Documentation

Documentation
o Also referred as charting

o A vital aspect of nursing practice
o Involves entering the data in clients record
o Permanent record of client information and care
o Requires use of clear, concise, and complete words

Reporting
o when 2 or more people share information about client care, either face to face or by telephone

Purposes of Documentation
1. Communication
o Ensures continuity of care by sharing information to convey meaningful data about the client.
2. Legal Documentation
o provide proof of what exactly happened to client; admissible evidence in a court of law
3. Education
o education tool for students through a review of the clients record
4. Research
o health related data for researchers; can be initially used to screen possible subjects for research study.
5. Reimbursements
o basis for decisions regarding care to be provided & reimbursement to the agency, to cover health care related
expenses
6. Auditing Monitoring (Quality Assurance)
o to determine the degree to which nursing care standards are met
o monitors quality of care received by client and the competence of health care givers
o Primary purpose of QA is to provide highest level of client care
7. Planning Client Care
o provides data which entire health team uses to plan care for client
8. Statistics

Characteristics of a Good Documentation

Characteristics Description Example/s
Brevity o Concise and simple yet meaningful
o Start each entry with a CAPITAL LETTER and
end entry with a PERIOD even if entry is a
single word phrase or word.

Factual o Contains descriptive, objective information Incorrect: The client experiences hallucination
Correct: The client says, Im beginning to hear
voices
Accurate o Use clear and exact measurements
o Objective facts not opinions or interpretation
o Describe behaviors rather feelings to
determine actual problems of client.
o Document Refusal of medication and
treatments
o Client complaints in quotation marks to
indicate that it is his statement.

Incorrect: The client has fever
Correct: The client has oral temperature of 38.6C
Incorrect: Ate with a poor appetite
Correct: Ate 50% of the food served
Incorrect: Uncooperative
Correct: Refused medications
Incorrect: Depressed
Correct: Seen crying
Skin cold and clammy. diaphoretic. prefers to sit up.
Vital signs taken as follows: Temp37.6C, PR110bpm,
RR26cpm, BP146/90mmHg
Complained of chest pain radiating down the left
arm
Completeness

o Contains essential, appropriate, and relevant
information
730 am, client verbalizes chest pain described as
pressing. Client rates pain as 7 on a scale of 0-10.
Nitroglycerine 10mg PRN administered. Client
verbalizes pain relief after 10min, rates pain as 0 on
a scale of 0-10. Physician notified.
Ray A. Gapuz, R.N.
Chronology/
Timing
o Continuous charting for each entry unless a
time change occurs. No need for new line for
each new entry.
o Date is entered in the column on the first line

page of nurses notes and whenever dates
changes.
o Time is entered in the time column whenever
a new entry occurs
o Avoid time changes. Avoid double chart. If
something appears on a particular sheet, it
doesnt need to appear on nurses notes,
unless there is alteration from the normal.
ex. BP or BT
Current o Updated based on the facilitys standard and
client care requirements

Confidentiality o Only health personnel who participate in the
care of client are allowed to read the chart

Organized o Data organized in a logical manner S- Client says I feel tired
O Pallor
A - Activity Intolerance
P Provided frequent rest periods
Properly Signed/
Signature
o Sign each entry with nurses full name and
credential/status at the end of the charting,
at the right hand margin of nurses notes.
Ray A. Gapuz, R.N.
Ray A. Gapuz, Nurse
Ray A. Gapuz, Staff Nurse
Properly Corrected
Errors
o Corrected data entries are properly labeled
o Write error above the single horizontal line
and sign your signature.
Error
The client verified the procedure
Use of Ink /
Permanence
o Use non erasable ink
o no felt pen, sign pen, or pencil
o Used as evidence in legal court

Use standard
terminology
o Abbreviations and symbols approved by
institution are used.

Legal Awareness o Chart only what you personally have done
and observed.
o Do no discard any part of the client record

Do not use word
patient or pt in the
chart
o Chart belongs to the patient. All info in the
chart pertains to the patient.

COMMON RECORD KEEPING FORMS

Forms Purposes
Admission Nursing
History Forms
o Serve to guide the nurse to facilitate and identification of nursing diagnosis
Flow Sheet o Enable health team members to assess clients status based on data such as v/s, weight, and
medications
Kardex o Source of the most concise and accurate information related to client.
o Contains routine information on the clients activity and treatment
o Eliminates constantly browsing thru clients chart for routine information
o Usually contains info: name, age, religion, physician, diagnosis, medications, treatment, nursing care
plan, scheduled procedure, history of allergies, diet, contact person in case of emergency
o Entries usually in pencil so that they can be changed as clients condition changes. This implies kardex
is for planning and communication purposes only. IT IS NOT A RECORD.
Acuity Records o Guide to determine duration of care and number of staff needed to provide care to a group of clients
Standardized Care
Plans
o Facilitate the establishment of guidelines which are used for clients with similar health problems
Discharge
Summary Forms
o Summary of instructions for the client and family, on various aspects of the clients health status

METHODS OF DOCUMENTATION
Narrative Charting Descriptive account when chronologically in paragraphs that contains:
o clients condition
o interventions and treatments
o clients response to treatment
Source Oriented
Charting (Traditional)
Narrative recording of each member of the health team using separate sheets (separate
recording of data for doctors and nurses)
5 Basic Components
o Admission Sheet
o Physicians Order Sheet
o Medical History
o Nurses Notes
o Special Records and Reports (referrals, x-ray reports, lab findings, report of surgery,
anesthesia record, flow sheets, v/s, I&O, and medications)
Problem Oriented
Charting
Logical method of documentation composed of:
1. Database
2. Problem List
3. Plan of Care
4. Progress Notes
Includes narrative notes and can be written using SOAP, SOAPIE, or SOAPIER
o S ubjective Data
o O-bjective Data
o A-nalysis of Data
o P-lan
o I-ntervention
o E- valuation
o R-evision
Flow Sheets
Discharge notes and referral summaries
PIE Charting A direct form of charting composed of
1. Flow Sheet
2. Progress Notes
3. Plan of Care - problem, intervention, evaluation
Focus Charting Utilizes a column format for
1. Data (subjective and objective)
2. Action (intervention)
3. Response of client
Charting by exception Narrative form of charting where significant findings are documented
Computerized Charting Utilizes nursing information systems that facilitate documentation thru the use of
computers Ex. Voice activated terminals, bedside computer terminals
Point of Care Charting Portable bedside computer that facilitates immediate input and retrieval of client data

TYPES OF REPORTS PREPARED BY NURSES

Change of shift reports
or endorsement
For continuity of care among nurses who are taking care of the client
Based on health care needs of client
Telephone Reports To inform physician of changes in clients condition
To communicate client info to nurses in other units during client transfer
Telephone Orders Only RNs may receive and need to be verified by reporting it clearly
Should be countersigned by the Physician who made the order within 24 HOURS.
Transfer Report For continuity of care when client is transferred from one unit to other
Incident Report To provide a form for the identification of trends in the system or unit operations, that
may serve as a basis for changes in policies and procedures

Key Points
Clients have the right to read their record
Chart can be accessed by the client, PT, and the pharmacist or other members of health team. The clients consent is
needed before chart can be seen by other persons like relatives.

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Documentation

o Also referred as charting

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