1. Chapter 37 Documenting and Reporting

2. The Health Record
The health record is a manual or electronic account of a client’s relationship with a healthcare facility.
The nurse, being the primary caregiver, must record client information clearly, accurately, and frequently.
The commonly used term for documentation is “charting.”
The client’s health record is usually called the “chart.”

3. The Health Record (cont’d)
Accurate and complete documentation in the client’s health record is an essential communication tool.
It is used:
To maintain effective communication among all caregivers
To provide written evidence of accountability
To meet legal, regulatory, and financial requirements
To provide data for research and educational purposes

4. Communication The health record is a communication tool:
Helps caregivers to exchange information with one another
Offers the client documentation and verification of his or her own health status
It includes information about the client’s condition, treatments, responses to treatments, and plans and instructions for treatment of the client.

5. Accountability
The health record is documented evidence that the healthcare agency and providers have acted responsibly and effectively.
Legal requirements and protection
It is a legal record.
Regulatory requirements
To prove the agency has met standards of care
Financial accountability
Enables third-party payers to reimburse the facility

6. Research and Education
Healthcare planners examine health records of individuals and groups to determine patterns of illness, trends, or effective treatment strategies.
Health records, particularly those kept in computer databases, provide excellent research opportunities in healthcare.
It is also an excellent educational tool.

7. Question Is the following statement true or false?
If health records were not documented, and if it is audited, it is considered correctly done in the eyes of the law.

8. Answer
False If health records are audited, if it was not documented, it was not done in the eyes of the law. This does not exempt the nurse who makes an error.

9. Documentation Systems
The health record is either a manual (paper) document, an electronic document, or a combination of both.
Electronic documents are located in a medical information system (MIS), which is housed in a computer network.
Another documentation system is referred to as electronic medical records (EMRs).

10. Manual and Computerized Documentation
Manual records
Can be kept at the client’s bedside for convenience; documents all important data
Computer records
Can simultaneously be transmitted to a physician’s office or to a distant location for interpretation
All information included in the MIS or EMR is similar to that found in the manual record.
Requires knowledge of use of the computer system

11. Contents of the Health Record
The health record contains four general categories of information.
Assessment documents
Plans for care and treatment
Progress records
Plans for continuity of care
A client’s healthcare information should be confidential.

12. Contents of the Health Record (cont’d)
Assessment documents
Admission record
Medical history and physical
Nursing admission history
Minimum data set (MDS)
Laboratory record
Consultation

13. Contents of the Health Record (cont’d)
Plans for care and treatment ensure that all caregivers provide the same care and treatments for the client.
Problem list
Physician’s orders
Nursing care plan
Teaching plan
Clinical care path
Consents for treatment

14. Contents of the Health Record (cont’d)
Formats of written documentation are based on assessment, nursing diagnosis, planning and goal setting, implementation/interventions, and evaluation.
Flow sheet
Medication administration record
Progress note

15. Contents of the Health Record (cont’d)
Plans for continuity of care forms are used to ensure that the client’s care is consistent and effective.
Teaching record
Transfer form/screen
Discharge/transfer summary

16. Documentation Formats
Narrative–chronological
Progress notes, nurses’ notes, narrative charting
Problem-oriented (focus)
Area charting, focus charting
SOAP, SOAPIER, APIE, PIE, DAPE, DARP, and DARE
Discipline area documentation
Charting by exception (CBE)

17. Documentation Formats (cont’d)
System flow sheet
Case management
Critical pathway
Collaborative pathway
Care mapping
Graphic flow sheet
Medication administration record (MAR)

18. Question Is the following statement true or false?
CBE uses a SOAPIER or a system flow sheet format for certain progress notes.

19. Answer
True Charting by exception (CBE) uses a SOAPIER or a system flow sheet format for progress notes where abnormal signs or symptoms (the “exception” to normal status) are specifically identified, assessed, and interventions are documented.

20. Advantages and Disadvantages
Narrative charting
Very thorough and detailed
Time-consuming
Documentation by discipline
Helps providers in each subspecialty find their own forms quickly and follow the progress of their therapies without having to read notes from other disciplines
Can be difficult to monitor data as a holistic view of the client

21. Advantages and Disadvantages (cont’d)
Charting by exception
Efficient, especially for the client who is physically stable with an uncomplicated care plan
May be a disadvantage when a legal defense claim, such as negligence, is necessary
Case management or critical pathways
Client is the focus of case study, achieves specific outcomes identified in a multidisciplinary team approach, may not be suitable for a client with special or complex individual needs.

22. Advantages and Disadvantages (cont’d)
Medication administration record (MAR)
Lists all medications that the physician has ordered for the client, as well as other information
Used by nonlicensed personnel as well as licensed nurses

23. Data Commonly Found on a Flow Sheet
Vital signs, intake and output
Activities of daily living (ADLs)
Dietary or eating patterns
Neurologic checks (“neuro checks”)
Restraint observation and documentation
Frequent blood sugar monitoring
Postoperative records
Wound care and monitoring

24. Guidelines for Documentation
Document what you see.
Be specific.
Use direct quotes.
Be prompt.
Be clear and consistent.
Record all relevant information.
Respect confidentiality.
Record documentation errors.

25. Recording Documentation Errors
In case of an error in documenting, the nurse should cross out the incorrect statement with a single line, enclose it in parentheses, and write ERROR and initials next to it.
Some agencies recommend using recorded in error (RIE) instead. Other agencies use the term “mistaken entry.”
After filling in the term that the agency uses, record the correct statement.
The EMR has a mechanism for “late entries,” in which the nurse may identify an earlier error.

26. Reporting of Information
“Report-off”—the nurse summarizes the activities and conditions of assigned clients because he or she is leaving the unit for a break or at the end of a shift.
May be very brief or quite detailed
Change-of-shift reporting is a means of exchanging information between the outgoing and incoming staff on each shift.
In walking rounds, caregivers move from client to client, discussing pertinent information.

27. Question
What methods may be used to for change-of-shift reporting? (Select all that apply.) a. Team leader reports to the entire incoming shift. b. One caregiver reports to another caregiver. c. Written report from one caregiver to another. d. Verbal report is given to the caregiver at client’s bedside. e. Report may be recorded on a tape recorder.

28. Answer
a. Team leader reports to the entire incoming shift. b. One caregiver reports to another caregiver. c. Written report from one caregiver to another. e. Report may be recorded on a tape recorder. A change-of-shift report may be given in person, in writing, or by tape recorder. If the report is verbal, it is given in a location where clients and visitors cannot overhear the conversation.

29. End of Presentation