment, care, and response of the patient while receiving medical and nursing care. It justifies claims for reimbursement, may be used as evidence of care in a court of law, shows the use of the nursing process, and provides data for quality improvement studies, projects, or initiatives. Each person who provides care for the patient adds documentation to the health record (sometimes referred to as the chart or the medical record). The health record contains all orders, tests, treatments, and care that occurred while the person was under the care of the health care provider. The health record is a communication tool for the professionals involved in patient care. Health team members use documentation to communicate what has been done, how the patient responded, and the current plan for care. Many different forms are used for documentation, and the most common forms are shown in the chapters specific to their content; for example, an intravenous (IV) flow sheet (parenteral infusion record) is shown in Chapter 37.

Various organizations set the standards for documentation, such as the Centers for Medicare and Medicaid Services, the American Health Information Management Association, The Joint Commission, and other entities. Common types of paper sheets (forms) or electronic screens included in patients’ health records are listed in Table 7.1.

Legal & Ethical Considerations

Most health agencies use an electronic health record (EHR) to document care provided to a patient. An EHR is a comprehensive tool that contains information including health care demographic information, health care provider notes, nursing notes, laboratory data, radiology reports, and insurance information (U.S. Department of Health and Human Services Cybersecurity Program, 2022). The EHR can be accessed by the patient, health care providers, and affiliated agencies that collaborate with the health care provider such as laboratories or imaging centers. The patient can also give permission inside the EHR to allow external, non-affiliated agencies to have access. This increases continuity of care, anywhere the patient is seen or treated.

Although much less common, some agencies may still use a medical record, a paper chart where patient care is documented. If a medical record is kept electronically, and is not associated with a larger electronic health record, it is known as an electronic medical record, or EMR. The EMR contains the same information that the paper medical record contained; it is simply stored in a digital format. Do not confuse an EMR with an EHR. These terms are often used interchangeably, but what they contain and who can access them are very different.

Insurance companies, Medicaid, and Medicare rely on documentation to review the patient’s actual length of stay in health care agencies, visits with health care providers, procedures performed, and medical diagnoses established. This information is used to calculate payment that is eligible for reimbursement. It is critical that all information about a patient’s visit or hospital stay is thoroughly documented to represent exactly what was done, the medical diagnoses assigned by the health care provider, nursing care given, and diagnostic tests performed. Evaluation data indicating whether care and treatment was successful or unsuccessful must be present in the documentation to justify the length of the hospital stay.

Documentation, also called charting, is necessary for accreditation of the health care agency, and for research data collection. For example, statistics may be collected for the number of cases of pneumonia treated, the average age of the patients, results of the treatment, and record treatments that were given. This information can be used to determine things like whether pneumonia was present in certain populations or age groups, or which treatments were most effective. Documentation is also useful for supervisory purposes as a portion of evaluation of staff performance.

The patient’s health record is a legal document and can be used as evidence of events that occurred and treatment that was given. Thorough documentation provides a way to show that standards of care have been met.

Table 7.1

Paper Sheets or Electronic Screens Used for Hospital Documentation

Sheet or Screen Type of Information Included

General Sheets and Screens

Demographic sheet or screen Patient data, including the patient’s name, address, phone number, next of kin, hospital identification number, religious/spiritual affiliation, place of employment, insurance company, occupation, name of admitting health care provider, and admitting diagnosis.

Provider orders The provider’s orders for patient care, including diagnostic studies, nonsurgical and surgical treatments, medication orders, and consultations.

Trended information Record of serial measurements and observations, such as vital signs (temperature, pulse, respiration, blood pressure); weight; intake and output or a 24-hour period.

Nursing care plan Care plan for the patient, including problem statements/nursing diagnoses, goals and expected outcomes, and nursing interventions.

Nursing notes Documentation of the nursing process (i.e., assessment, data analysis/problem identification [nursing diagnosis], planning, implementation, and evaluation) or the NCSBN Clinical Judgment Measurement Model (i.e., recognize cues, analyze cues, prioritize hypotheses, generate solutions, take action, and evaluate outcomes); a record of interventions implemented and the patient’s response to them.

Care flow sheet or screen Sheet or screen on which check marks or short entries are made to indicate dietary intake, type of bath, wound dressing changes, oxygen in use, health care provider visits, equipment in use, level of activity, and so forth.

Medication administration record (MAR) Documentation of all medications ordered, doses given, and doses not taken or declined by the patient.

History and physical examination sheets or screens Primary care provider’s record of the patient’s medical history and findings of the current physical examination.

Table Continued

Sheet or Screen Type of Information Included

Nurse’s admission history and assessment Nurse’s current history, including usual habits, medications usually taken, reason for admission, and physical assessment findings at admission.

Progress sheet or screen Primary care provider’s notes regarding the patient’s progress.

Laboratory reports Results of laboratory tests.

Radiology reports Results of imaging examinations (e.g., X-rays, CT scans, MRI scans, etc.).

Admission sheets or screens General information on patient identification, conditions for admission, and consent for general medical and nursing care.

Miscellaneous Sheets or Screens

Ancillary staff sheets or screens Records of treatments by physical therapists, occupational therapists, respiratory therapists, speech therapists, and so forth.

Consultation sheets or screens Record of another health care provider’s findings after being called in to consult by the primary care provider.

Diabetes care flow sheet or screen Record of blood glucose determinations and amounts of insulin administered.

Discharge form Information for the patient about instructions given regarding wound care, medications, rest, activity restrictions, needed exercises, diet, and signs and symptoms to report to the primary care provider; also includes when to see the provider next.

Discharge planning sheet or screen Records by social services, home health agencies, case managers, and clinical nurse specialists regarding the discharge plans and patient’s needs.

Fall risk assessment Information regarding the patient’s potential fall risk; particularly used for older adults, or patients with neuromuscular impairments or who are frail.

Frequent observations sheet or screen Sheets or screens used when frequent measurements of vital signs or neurologic assessments are needed (e.g., after surgery, after head trauma).

Intravenous (IV) flow sheet Record of IV fluids and additives infused, type of IV catheter in use, date tubing was changed, and date dressing was applied.

Pain assessment Record of pain level, when assessed, measures taken to reduce it, patient’s response to treatment, and effectiveness of treatment.

Preoperative checklist List used to verify that the patient is ready to go to surgery.

Skin risk assessment Data from thorough skin assessment performed on admission; evaluation of risk factors for skin breakdown; diagrams showing areas of redness, breaks in the skin, or pressure injuries.

Surgical or treatment consent form Signed patient authorization for surgery or treatment.

Time-out sheet or screen Patient verification, site-mark verification, and time-out performed before surgical procedure.

Transfer sheet or screen Information pertinent for the transfer of the patient to another unit or facility or agency.

Documentation is also used to track the application of the nursing process. The nurse records observations made about the patient, notes the care and treatment that was delivered, and adds the patient’s response. Documentation shows progress toward the expected outcomes listed on the nursing care plan.

AACN EssentialsQuality and Safety

Health Record Audits

Documentation in the health record is audited regularly as part of the health care agency’s quality improvement program. Evidence that care adheres to accepted standards must be present in the nurse’s notes. The results of audits of the health records indicate where improvement may be needed.

Documentation and the Nursing Process

• Learning Objective: Summarize the integration of documentation into the nursing process.

An initial assessment is documented for each shift. Standard areas of assessment are present electronically or on a flow sheet, and additional notes can be added if abnormalities exist. Nurses also document in the nursing notes, nursing care plan, or interprofessional care plan as determined by the agency and the type of health record they maintain.

Plans of care are often organized by problem statement or nursing diagnosis. These are entered on the care plan, which is created soon after the admission assessment is complete. The plan is reviewed and updated every 24 hours or as needed if situations change. Implementation of each intervention is documented, including the specifics of what was done, how it was done, when it was done, and the patient’s response. This type of documentation shows whether there is progress toward the stated expected outcomes and goals. Evaluation data must be documented showing that expected outcomes have been achieved before a problem statement is “resolved” or deleted from the care plan. When expected outcomes are not being met, the care plan is altered to better represent the patient’s needs and current status.

Think Critically

If evaluation data are not showing progress toward expected outcomes, what part of the nursing care plan needs to be altered? Where in the health record would this be done?

The Health Record

• Learning Objective: Summarize legal aspects of the health record, including issues of ownership and storage.

The health record contains data on a patient’s stay in the health facility or while under the care of a health care provider. Each type of facility has a particular type of record used to document information about the patient.

As a legal record, the health record’s contents are confidential; this means you can only give out information with the patient’s written consent because the health record contains personal information regarding the patient. Protecting the patient’s privacy is of prime importance. Do not discuss patient information with others not directly involved in the patient’s care. Only health professionals caring directly for the patient should have access to the health record. Researchers and educators may also have access to specific patient records under certain conditions.

The owner of the patient’s record is state-specific. In certain states, the patient owns their own record. In other states, the patient owns their own health data included in the record, but the health care provider or agency owns the actual record. In all states, per federal law, patients do have the right to access information contained in their record (see Chapter 3) (Office for Civil Rights, n.d.). Health agencies must maintain electronic or paper records per their individual state laws (Office of the National Coordinator for Health Information Technology, n.d.). There is often a different time requirement for maintaining adult records versus those of children. Follow agency policy, which will be established according to state law, for helping patients gain access to information in their record.

Think Critically

You are working on a hospital unit where your neighbor’s spouse is a patient. When the neighbor asks you to tell her what the primary care provider wrote in their spouse’s health record, how will you answer?

Methods of Documentation (Charting)

• Learning Objective: Compare methods of documentation, including advantages and disadvantages of each.

Different methods of documentation (also known as charting) are used in various health care agencies. The eight main methods of documentation are (1) source-oriented (narrative) documentation, which is organized by “source” or author of the documentation entry; (2) problem-oriented medical record documentation (POMR), which focuses on the problems the patient experiences as a result of being ill; (3) focus documentation (F-DAR), which centers on the immediate health concern experienced by the patient; (4) SOAP documentation, (5) Problem Identification, Interventions, and Evaluation Documentation (PIE Charting), (6) charting by exception, which focuses on deviations from predefined norms, using preset protocols and standards of care; (7) electronic documentation, in which a program helps to facilitate electronic documentation; and (8) case management system documentation, which tracks variances from the clinical pathway.

Whatever method of documentation is used, you are required to document the patient’s progress periodically during the shift, at each outpatient encounter, or at the time of a home health visit. The health record entries are either in your notes or on flow sheets (Fig. 7.1). Flow sheets track routine assessments, treatments, and frequently given care. The specific time frame required for documentation is found in the agency’s policy and procedure manual. At the minimum, one assessment must be recorded per shift. Some agencies require more frequent documentation updates. It is also best practice to document any time something is done for the patient, and the patient’s response.

Source-Oriented or Narrative Documentation

• Learning Objective: Describe source-oriented or narrative charting, including advantages and disadvantages.

These records are organized according to the source of information. There are separate areas for health care providers (focusing on medical problems), nurses (focusing on problem statements/nursing diagnoses), dietitians, and other health care professionals to document their assessment findings and plan the patient’s care. Narrative notes, which often look like a paragraph, are phrases and sentences written without any standardized structure, content, or form. Narrative documentation used in source-oriented records requires documentation of patient care in chronologic order. Assessments usually follow a body systems format. The content is similar to a set of dated and timed journal entries (Fig. 7.2).

Advantages of the source-oriented (narrative) method:

• It gives information on the patient’s condition and care in chronologic order.

• It indicates the patient’s baseline condition for each shift.

• It includes aspects of all steps of the nursing process.

Disadvantages of the source-oriented (narrative) method:

• It encourages documentation of both normal and abnormal findings, making it difficult to separate pertinent from irrelevant information.

• It requires extensive documentation time by the staff.

FIG. 7.1 Computer activity flow sheet. Created by Susan C. deWit, RN; Carolyn Sims, LPN.

Computer activity flow sheet shows details including ambulate, activity response, feeding, diet, ate percentage, hygiene, standard prec, skin, INC or WDS upper, IV lines. At the top right corner, details of patient, hospital, date, room, age, sex, and ID are given.

FIG. 7.2 Example of source-oriented (narrative) charting.

Table of four columns shows the example of source-oriented charting. The column headers are date, time, problem, and nurse’s notes. Time: 2015; Nurse’s notes: States has “sharp throbbing” abdomen pain at a 7 on a 0 to 10 pain scale. Started at 2000 when amb down hall. T 99, P 88, R 24, BP 146/82. Unrelieved by change in position or rest. Time: 2020; Nurse’s notes: Meperidine 75 milligrams IM RUOQ. Time: 2045; Nurse’s notes: Resting quietly in bed. P 86, R 20, BP 146/78. States pain level at 4 on 0 to 10 pain scale.

Table 7.2

Major Components of the Problem-Oriented Medical Record

Area Contents

Database Initial assessment, general health history, findings of the physical examination, results of diagnostic and laboratory tests, psychosocial information, nursing assessment, and patient’s response to the illness or problem.

Problem list A list of problems derived from the information in the database which is continually updated with resolved problems archived and new problems added. Problems are listed in the chronologic order in which they were identified, not by priority. Both actual and potential problems are listed.

Plan A three-part plan of care is devised based on the identified problems. For each problem, there is a plan for diagnostic studies, a therapeutic plan, and a patient education plan. The health care provider orders therapies for medical problems, and the nurse plans care for nursing problems.

Progress notes

Contain the assessments, plans, orders, treatments, and interventions of the health care providers, nurses, and other members of the interprofessional health care team involved in the patient’s care. Notes are organized by problem number from the problem list. Often the problem is addressed in SOAP format:

S: Subjective data that include symptoms and patient’s description of the problem

O: Objective data based on health care team’s observations, physical examination, and diagnostic tests

A: Assessment or analysis of the meaning of the data obtained

P: Plan to resolve the problem

Discharge summary A summary of the problems the patient had, how they were resolved, and the plan for care after discharge.

• It discourages health care providers and other health team members from reading all parts of the health record because of the lengthy descriptive entries in it.

Problem-Oriented Medical Record Documentation (POMR)

• Learning Objective: Describe problem oriented health record (POMR) charting, including advantages and disadvantages.

POMR documentation focuses on patient status, emphasizing the problem-solving approach to patient care and providing a method for communicating what, when, and how things are to be done to meet the patient’s needs. The POMR contains five basic parts: the database, the problem list, the initial plan, the daily progress notes (in which all members of the health care team document), and the discharge summary (Table 7.2). The precise form these records take varies greatly between agencies, but the essentials of documentation are the same.

Advantages of POMR documentation:

• It provides documentation of comprehensive care by focusing on patients and their problems.

• It promotes the problem-solving approach to care.

• It improves continuity of care and communication by keeping data relevant to a problem all in one place so that it is more available to all who are providing care.

• It allows easy auditing of patient health records in evaluating staff performance or quality of patient care.

• It requires continual evaluation and revision of the care plan.

• It reinforces application of the nursing process.

Disadvantages of POMR documentation:

• It results in loss of chronologic documentation if recorded on paper.

• It is more difficult to track trends in patient status.

• It fragments data because of the increased number of flow sheets or electronic entries required.

Focus Documentation (F-DAR)

• Learning Objective: Describe focus documentation, SOAP documentation, problem identification, interventions, and evaluation (PIE) charting, including advantages and disadvantages.

Focus charting is similar to the POMR system, but it substitutes focus for the problem, eliminating the negative implication associated with the word problem. Focus charting is directed at a problem statement (fluid volume deficit), a nursing diagnosis, a concern (decreased fluid intake), a sign (poor skin turgor), a symptom (anxiety), or an event (return from surgery). The focus note has three components: Data, Action, and Response (DAR) or Data, Action, and Evaluation (DAE) (Fig. 7.5). The data component contains subjective and objective information that describes or supports the focus of the note. The action component includes interventions that are planned, as well as performed. The response component describes the outcomes of the interventions.

Advantages of F-DAR documentation:

• It is compatible with the use of the nursing process.

• It shortens documentation time by using many flow sheets and checklists.

• The focus is not limited to problem statements or nursing diagnoses.

Disadvantages of F-DAR documentation:

• If the record is not complete, patient problems may be missed.

SOAP Documentation

Another method for documentation is the SOAP format (for Subjective information, Objective data, Assessment data, and Plan) (Fig. 7.3A). Some agencies use the acronym SOAPIE documentation, which includes Implementation and Evaluation (SOAPIE) (Fig. 7.3B), or SOAPIER, which includes Revision. It is not necessary to use each component of the SOAPIER format every time you make an entry. If there are no subjective data, the S can be omitted or labeled “none.” If there is no revision, the R can be left out.

FIG. 7.3 (A) example of problem-oriented medical record (POMR) charting. (B) Example of SOAPIE (Subjective, Objective, Assessment, Plan, Implementation, Evaluation) charting.

A) Chart of four columns shows problem-oriented medical record charting. The column headers are date, time, problem, and Nurse’s notes. Problem: Hash 2 Acute pain, Abd; Nurse’s notes: S: States having RUQ pain radiating to right shoulder. Is “like a knife is poking me.” States is a 6 on a scale of 0-10. O: Pale, diaphoretic and shaky. Splinting and c bar hands. T 100 degrees Fahrenheit, P 112, R 22, BP 134/88. A: Abd pain. P: Institute NPO status; provide intervention when order received. B) Chart of four columns shows SOAPIE charting. Problem: hash 1 Hyperthermia; Nurse’s notes: S: States feeling “warm and restless.” O: Face flushed; skin hot to touch. T 103 degrees Fahrenheit, P 120, R 26, BP 160/90. A: Hyperthermia r/t wound infection. P: Medicate for increasing temperature. I: Acetaminophen 500 milligrams. E: T 101.6 degrees Fahrenheit, P 95, R 24, BP 154/86.

Advantages and disadvantages of the SOAP (or SOAPIE or SOAPIER) method of documentation are similar to those associated with POMR and F-DAR charting.

Problem Identification, Interventions, and Evaluation Documentation (PIE Charting)

Another method of documentation is PIE charting, which follows the nursing process and stands for Problem identification, Interventions, and Evaluation (Fig. 7.4). Problem statements/nursing diagnoses are recorded in the P section of the PIE format; each problem or nursing diagnosis is labeled with a number (e.g., P1, P2). Interventions are documented in the I section of the PIE format and are listed by the corresponding problem statement/nursing diagnosis (e.g., I1 is an intervention to address P1). Finally, evaluation of the patient’s progress is noted in the E section of the PIE format. Evaluations are also numbered based on the initial problem list (e.g., E1 is an evaluation of the patient’s progress regarding P1).

Advantages and disadvantages of PIE documentation are similar to those associated with POMR and F-DAR documentation.

Charting by Exception

• Learning Objective: Describe charting by exception, including advantages and disadvantages.

Charting by exception was developed in the early 1980s by a group of nurses in Wisconsin. The goal was to decrease the lengthy narrative entries of traditional documentation systems and reduce repetition of data. Charting by exception is based on the assumption that all standards of practice are carried out and met with a normal or expected response unless otherwise documented. Agency-wide and unit-specific protocols (standard procedures) and standards of nursing care are the heart of the system. The standards and protocols are integrated into flow sheets and forms, and the nurse needs only to document abnormal findings or responses related to the problem statements listed on the nursing care plan.

Charting by exception is the direct opposite of the saying, “If it wasn’t documented, it wasn’t done.” Charting by exception assumes that, unless documented to the contrary, all standards and protocols were followed and all assessment values were within expected and acceptable limits. This type of documentation may present some legal problems when a record is called into court because only the abnormalities are documented.

Advantages of charting by exception:

• It highlights abnormal data and trends in the patient’s condition.

• It decreases narrative documentation time.

• It eliminates duplication of charting.

• It lends itself to computerized documentation systems.

Disadvantages of charting by exception:

• It requires development of detailed protocols and standards.

• It may require training new staff to use unfamiliar methods of documentation.

• Nurses become so used to not charting that important data can easily be omitted.

FIG. 7.4 Example of PIE (Problem identification, Interventions, Evaluation) charting.

Chart of PIE is shown. The column headers are date, time, problem, and nurse’s notes. Problem: Pain r/t ROM exercises of R knee by CPM machine. The nurse’s notes are as follows: P. Educate pt in use of PCA and measures for distraction. I. Instructions for use of PCA given; encouraged to watch TV movie for distraction. Knee position on CPM machine OK. E. Using PCA as needed; pain decreased. States is tolerable at 3 on a scale of 0 to 10. Watching movie.

FIG. 7.5 Example of focus charting.

Chart of focus charting is shown. The column headers are date, time, problem, and patient progress. Problem: Altered skin integrity right ankle. The patient progress is as follows: D. Slight serous drainage on dressing; wound 1 multiplies by 2 centimeters c bar left red border; no odor; states hurt slightly. A: Cleansed c bar sterile saline. DuoDerm thin applied. R: Wound clean; minimal drainage present.

Electronic Documentation

• Learning Objective: Describe the use of the electronic health record (EHR), including types of documentation systems, security considerations, advantages, and disadvantages.

Electronic documentation is accomplished via an electronic health record (EHR), a computerized comprehensive record of a patient’s history and care across all facilities and admissions. EHRs provide vital information to health care personnel instantly so that they can immediately review previous problems, treatments, and responses.

AACN EssentialsInformatics and Healthcare Technologies

Nursing Informatics

Nursing informatics is “the specialty that transforms data into needed information and leverages technologies to improve health and health care equity, safety, quality, and outcomes” (American Nurses Association, 2022). The electronic health record is a component of informatics.

Confidentiality is a major consideration when an agency adopts, upgrades, or changes an electronic documentation system. Encryption and authentication software is used when reports are transmitted outside of the health care facility campus. Despite evolving methods of security, electronic systems still have vulnerability. Within health systems, computer records are protected by passwords and a firewall. Each user who has access to patient records must have a secure password, which must be changed regularly to maintain security. Based on their position or job code, each individual is given a level of security that allows access to only the specific information required to perform their job.

When working on documentation at the computer, never leave the terminal while any part of a patient’s health record is on the screen. Log out when you are done viewing or documenting in the electronic health record. Situate terminals so that passersby cannot view the information displayed and use privacy screens which also obstruct view from others. Organizations have specific policies outlining access, security, and use of the EHR. Organizations require all employees of health care organizations to sign nondisclosure agreements (see Chapter 3) regarding confidential patient information.

See Box 7.1 for tips on essential elements of electronic documentation.

Legal & Ethical Considerations

Confidentiality and Security With Computer Documentation

You have a legal obligation to guard your password and not give it to anyone at any time for any reason. Be sure to shred any printed or paper documents, such as report sheets or paper that you may have jotted notes on, that has any identifiable information before finishing your shift. In addition, keep them concealed while working. HIPAA requirements (see Chapter 3) mandate that all patient information be kept confidential.

Although your password gives you access to the records of patients to whom you are assigned, you will not be able to access records of patients who are being seen elsewhere. Only administrative personnel can view the record of any patient in the hospital.

Computerized provider order entry (CPOE) is a part of electronic documentation that provides for efficient workflow. Orders entered into the computer directly by the prescribing health care provider are automatically routed to the appropriate clinical areas for action. For example, an order for a new medication is entered on the computer and then automatically posted to the electronic medication administration record (eMAR) for that patient. The pharmacy is notified electronically to fill the order. Because the electronic order is always legible, transcribing errors are eliminated.

Box 7.1 Essential Elements of Computer Documentation

• Attend mandatory electronic documentation orientation held by the agency. Request a “quick reference guide”, if available, that can provide you with quick information about use.

• Ask to be introduced to the “superuser” in your work area; this person can be used as a resource when questions arise.

• Refresh the computer screen often to keep track of the most current orders and entries.

• Document in a timely manner; when time permits documenting at the point of care is preferable.

• Do not “copy and paste” anyone else’s documentation.

• Never share passwords or computer codes; when passwords or codes are assigned by the Information Technology department, they are tied directly to your legal electronic signature.

• Review your notes for accuracy before you select “confirm” or “save.”

• Never walk away from your terminal without logging off.

In electronic documentation, it is important to have standard terminology that can be used by the entire interprofessional team. The Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT) is a reference vocabulary developed for this purpose (SNOMED International, 2023). The vision for this initiative is to have one global language of health care by 2025.

The Centers for Medicare and Medicaid Services (CMMS) operates the Medicare Promoting Interoperability Program. This is an initiative for eligible hospitals and critical access hospitals (CAHs) focused on improving connectivity and patient access to health information (CMMS, 2023). To maintain reimbursement eligibility without payment adjustments, these agencies must be meaningful users of Certified EHR Technology (CEHRT) that meets certain criteria (CMMS, 2023).

Documentation can be done in real time if a hospitalized patient is in a room with a computer terminal (Fig. 7.6) or a handheld tablet that can be carried between rooms. Computer-assisted documentation can save nurses’ time. Entries can be made at the point of care, at the time a change in condition is observed, or when a treatment is given. The information is recorded in the moment. This decreases the need to document later in a shift and reduces the likelihood of forgetting certain elements of care that need to be recorded. If the system uses a drop-down table or menu to select from, you can quickly choose the appropriate description or intervention and do not have to enter free text. Test and diagnostic results can be electronically added to the record as they are received, allowing for more rapid information flow between members of the interprofessional health care team.

Computerized systems for documenting patient care vary and are organized in one of the formats discussed earlier in this chapter. There are several systems of electronic documentation that are used at places of care nationwide within the United States. Patients can enable their record, if they wish, to be viewed by any health care organization that has the same computerized system, which enhances continuity of care. Fig. 7.7shows an example of a patient’s electronic health record.

FIG. 7.6 Nurse using a workstation on wheels at the bedside to do point-of-service documentation.

In fully implemented EHRs, clinical information from all sources flow into the record. This results in a longitudinal record that contains documentation of all of a patient’s health care through time. The record is divided into episodes of care. An episode of care can occur in the outpatient or inpatient setting, any time the patient received assessment and/or intervention. As mentioned earlier, laboratory results, diagnostic imaging results, pathology reports, medication administration, and other information from all care delivery settings are available via the EHR. This provides virtually instant access to a complete health history.

Cultural Considerations

Helpful Specific Cultural/Global Information

Documenting the following patient information promotes continuity of care within the interprofessional team.

Primary language spoken

• Specific communication needs (The Joint Commission requirement); this may include a professional interpreter, hearing assistance, or other means to facilitate communication

• Head of family or spokesperson if the patient does not speak for themselves.

• Dietary preferences and foods not permitted in the diet.

• Ability to read and write in English.

• Beliefs about cause and meaning of illness.

• Special needs related to cultural, religious, or spiritual beliefs.

• Individual needs for uninterrupted time for meditation or prayer.

Advantages of electronic documentation:

• The date and time of the notation are automatically recorded.

• Notes are always legible and easy to read.

• There is quick communication between departments about patient needs.

• Multiple health care providers can access the same patient’s information at one time.

• Documentation time is usually reduced (vs. documenting on paper).

• Electronic records can be retrieved quickly.

• Reimbursement for services rendered can be completed faster.

• A complete longitudinal record of the patient’s health history at one point of access is available.

• Well-designed systems can reduce errors, having a favorable effect on patient safety and health outcomes.

Disadvantages of electronic documentation:

• A sophisticated security system which is continually monitored and upgraded must be maintained to prevent unauthorized personnel from accessing patient records.

• Initial costs to adopt an electronic system of documentation are considerable due the amount of hardware needed, which is in addition to the cost of the actual program.

• Implementation of a full EHR system (for an agency that has not previously documented electronically) can take considerable time. This results in the need to use two systems, paper and electronic, during that transition.

• Significant cost and time are involved in continually training staff to effectively use the system.

• Computer downtime can create problems of input, access, and transfer of information. Well-established backup plans (downtime procedures) must be developed.

Case Management System Documentation

• Learning Objective: Recall the use of case management system charting.

Case management is a method of organizing patient care through an episode of illness so that clinical outcomes are achieved within an expected time frame and at a predictable cost (see Chapters 1 and 2). A clinical pathway or interprofessional plan of care takes the place of the nursing care plan. Documentation of variances from the clinical pathway is placed within the documentation. For example, a patient is admitted for abdominal surgery. The wound is healing well, but the patient develops pneumonia. The variance would be documented as in Fig. 7.8.

FIG. 7.7 Example of portion of a patient’s electronic health record.

The web page shows a patient’s electronic health record. The info panel on the extreme left shows Patient summary, authority of admission, admission history, history and physical, orders, MAR, vital signs, assessments, basic nursing care, provider notes, nursing notes, laboratory diagnostics, and patient teaching. Patient summary is selected and shows the following information: risk alert: fall risk, pressure sore risk, and obstructive sleep apnea risk with no data entered; basic information including code status (full code), isolation status and alerts with no data entered and allergies with NKA entered; problem list including medical diagnosis primary diagnosis of hypotension, secondary diagnosis of mechanical fall, and tertiary diagnosis with no data entered along with nursing diagnosis with no data entered; active invasive items including IV lines; patient monitoring including a table for chart time, temperature, pulse, respiration, blood pressure, oxygen saturation; and active wounds including legends on right hip and bruising.

FIG. 7.8 Example of variance documentation.

Chart divided into three columns shows variance documentation. The data are as follows: Variance: Airway clearance Cause: Pneumonia 7/23 Action taken: 7/23 increased fluids to 2000 milliliters per day. 7/24 Albuterol inhaler for wheezing. 7/24 Incentive spirometer use encouraged every 1 degree while awake. 7/26 Instructed in home molecular oxygen use. 7/26 Unit Air contacted for oxygen delivery.

Think Critically

Which method of documentation seems easiest to you? Can you explain why?

The Documentation Process

• Learning Objective: Describe appropriate documentation of health records.

When documenting patient care, record the patient’s needs, problems, and activities in terms of behaviors. Documentation maintains focus on the immediate past and the present, never the future. In other words, only record what you have done for the patient, not what you plan to do. For example, after assisting a patient to ambulate, you could record, “Ambulated 20 feet down the hall and back with assistance.”

Documentation should follow basic principles, be accurate, objective, and brief (yet complete). When these guidelines are followed, documentation presents a logical view of the patient to anyone who reads the nursing notes.

You, as the nurse, must choose which behaviors and observations are noteworthy. In most agencies, if data (such as patient voiding) are recorded on a flow sheet, they need not be documented again in the nurse’s notes. No other notation is made in the nurse’s notes unless there is a problem or some significant related data. Remember that if the behavior or finding is abnormal or is a change from previous behavior or data, document it.

Basic Principles of Documentation

• Learning Objective: Recall the basic principles of documentation.

Legibility of a record is of critical importance. An electronic record will always be legible. However, in handwritten documentation, legibility can be difficult. If the writing is not easily legible, misperceptions of what was written can occur. This can also present problems in legal proceedings when handwriting cannot be read. This is one of many reasons that most health agencies have transitioned to electronic documentation.

Full sentences are not necessary when documenting. Articles (a, an, and the) may be omitted. Because the record is about a particular patient, the word patient is left out whenever it is the subject of the sentence. Each statement should begin with a capital letter and end with a period. Rather than stating, “Patient left for surgery via stretcher at 10:15,” simply state, “To surgery via stretcher at 10:15.”

Abbreviations, acronyms, and symbols are to be avoided when handwriting, as these can easily be misinterpreted and lead to errors. The Joint Commission (TJC, 2023) has a very specific set of abbreviations to avoid called the “Do Not Use” list.

Accuracy in Documentation

• Learning Objective: Give examples of patient documentation that demonstrate accuracy.

Be specific and definite in using words or phrases that convey the meaning you wish expressed. Avoid using the words appears to or seems in phrases such as appears to be resting. Document the behavior; the patient either is or is not resting. Words that have unclear meanings and slang should not be used in documentation. For example, how much is “a little,” “a small amount,” or “a large amount”? What do phrases such as ate well, taking fluids poorly, and tolerated well mean? Although such words give a general idea of what is meant, they are not specific: they are subjective phrases. Someone else reading the notes will not know if the patient who “ate well” had half a piece of toast, juice, and a cup of coffee or ate a bowl of cereal, scrambled eggs, two slices of bacon, 4 oz. of orange juice, and two cups of coffee. Instead of documenting a conclusion such as “taking fluids poorly,” record the behavior and the specific amounts of liquid taken in a particular amount of time, such as “given fluids at frequent intervals, but takes only a few swallows; intake from 0700 to 1000: 30mL of coffee, 60mL of orange juice, and 50mL of water.” Specific data about size, amounts, and other measurements provide a means for the reader to determine whether the condition is getting better, getting worse, or staying the same. Rather than use the phrase tolerated well, describe what happened, even if it is a statement such as “walked in hall 100 yards without difficulty.”

Objectivity in Documentation

• Learning Objective: Give examples of patient documentation that demonstrate objectivity.

When documenting, record only the facts. Do not insert your opinion or conclusion about information that is being documented. For example, if the patient is verbally challenging and loudly says “Leave the room, I don’t want you in here right now,” record the exact words that the patient says, and do not assign meaning to them. Do not state that you interpreted the patient’s words to be angry, frustrated, or hostile. Simply record what you observed, and what your response was and your plan for ongoing care, such as “Entered room to assess vital signs. Stated ‘leave the room, I don’t want you in here right now’. No apparent distress noted; in bed watching television. Exited room and will attempt to collect vital signs again in 30 minutes.”

Brevity and Completeness in Documentation

• Learning Objective: Give examples of patient documentation that demonstrate brevity and completeness.

Completeness of information is important; however, what is documented should also be clear and brief. You should record information about the patient’s needs and problems and specify the nursing care given for those needs or problems. In other words, any time you document anything abnormal, also document what you did about it, or at minimum who you notified.

For example, if you document, “Skin at intravenous site reddened and slightly swollen,” you must include a note about what you did about the problem. The full note should read, “Skin at right forearm intravenous insertion site reddened and slightly swollen in 4-cm area. Intravenous catheter discontinued and cool moist pack applied for 20 minutes. Redness and swelling receding. New intravenous access restarted in left hand with 20-gauge catheter.” For documentation completeness, note something about most or all of the seven pertinent characteristics listed in Box 7.2.

What constitutes complete documentation may vary among hospitals, extended-care facilities, and other health care agencies. Home care documentation must particularly note safety factors in place and the need for continued care (Fig. 7.9). Long-term care facilities may require only a monthly summary for patients in stable condition or a note when their condition changes (Fig. 7.10), whereas hospitals caring for acutely ill patients require continual documentation of the patient’s condition, with entries made every few hours or more often if needed.

What to Document

• Learning Objective: Recall types of information to document and general documentation guidelines.

In addition to assessment data related to signs and symptoms, information on the topics in Box 7.3 is to be documented either on flow sheets or in the nurse’s notes. The documentation examples included with the procedures throughout this book show how to describe different types of information.

General Documentation Guidelines

In addition to those mentioned above, there are several other general rules to consider when documenting (Box 7.4). Fig. 7.11 shows the use of regular versus military time for health record entries.

Box 7.2 Guidelines for Documenting a Sign or a Symptom

Location in the body: Describe the exact location of where the concern is occurring in or on the body.

Quality: Describe what the patient is feeling in their own terms; for example, a person having a myocardial infarction (heart attack) might describe the chest pain as feeling as if the chest is being “squeezed.” Other descriptions may include words such as “sharp”, “stabbing”, “dull”, or “pulsating”.

Quantity: Document the intensity of the symptoms (i.e., mild, moderate, or severe). Use a scale of 0–10 for pain, with 10 being the highest. Indicate the degree of impairment and the frequency, volume, and size or extent of the sign or symptom. Note the number of times the patient has had the symptom. For symptoms like vomiting or diarrhea, also include the amount each time.

Chronology: Note the sequence of development of symptoms or the primary problem:

1. Time of onset of the sign or symptom (or when the problem occurred)

2. Duration (minutes, hours, or days)

3. Pattern of variation and frequency and the course of the signs or symptoms (e.g., whether symptoms have stayed the same, gotten better, or gotten worse since the issue began)

Setting: Document where the patient was when the symptom or problem began (e.g., at home, in bed, in the car). Also record what the patient was doing (e.g., running, sleeping, eating), and who is the patient with (e.g., mother, spouse, boss) when the symptoms or problem began.

Aggravating or alleviating factors: Record what the patient says makes the signs or symptoms worse and what makes them better? For example, document if the patient noticed breaking out in a rash after using a certain kind of laundry detergent, or whether certain foods cause reflux and a burning sensation in the chest.

Associated signs and symptoms: Signs and symptoms rarely occur singly; document any other issues the patient reports in addition to their primary concern. For example, document if the patient reports having nausea with vomiting, or if they have a headache with neck pain.

FIG. 7.9 Printout from home care agency electronic documentation. Modified from Mission Hospice and Home Care, San Mateo, California.)

Specimen of routine home health assessment shows the names of patient, nurse, visit date, and time at the top. The section headings along with information are as follows: • Data/Safety/Dx - Patient Data: Source of information, residence, lives with, financial concerns, assistance with care, main caregiver, caregiver availability, assistance type, health risks. • Data/Safety/Dx – Safety: Pt with Hx of falls. • History/Vitals/Pain - Primary Pain Location Descript: present pain, acceptable pain. • Vital signs: Temperature, radial pulse, apical pulse, pulse rhythm/quality, respirations. • Psychosocial/Skin/Ulcers: Skin S/S, stasis ulcer. • Cardiovascular: Cardiovascular signs/symptoms, heart (cardiac) sounds. • Head/Ears/Eyes/Nose/Throat: HEENT S/S, Status of vision, hearing/understanding, expression ability, speech patterns.Continuation of specimen of routine home health assessment shows the names of patient, nurse, visit date, and time at the top. The section headings along with information are as follows: • HENT/Res/CV/Neu – Neurological: Neuro S/S, mental status, confusion occurrence, anxiety, depression identification, behavior issues and occurrences. • HENT/Res/CV/Neu – Respiratory: Respiratory sign, lung fields right, lung fields left, dyspnea. • Musc/ADLs/IADLs – Musculoskeletal • GI/GU/Endc/Plan: Immune system, medication change since last visit. • Gastrointestinal: Last BM, present bowel pattern, bowel incontinence occurrence. • Genitourinary: Genitourinary S/S, Urinary incontinence. • Medical Safety: Med safety measures. • GI/GU/Endc/Plan – Nutrition: Nutritional S/S, nutritional requirements, meal patterns, Skin turgor. • GI/GU/Endc/Plan – Planning: Plan for next visit, education/assist, medications assessed for, instructed/copy to, plan of care discussed with.

Box 7.3 Types of Information to Be Documented

• Activity

• Admission information

• Assessment data (all body systems)

• Concerns expressed by patient and/or family

• Death

• Diagnostic tests

• Diet

• Discharge

• Dressings and wound care

• Elimination

• Hygiene

• Intake and output

• Intravenous infusions

• Medications

• Mental state

• Mood

• Oxygen use

• Pain or discomfort

• Patient education

• Preoperative/postoperative care

• Primary care provider’s visits and calls to provider

• Postoperative care

• Procedures performed

• Sleep

• Specimens obtained and their disposition

• Travel from the unit

• Tubes and equipment in use

• Visitors

Box 7.4 General Guidelines for Documenting

• Verify you are on the correct patient’s computer screen before beginning to document in the electronic record.

• Record the initial assessment at the beginning of the shift.

• Document using a 24-hour clock (military time; see Fig. 7.11) (if this is the format used by the agency)

• Recognize that documentation is done only by the person who made the observation or performed the intervention and who is legally responsible for the accuracy and quality of care.

• Record objective data after completing each task.

• Never document before a task is actually done.

• Follow hospital policy for amending the record if a change needs to be made.

• Identify care given by another health care team member by documenting their name (e.g., “Dr. Joseph removed stitches from RLQ abdominal incision at 1815”).

• Record a patient’s explanation any time they refuse a medication or treatment. Document the exact words the patient used when refusing to adhere to the recommended plan of care. Document instructions given to the patient and the patient’s response to the information.

• Spell all entries correctly. Use a dictionary or electronic “spell checker” to check words you are unsure how to spell.

• If you suspect that a medical order or progress note is incorrect, seek clarification from the person who wrote the order or the note. If you make an error when documenting, follow agency policy for correcting the error.

FIG. 7.10 Example of long-term care facility documentation.

Chart of long-term care facility documentation divided into two columns as date/time and licensed nurses progress notes. Licensed nurses progress notes: Patient asked both nurses at med carts for IM injection Cortisone and “could I have meds right now?” Instructed to take seat at breakfast table. Patient’s roommate called nurse. Patient supine on floor no changes to LOC. Walker at side A/O. Answered all questions appropriately, no delta in speech and mentation. VS taken by this RN: T 98.6, P 76, R 16, BP 120/80. Denies HA, no s/s stroke/TIA- clear conversation, no paralysis. C/O right knee discomfort. When asked what happened- why she fell. Assisted to chair. Denies pain. Neuro VS unremarkable: PERL hand grips strong- no s/s hypoglycemia, no sweating or lethargy.

FIG. 7.11 Military time versus civilian time. From Potter, P. A., & Perry, A. G. (2005). Fundamentals of nursing (6th ed.). St. Louis, MO: Mosby.

Documentation is crucial in health care as it provides a record of a patient's history, treatment, and care, serving for reimbursement justification, legal evidence, and quality improvement. Documentation is communicated through health records, which include all orders and treatments. Organizations like the Centers for Medicare and Medicaid Services set standards for documentation. Most care is documented in electronic health records (EHRs), which can be accessed by patients and providers, enhancing continuity of care. The health record is confidential and requires patient consent for sharing. Different documentation methods, from source-oriented to electronic systems, have their advantages and disadvantages, with electronic documentation providing legibility and quick access. Key principles of accurate documentation include objectivity, specificity, and confidentiality, ensuring that patient information is clear and precise, while adhering to laws and agency policies regarding access and corrections.