Documentation NUR101 Lecture #5 Fall 2009 K. Burger, MSED, MSN, RN, CNE PPP by S. Niggemeier, MSN, BSN, RN

Purpose of Documentation  Supports Nsg actions indicates client’s condition  Primary communication tool  Legal protection  Reimbursement  Education  Quality Assurance  Research  Historic and legal document  Decision analysis

Types of Documentation  Nurses Notes  Flow sheets  Graphics  Nursing Care Plans  Caremaps  Critical Pathways  Computer charting

Methods of Documentation  Traditional (source oriented client record)  Problem Oriented Medical Record (POMR) -SOAP -PIE -Focus DAR  Charting by exception

Documentation  NN (nurses notes) best assessment of pt. care. Most used section of the medical record in legal cases  Documentation or Charting is a skill  Record of pt.’s condition, activities and events that occurred to the PATIENT.  Not a diary of your activities.  Includes Subjective & Objective info

Documentation  Chart facts, not your opinion  Use quotations if pt. said it.  Be specific!! Using nonspecific terms implies doubt about your knowledge. i.e. appears/seems/tolerated well etc.  In most cases when care or observations are not charted it means it wasn’t done  ABC’s: Accuracy/Brevity/Completeness

Guidelines for Documentation: Content  Focus on pt.  Not a novel or essay  Use short sentences  Abbreviations  Symbols  Don’t need to use word pt.

Guidelines for Documentation: Timing  Chart as soon as possible after care/observations  NEVER chart what you plan to do  Date & time each entry in the margin

Guidelines for Documentation: Format  Use forms as per agency policy(i.e. flow sheets, graphic sheet, NCP, progress notes)  Follow agency guidelines regarding color ink, approved abbreviations, format of time (i.e. military/standard)  Write LEGIBLY-questionable info implies doubt suggests you lack reasonable knowledge  NEVER skip lines!!  Use correct grammar/spelling

Guidelines for Documentation: Accountability  Record is permanent  Sign full name and title  No erasures  Do Not write ERROR for a mistake  Single line thru mistake, print “Mistaken Entry” or ME (if acceptable) above or next to mistake, enter correction, initial & date per policy

Guidelines for Documentation: Confidentiality  Students only use patient initials on assignments  Only caregivers need to know info in chart  Follow facility policy for pt. review of chart.

Other Guidelines for Documentation  Hospitals- computers  Home care- laptops  Telephone orders

Change of Shift Reports  Face – to Face, Taped, Written, Walking Rounds  Must provide significant info about client in a logical order  Should be factual and free from gossip and/or opinion  Utilize SBAR for hand off reports [ See previous lecture on communication]

Documentation Practice