1. Documentation of Nursing Care
Chapter 7
Documentation of Nursing Care

2. Chapter 7

3. Identify three purposes of documentation.
Learning Objectives
Theory
Identify three purposes of documentation.
Correlate the nursing process with the process of charting.
Discuss maintaining confidentiality and privacy of paper or electronic medical records.
Compare and contrast the five main methods of written documentation.

4. Purposes of Documentation
Provides a written record of the history, treatment, care, and response of the patient while under the care of a health care provider Is a guide for reimbursement of costs of care May serve as evidence of care in a court of law Shows the use of the nursing process Provides data for quality assurance studies
Each person who provides care for the patient adds written documentation to the medical chart.
Insurers rely on documentation to determine actual length of stay, procedures performed, and diagnoses established, and to calculate charges due for reimbursement.
Each supply item used and each piece of equipment in service must be documented.

5. Purposes of Documentation
Is a legal record that can be used as evidence of events that occurred or treatments given Contains observations by the nurses about the patient’s condition, care, and treatment delivered Shows progress toward expected outcomes
Charts are also used for research data collection.
Documentation, also called charting, is used to track the application of the nursing process.
Documentation is also used for supervisory purposes to determine how staff members are performing.
Why is accurate documentation important?

6. Documentation and the Nursing Process
Written nursing care plan or interdisciplinary care plan is framework for documentation Charting organized by nursing diagnosis or problem Implementation of each intervention documented on flow sheet or in nursing notes Evaluation statements placed in nurse’s notes and indicate progress toward the stated expected outcomes and goals
Standard areas of assessment are usually noted on flow sheets, and a written note is added if an abnormality exists.
Evaluation data must be documented showing that expected outcomes have been achieved before a nursing diagnosis is marked "resolved" or deleted from the nursing care plan.
What should happen when expected outcomes are not being met?

7. Contains data about patient’s stay in a facility
The Medical Record
Contains data about patient’s stay in a facility
Only health care professionals directly caring for the patient, or those involved in research or teaching, should have access to the chart
Patient information should not be discussed with anyone not directly involved in the patient’s care
Each type of health care facility has a particular set of forms used to record information about patient care.
The medical record is a legal record, and its contents must be kept confidential.
The medical record can only be given out with the patient’s written consent.
The chart is the property of the health facility or agency, not the patient or physician, but patients do have a right to information contained in the chart under certain circumstances.

8. Methods of Documentation (Charting)
Source-oriented (narrative) charting Problem-oriented medical record (POMR) charting Focus charting Charting by exception Computer-assisted charting Case management system charting
Whatever the method used, the nurse is required to chart the patient’s progress periodically during the shift, as defined by the organization.
Chart entries are either in notes or on the various flow sheets, which track routine assessments, treatments, and frequently given care.

9. Source-Oriented or Narrative Charting
Organized according to source of information Separate forms for nurses, physicians, dietitians, and other health care professionals to document assessment findings and plan the patient’s care Narrative charting requires documentation of patient care in chronologic order
Narrative notes are phrases and sentences written without any standardized structure, content, or form in chronologic order—similar to a set of journal entries.
Assessments usually follow a body systems format.

10. Source-Oriented or Narrative Charting (cont’d)
Advantages
Information in chronologic order
Documents patient’s baseline condition for each shift
Indicates aspects of all steps of the nursing process
Disadvantages
Documents all findings: makes it difficult to separate pertinent from irrelevant information
Requires extensive charting time by the staff
Discourages physicians and other health team members from reading all parts of the chart
Because source-oriented charting encourages documentation of both normal and abnormal findings, it can be difficult to separate pertinent from irrelevant information.
Source-oriented charting is time-consuming.
Entries are lengthy, which discourages a thorough reading.

11. Example of Source-Oriented (Narrative Charting)
See Figure 7-2 in text.
Narrative charting always provides a complete listing of what is happening with the patient.

12. Problem-Oriented Medical Record Charting (POMR)
Focuses on patient status rather than on medical or nursing care
Five basic parts: database, problem list, plan, progress notes, and discharge summary
Page 85 Table 7-2
POMR charting emphasizes the problem-solving approach to patient care and provides a method for communicating what, when, and how things are to be done in order to meet the needs of the patient.
It focuses on what, when, and how things are to be done to meet the needs of the patient.
The SOAP, SOAPIE, or SOAPIER format is used for progress notes.
Who developed the POMR?

13. Problem-Oriented Medical Record Charting (POMR) (cont’d)
Advantages
Documents care by focusing on patients’ problems
Promotes problem-solving approach to care
Improves continuity of care and communication by keeping relevant data all in one place
Allows easy auditing of patient records in evaluating staff performance or quality of patient care
Requires constant evaluation and revision of care plan
Reinforces application of the nursing process

14. Problem-Oriented Medical Record Charting (POMR) (cont’d)
Disadvantages
Results in loss of chronologic charting
More difficult to track trends in patient status
Fragments data because more flow sheets required
This type of charting hampers putting the pieces of the patient’s situation together and restricts seeing trends.

15. P—problem identification I—interventions E—evaluation
PIE Charting
P—problem identification
I—interventions
E—evaluation
Follows the nursing process and uses nursing diagnoses while placing the plan of care within the nurses’ progress notes
The problems, teaching, and discharge needs are listed under the P of the PIE format.
Interventions performed are documented under I.
The outcomes of the interventions are evaluated and documented under E.

16. Example of PIE (Problem, Intervention, Evaluation) Charting
See Figure 7-4 in text.
PIE charting allows the nurse to see several parts of the patient’s situation together on one page.

17. Focus Charting
Directed at nursing diagnosis, patient problem, concern, sign, symptom, or event
Three components:
D: data, A: action, R: response (DAR) OR
D: data, A: action, E: evaluation (DAE)
Focus charting is similar to the POMR system but it substitutes focus for the problem, eliminating the negative connotation attached to “problem.”
What is the difference in focus charting and the POMR system?

18. Focus Charting (cont’d)
Advantages
Compatible with the use of the nursing process
Shortens charting time: many flow sheets, checklists
Disadvantages
If database insufficient, patient problems missed
Doesn’t adhere to charting with the focus on nursing diagnoses and expected outcomes
Not limited to patient problems or nursing diagnoses.

19. Example of Focus Charting
See Figure 7-5 in text.
Focus charting is similar to PIE charting.

20. Charting by Exception
Based on the assumption that all standards of practice are carried out and met with a normal or expected response unless otherwise documented A longhand note is written only when the standardized statement on the form is not met
The standards and protocols are integrated into flow sheets and forms, and the nurse needs only to document abnormal findings or responses correlated with the nursing diagnoses listed on the nursing care plan.
Why could this type of charting present some problems with legalities?

21. Charting by Exception (cont’d)
Advantages
Highlights abnormal data and patient trends
Decreases narrative charting time
Eliminates duplication of charting
Disadvantages
Requires detailed protocols and standards
Requires staff to use unfamiliar methods of recordkeeping and recording
Nurses so used to not charting that important data is sometimes omitted
This type of charting may present some problems when a chart is called into court, because only the abnormalities are documented in writing.

22. Computer-Assisted Charting
Electronic health record (EHR)
Computerized record of patient’s history and care across all facilities and admissions
Computerized provider order entry (CPOE)
Provides efficient work flow
Automatically routes orders to appropriate clinical areas
The EHR is the type of record that is a goal for the future for every patient.
Systems are under design and study to accomplish this goal.
Security and confidentiality of records are still a major concern.
What is the Systematized Nomenclature of Medicine Clinical Terms?

23. Computer-Assisted Charting (cont’d)
Documentation done as interventions are performed using bedside computers Variations depending on the system Some produce flow sheets with nursing interventions and expected outcomes Others use a POMR format to produce a prioritized problem list Never leave the terminal while part of the patients chart is on the screen Never share you password with ANYONE Deferent levels of security dependent on your job title
This method is very cost-effective in terms of nursing time, because information is entered from the patient’s room—so no time need be spent trying to recall important details.
Some systems allow clinicians to select data from display screens to build the flow sheets and progress notes.

24. Computer-Assisted Charting (cont’d)
Advantages
Date and time of the notation automatically recorded
Notes always legible and easy to read
Quick communication among departments about patient needs
Many providers have access to patient’s information at one time
Can reduce documentation time
Reimbursement for services rendered is faster and complete
Can reduce errors
Electronic records can be retrieved very quickly.
Can provide a complete record of the patient’s medical history.
Security must be maintained.

25. Computer-Assisted Charting (cont’d)
Disadvantages
Sophisticated security system needed to prevent unauthorized personnel from accessing records
Initial costs are considerable
Implementation can take a long time
Significant cost and time to train staff to use the system
Computer down time can cause problems
Page 90 Tips for computer Charting Box 7-1
Computer downtime can create problems of input, access, transfer of information.

26. Case Management System Charting
A method of organizing patient care through an episode of illness so clinical outcomes are achieved within an expected time frame and at a predictable cost
A clinical pathway or interdisciplinary care plan takes the place of the nursing care plan
Where is documentation of variances placed?
Ask the students which method of charting seems most logical? Why?

27. Accuracy in Charting
Be specific and definite in using words or phrases that convey the meaning you wish expressed Words that have ambiguous meanings and slang should not be used in charting Appears to be……. Large among…… Ate well………. Good…….
Specific data about size, amounts, and other measurements provide a means for determining whether the condition is getting better, getting worse, or staying the same.
What abbreviations, acronyms, and symbols are too dangerous to be used?

28. Brevity in Charting
Sentences not necessary
Articles (a, an, the) may be omitted
The word “patient” omitted when subject of sentence
Abbreviations, acronyms, symbols acceptable to the agency used to save time and space (policy and procedure)
Choose which behaviors and observations are noteworthy
A rule of thumb is that is the behavior or finding is abnormal or a change from previous behavior or data , chart it.
In most agencies, if data are recorded on a flow sheet, they need not be documented again in the nurse’s notes.
A rule of thumb is that if the behavior or finding is abnormal or a change from previous behavior or data, chart about it.

29. Legibility and Completeness in Charting
If writing not legible, misperceptions can occur Be sure to include as much information as needed What constitutes complete charting may vary among hospitals and health care agency's
What constitutes complete charting may vary among hospitals, extended-care facilities, and other health care agencies.
What is particularly important to document in home care?
Record information about the patient’s needs and problems and specify nursing care given for those needs or problems.

30. Types of Information to be Documented
Box 7-3 page 95 Box 7-2 – page 95- Guidelines for Charting about a Sign or a Symptom

31. The Kardex
Not a part of the permanent medical record A quick reference for current information about the patient and ordered treatments Usually consists of a folded card for each patient in a holder that can be quickly flipped from one patient to another
Hospitals that have instituted a completely computerized patient care system may not have this type of Kardex anymore.
How may the Kardex be used by a unit secretary?

32. Information on the Kardex
Room number, patient name, age, sex, admitting diagnosis, physician’s name
Date of surgery
Type of diet ordered
Scheduled tests or procedures
Level of activity permitted
Notations on tubes, machines, other equipment in use
Nursing orders for assistive or comfort measures
List of medications prescribed by name
IV fluids ordered
The Kardex can be a tool to use as a reference when giving a report on your patients.

33. Charting Chuckles

34. These are actual entries made in medical charts:
1. She has no rigors or shaking chills, but her husband states she was very hot in bed last night Patient has chest pain if she lies on her left side for over a year On the second day the knee was better, and on the third day it disappeared The patient is tearful and crying constantly. She also appears to be depressed The patient has been depressed since she began seeing me in Discharge status: Alive but without my permission The patient refused autopsy The patient has no previous history of suicides Patient has left white blood cells at another hospital Patient's medical history has been remarkably insignificant with only a 40-pound weight gain in the past three days.

35. 12. Patient had waffles for breakfast and anorexia for lunch. 13
12. Patient had waffles for breakfast and anorexia for lunch She is numb from her toes down While in ER, she was examined, x-rated and sent home The skin was moist and dry Occasional constant infrequent headaches Patient was alert and unresponsive Rectal examination revealed a normal-size thyroid She stated that she had been constipated for most of her life, until she got a divorce I saw your patient today, who is still under our car for physical therapy Both breasts are equal and reactive to light and accommodation Examination of genitalia reveals that he is circus sized The lab test indicated abnormal lover function The patient was to have a bowel resection. However, he took a job as a stockbroker instead Skin: somewhat pale but present.

36. 26. The pelvic exam will be done later on the floor. 27
26. The pelvic exam will be done later on the floor Patient was seen in consultation by Dr. Blank, who felt we should sit on the abdomen, and I agree Large brown stool ambulating in the hall Patient has two teenage children but no other abnormalities.

37. “unresponsive and in no distress”
“nonverbal, noncommunicative and offers no complaints”
“irregular heart failure”
“his Hct is stable but dropping”
“I don’t want to be incubated again”
“pulses are fixed and dilated”
in asking about code status – “do you want your wife to receive artificial insemination”
“Findings compatible with ileus. Bladder is still in colon”
“be sure to check eyes and nose” (Is and Os)
Reason for leaving AMA – “pt wants to live”
“I had a kiwi on my chest” (keloid)
“dictated home O2, transcribed homo too”
“that bacterial virus is a doozy”
“noncompliant smoker”
“denies any rectal breeding”

38. “fireballs in the uterus”
Reason for office visit – “F\U chest rumbles”
“partial TAH”
Nursing notes in the ICU – bedside attempted to urinate”
Indication for flex sig – “blood when whipping himself”
“chicken pops”
“if she wants children, think about recommending birth control pills”
“holy systolic murmur”
“pt expired and was dc’d home”
“She diuresed pretty well. I gave her 40 of Lasix and she put out 2000 liters.”
“My back has been hurting ever since they gave me that cauterizer.” (Foley catheter)
discharge dx=nephrolithiasis; discharge instructions=”drink plenty of urine”
“She did not lose control of her rectum”
Plan – “gently dehydrate”
“allergic to Sulpher”
“platelets 1889 – dx thrombocytopenia”
chief complaint – “bazaar behavior”
“depakote shot for pain”
“albeauty inhaler”

39. “I follow him for his paranoia”
“We will watch her diarrhea closely”
NH order – “check pulse everyday”
“They took a 50 cent piece out of my colon” (hemicolectomy)
“She has encephalitis of her right leg.”
“I need a colectomy because I have pollen in my colon.”
“This is a 981 YO female with a host of medical problems.”
“The patient is actually a fairly reliable historian.”
“hyperglycemia toe”
“brachycardia”
“pt was given a banana bath”
“Will hold glyburide for now because of reverse hypoglycemia.”
“pneumonia left femur”
“2-4 packs of whiskey QD”

40. “This is a 75 YO type 2 hypertensive”
Order “Please feed patient only when awake.”
“Check orthostasis while on the floor”
“She is to wear STD stockings”
“nonaudible wheezing noted”
When asked if she had a discharge, the patient said “No, but I have Blue Cross Blue Shield.”
“Yes, I just met the Infectious Waste doctor.”
Nurse to doctor: “I just want to let you know that this lady has had decreased urinary intake.” (Doctor aware)
“He is allergic to wives.”
“No clubbing, cyanois, or extremities.”
order: “Incentive spriometry Q 1 hour until awake.”
“fibromyalgia rheumatica”
“Pleasant man lying comfortably in bed. Appears somewhat uncomfortable”
“Her stomach showed 3+ edema up to the knees.”

41. The End