1. Documenting and Reporting
Chapter 15
Documenting and Reporting

2. Ethical and Legal Consideration
Protected legally
Restricted access
Bound by strict ethical codes and legal responsibility
Protect client’s privacy by not using name or any statements to identify client

3. Purposes of Documentation
Communication
Client’s Care
Quality Assurance
Research
Education
Reimbursement
Legal Documentation
Health Care Analysis

4. Source-Oriented Records
Traditional client record
Each discipline makes notations in a separate section
Advantages/disadvantages
Narrative charting used

5. Narrative Documentation
5/1/ – Patient A/O x 3, pleasant. Obeys simple commands, gait unsteady, requires assist x1 with ADLs Face pale pink, MM moist, IV NS c 20meq 125cc/hr –C/D/I. PERRL. Skin D/C/I, no breakdown. Extremities warm, pink, intact, productive cough with mod amount thick yellow secretions AHR 102, strong. Resp 22, regular, unlabored, clear in all lobes. BS + in all 4 quads. BM at this time – mod brown soft. denies,, diarrhea, difficulty with voiding. Unable to palpate bladder. Voiding per BRP. Pulses palpated, strong, bil both upper and lower extremities. Cap refill brisk, skin turgor > 3 secs. No edema noted. Grasp bil equally strong, pedal pushes bil equally strong. Educated pt on diet changes to help with CHF (decrease salt intake). Call light within reach. Denies pain at this time. Will cont to monitor J.Lopez, RN

6. Problem-Oriented Medical Records (POMR)
Data arranged according to client problem
Health team contributes to the problem list, plan of care, and progress notes
Advantages/disadvantages

7. Problem-Oriented Medical Records (POMR)
Four basic components
Database
Problem list
Plan of care
Progress notes
Uses SOAP, SOAPIE, SOAPIER documentation

8. Figure 15-2 pg. 255 8

9. SOAP (IE) Documentation
5/1/12
1730
#1 – Abd. Pain r/t abdominal incision secondary to appendectomy
S- States “I’m hurting.”
O – BP 158/92, P 110; rates pain = 8 on 1-10 pain scale; holding abd.
A – Postoperative pain
P – Administer analgesic as needed.
I – Stadol 2 mg IV . See MAR K. Bradshaw RN
1745
E – Denies pain K. Bradshaw RN

10. PIE Documentation Problem Interventions Evaluation
Consists of a client assessment flow sheet and progress notes

11. Example of PIE charting

12. Focus Charting Progress notes organized into DAR format Data Action
Response

13. Example of Focus charting

14. Charting by Exception (CBE)
Only abnormal or significant findings or exceptions are recorded.
Flow sheets
Standards of nursing care
Documentation often involves a check mark or initials
Exceptions to standards described in narrative form on nurses’ notes
CBE Example
Nursing Assessment flowsheet

15. Computerized Documentation or Electronic Health Record (EHR)
Developed to manage volume of information
Used to store the client’s database, new data, create and revise care plans and document client’s progress
Information easily retrieved
Possible to transmit information from one care setting to another

16. Box 15-2 Selected Pros and Cons of Computer Documentation16

18. Documenting Nursing Activities
Record should describe the client’s ongoing status
Reflect the full range of the nursing process
Document evidence of the nursing process

19. Admission Nursing Assessment
Demographics
Baseline data
Critical elements

20. Nursing Care Plans Provides evidence of the nursing process
Traditional
Standardized

21. Kardex Summary of client plan of care and status Medical diagnoses
Daily treatments
Orders
PDF Kardex

22. Flow Sheets Graphic record Intake and output
Medication administration record
Skin assessment record

23. Progress Notes
Provide information about the progress is making toward achieving desired outcomes
Include information about client problems and nursing interventions

24. Nursing Discharge/Referral Summaries
Completed when client discharged or transferred
Written in terms that can be readily understood
Includes:

25. General Guidelines for Recording
Date and time
Timing
Legibility
Permanence
Accepted terminology
Know abbreviations in Tab 15-4 pg. 264
Do Not Use list pg. 265
Correct spelling
Signature
See also Practice Guidelines pg. 267

26. General Guidelines for Recording (cont'd)
Accuracy
Sequence
Appropriateness
Completeness
Conciseness
Legal prudence

27. 4/11/12 1730 Pt. transferred from PACU. VSS. Ax. Temp 97. 8 F
4/11/ Pt. transferred from PACU. VSS. Ax. Temp 97.8 F. P 108, BP 148/92. Pain = 7. LOC stable. A &O x 3. PERRLA. Grimacing with pain. LR infusing at 125ml/hr in R forearm. Foley catheter in place, draining clear yellow urine. Abdominal drsg. Clean, dry, & intact K. Bradshaw RN

28. Guidelines for Reporting Client Data
Should be concise, including pertinent information but no extraneous detail
Types of reporting:
Change-of-shift report
Telephone reports
Care plan conference
Nursing rounds

29. Military Time 0000 or 2400 = midnight 0001 = one minute after midnight
0730 = 7:30 a.m.
Noon = 1200
Simply add 1200 to the p.m. time
Ex. 5 pm = (5+1200) p.m. = 1700

30. Guidelines for Change-of-Shift Report
Follow a particular order
Provide basic identifying information
For new clients provide the reason for admission or medical diagnosis/es, surgery, diagnostic tests and therapies in the past 24 hours
Significant changes in client’s condition

31. Guidelines for Change-of-Shift Report (cont’d)
Provide exact information
Report client’s need for emotional support
Include current nurse-prescribed and primary care provider-prescribed orders
Clearly state priorities of care and care due after the shift begins
Opportunity to ask & respond

32. Guidelines for Receiving a Telephone Report
Document date and time
Record the name of person giving the information
Record the subject of the information received
Sign the notation
Repeat information to ensure accuracy

33. Guidelines for Giving a Telephone Report
SBAR often used
State the client’s name, medical diagnosis, changes in nursing assessment, vital signs related to baseline, significant laboratory data, related nursing interventions
Have chart ready to give any further information needed
Document the date, time, and content of the call

34. Telephone Orders (Box 15-7 pg. 270)
Write the order down on physician’s order forms
Read back & verify
Question the primary care provider if order that is ambiguous
Must be signed by primary care provider

35. Quality Improvement Evaluating and modifying quality of care
Too Err is Human (IOM, 2000)
Sentinel Event
Joint Website

36. QUESTIONS????

37. Critical Thinking Checkpoint pg. 270