Babitha's Note on documentation

DOCUMENTATION
&
REPORTING
Mrs. Babitha K Devu
Assistant Professor
SMVDCoN

Introduction
• Nursing documentation is a vital
component of safe, ethical and eﬀective
nursing practice, regardless of the context
of practice or whether the documentation
is paper-based or electronic.
• The documentation is intended to provide
registered nurses (RNs) with professional
accountability.

Introduction
• Although diﬀerent documentation
systems and technology may be used
throughout the province, quality nursing
documentation is expected in every area
of care or service delivery and in every
setting. Nurses must be familiar with, and
follow, agencies’ documentation policies,
standards and protocols.

Documentation as Communication
• Reporting and recording are the major
communication techniques used by health care
providers.
• DOCUMENTATION serves as a permanent
record of client information and care.
• REPORTING takes place when two or more
people share information about client care,
either face to face or by telephone.
• It clearly outlines all important information
regarding the client.

• Nurses are subject to increasing scrutiny
regarding their record-keeping. Legislation
such as the Human Rights Act 1998 and the
Data Protection Act 1998 has increased the
profile of, and access to, health records,
while patients are increasingly willing to
complain about their care.
• Whether complaints are resolved by health
care providers or settled in court,
comprehensive records are essential.

• It is important, therefore, that nurses keep
abreast of legal requirements and best
practice in record-keeping.
• The Code of Professional Conduct (NMC,
2002a) advises that good note-taking is a
vital tool of communication between
nurses.

Definitions
• Documentation is anything written or
electronically generated that describes the
status of a client or
the care or services given to that client. (Perry,
A.G., Potter, P.A., 2010).
• Nursing documentation refers to
written or electronically generated client
information obtained through the nursing
process. (ARNNL, 2010).

Definitions
• A record or chart or client record, is a
formal, legal document that provides
evidence of a client’s care and can be
written or computer based.
• A report is oral, written, or computer-based
communication intended to convey
information to others.
• The process of making an entry on a client
record is called recording, charting, or
documenting.

Purposes of Documentation
• Communication
• Planning client
care
• Auditing health
agencies
• Research
• Education
• Reimbursement
• Legal
documentation
• Health care
analysis
• The patient record is a valuable source of data for
all members of the health care team.
• Client records are kept for a number of purposes
including:

• Communication
 The record serves as the vehicle by
which different health professionals who
interact with a client communicate with
each other.
This prevents fragmentation, repetition,
and delays in client care.

• Planning Client Care
Each health professional uses data from the
client’s record to plan care for that client.
Nurses use baseline and ongoing data to
evaluate the effectiveness of the using care
plan.
The physicians plans treatment after seeing
the laboratory reports of patient.

• Auditing Health Agencies
An audit is a review of client records for
quality assurance purposes .
Accrediting agencies such as The Joint
Commission may review client records
to determine if a particular health
agency is meeting its stated standards.

• Research
The information contained in a record
can be a valuable source of data for
research.
 The treatment plans for a number of
clients with the same health problems
can yield information helpful in treating
other clients.

• Education
Students in health disciplines often use
client records as educational tools.
A record can frequently provide a
comprehensive view of the client, the
illness and effective treatment
strategies.

• Reimbursement
Documentation also helps a facility
receive reimbursement from the
government.
For a patient to obtain payment through
Medicare or insurance agencies the
client’s clinical record must contain the
correct diagnosis and reveal that the
appropriate care has been given.

• Legal Documentation
The client’s record is a legal document
and is usually admissible in court as
evidence.

• Health Care Analysis
Information from records may assist health
care planners to identify agency needs,
such as over utilized and underutilized
hospital services.
Records can be used to establish the costs
of various services and to identify those
services that cost the agency money and
those that generate revenue.

COMMUNICATION WITH IN THE
HEALTH CARE TEAM

• In today’s health care system, delivery
processes involve numerous interfaces
and patient handoffs among multiple
health care practitioners with varying
levels of educational and occupational
training.
• During the course of a 4-day hospital stay,
a patient may interact with 50 different
professionals, including physicians,
nurses, technicians, and others.

• Lack of communication creates
situations where medical errors can
occur. These errors have the potential
to cause severe injury or unexpected
patient death.
• Effective communication takes place
along two approaches.
1. Recording
2. Reporting

GUIDELINES / PRINCIPLES OF
RECORDING

Guidelines/ principles:
1. Factual
2. Timing
3. legibility
4. Permanence
5. Accepted
terminology
6. Correct signature
7. Spelling
8. Accuracy
9. Sequence
10.Appropriate
11.Complete
12.Concise
13.Legal prudence
14. Confidentiality

1. Factual
A factual record contains descriptive, objective
information about what a nurse sees, hears,
feels, and smells.
• Avoid vague terms such as appears, seems,
or apparently because these words suggest
that you are stating an opinion, do not
accurately communicate facts.

1. Factual
• Objective documentation includes
observations of a patient’s behaviors.
For example, instead of documenting “the
patient seems anxious,” provide objective
signs of anxiety and document “the patient’s
pulse rate is elevated at 110 beats/min,
respiratory rate is slightly labored at 22
breaths/min, and
the patient reports increased restlessness.”

1. Factual
• The only subjective data included in the
record are what the patient says. When
recording subjective data, document
the patient’s exact words within quotation
marks whenever possible.

2. Date and Time
• Document the date and time of each recording. This is
essential not only for legal reasons but also for client safety.
• Record the time in the conventional manner (e.g., 9:00 AM
or 3:15 PM) or according to the 24-hour clock (military
clock), which avoids confusion about whether a time was
AM or PM
• Follow the agency’s policy about the frequency of
documenting, and adjust the frequency as a client’s
condition indicates. For example, a client whose blood
pressure is changing requires more frequent documentation
than a client whose blood pressure is constant.

2. Date and Time
• As a rule, documenting should be done as soon
as possible after an assessment or intervention.
• No recording should be done before providing
nursing

3. Legibility
• All entries must be legible and easy to read to
prevent interpretation errors.
• Hand printing or easily understood handwriting is
usually permissible.

4. Permanence
• All entries on the client’s record are made in
dark ink so that the record is permanent and
changes can be identified.
• Dark ink reproduces well in duplication
processes.
• Follow the agency’s policies about the type of
pen and ink used for recording.

5. Accepted Terminology
People in the 21st century are often in a hurry and
use abbreviations when texting. Even though using
abbreviations is convenient, medical abbreviations
have been responsible for serious errors and
deaths .
• Use only the standard and recognized
abbreviations.
• Ambiguity occurs when an abbreviation can stand
for more than one term leading to misinterpretation.
For example CP stand for chest pain, cerebral
palsy, cleft palate, creatine phosphate, and
chickenpox

6. Signature
• Each recording on the nursing notes is signed
by the nurse making it.
• The signature includes the name and title; for
example, “M.S. REDDY, RN”
• With computerized charting, each nurse has
his or her own password, which allows the
documentation to be identified.

7. Correct Spelling
• Use correct spelling while documenting.
• Correct spelling is essential for accuracy in
recording. Avoid spelling mistakes.
• If unsure how to spell a word, look it up in a
dictionary or other resource .
• Two absolutely different medications may have
similar spellings; for example, Lasix and Losec

8. Accuracy
• The client’s name and identifying information
should be stamped or written on each page of
the clinical record.
• Before making any entry, check that it is the
correct chart.
• Do not identify charts by room number only;
check the client’s name.
• Special care is needed when caring for clients
with the same name.

8. Accuracy
• When a recording mistake is made, draw a
single line through it to identify it as erroneous
with your initials or name above or near the
line (depending on agency policy).
• Do not erase, blot out, or use correction fluid.
• The original entry must remain visible.
• When using computerized charting, the nurse
needs to be aware of the agency’s policy and
process for correcting documentation mistakes.

8. Accuracy
• Write on every line but never between lines. If
a blank appears in a notation, draw a line
through the blank space so that no additional
information can be recorded at any other time
or by any other person, and sign the notation.

9. Sequence
• Document events in the order in which they
occur; for example, record assessments,
then the nursing interventions, and then the
client’s responses.

10. Appropriateness
• Record only information that pertains to the
client’s health problems and care.
• Any other personal information that the
client conveys is inappropriate for the
record.
• Recording irrelevant information may be
considered an invasion of the client’s
privacy .

11. Completeness
• Not all data that a nurse obtains about a client can
be recorded.
• However, the information that is recorded needs to
be complete and helpful to the client and health care
professionals.
• Nurses’ notes need to reflect the nursing process.
• Record all assessments, dependent and
independent nursing interventions, client problems,
client comments and responses to interventions
and tests, progress toward goals, and
communication with other members of the health
team.

12. Conciseness
• Recordings need to be brief as well as
complete to save time in communication.
• Repeated usage of the client’s name and the
word client are omitted

13. Legal Prudence
• Accurate, complete documentation should give
legal protection to the nurse, the client’s other
caregivers, the health care facility, and the client.
• Admissible in court as a legal document, the
clinical record provides proof of the quality of care
given to a client.
• For the best legal protection, the nurse should
not only adhere to professional standards of
nursing care but also follow agency policy and
procedures for intervention and documentation in
all situations—especially high-risk situations.

14. Confidentiality
Clients have a right to protection of their privacy with
respect to the access, storage, retrieval and
transmittal of their records and to receive a copy of
their health records for a reasonable fee.
• Documentation, in any format, should be
maintained in areas where the information cannot
be easily read by casual observers.
• Although nurses often share client information with
the healthcare team, it is important that clients
understand that sharing confidential information
with team members occurs only in an eﬀort to

Types Of Records And Common
Record Keeping Forms

All records contain the following information:
• Patient identification and demographic data
• Informed consent for treatment and procedures
• Admission data
• Nursing diagnoses or problems and nursing or
interdisciplinary care plan
• Record of nursing care treatment and evaluation
• Medical history
• Medical diagnoses
• Therapeutic orders
• Medical and health discipline progress notes
• Physical assessment findings
• Diagnostic study results
• Patient education
• Summary of operative procedures
• Discharge plan and summary

TYPES OF RECORDS
• Hospital records are broadly classified into
four categories based on the area of
usage. They are:
1. Patients clinical record
2. Individual staff records
3. Ward records
4. Administrative records with educational
value.

TYPES OF RECORDS
• PATIENTS CLINICAL RECORDS
It is the knowledge of events in the patient
illness, progress in his or her recovery and the
type of care given by the hospital personnel.
These are
a) Scientific and legal
b) Evidence to the patient the his /her case is
intelligently managed.
c) Avoids duplication of work.
d) Information for medical and legal nursing
research.

TYPES OF RECORDS
• PATIENTS CLINICAL RECORDS
e) Aids in the promotion of health and care.
f) Legal protection to the hospital doctor and the
nurse.
• Examples:
• Physician’s order sheet
• Nurse’s admission assessment
• Graphic sheet and flow sheet- vital signs, I/O
chart
• Medical history and examination
• Nurses’ notes
• Medication records
• Progress notes

TYPES OF RECORDS
• INDIVIDUAL STAFF RECORDS.
A separate set of record is needed for each
staff, giving details of their sickness and
absences, their carrier and development
activities and a personnel note

TYPES OF RECORDS
• WARD RECORDS.
These are the records pertaining to a particular
ward.
• Circular record
• Round book
• Duty roaster
• Ward indent book
• Ward inventory book
• Staff patient assignment record
• Student attendance and patient assignment
record

TYPES OF RECORDS
• ADMINISTRATIVE RECORDS WITH
EDUCATIONAL VALUE.
• Treatment register.
• Admission and discharge register.
• Personnel performance register.
• Organogram / organization chart
• Job description
• Procedure manual

• A variety of paper or electronic forms are
available for the type of information nurses
routinely document.
• The categories within a form are usually
derived from institutional standards of
practice or guidelines established by
accrediting agencies.

Common Record Keeping Forms
• Admission Nursing History Forms
• A nurse completes a nursing history form
when a patient is admitted to a nursing
unit.
• The form guides the nurse through a
complete assessment to identify relevant
nursing diagnoses or problems.

Babitha's Note on documentation

• Flow Sheets and Graphic Records
• Flow sheets allow you to quickly and
easily enter assessment data about a
patient, including vital signs and routine
repetitive care such as hygiene measures,
ambulation, meals, weights, and safety
and restraint checks.

• Flow Sheets and Graphic Records
• Flow sheets help team members quickly
see patient trends over time and decrease
time spent on writing narrative notes.
• Critical and acute care units commonly
use flow sheets for all types of
physiological data.

• Patient Care Summary or Kardex
Kardex forms have an activity and
treatment section and a nursing care plan
section that organize information for quick
reference.
• An updated Kardex eliminates the need for
repeated referral to the chart for routine
information throughout the day.

The patient care summary or Kardex includes
the following information:
• Basic demographic data (e.g., age, religion)
• Health care provider’s name
• Primary medical diagnosis
• Medical and surgical history
• Current orders from health care provider (e.g.
dressing changes, ambulation, glucose
monitoring)

• Nursing care plan
• Nursing orders (e.g., education sessions,
symptom relief measures, counseling)
• Scheduled tests and procedures
• Allergies

• Standardized Care Plans
• Some institutions use standardized care
plans. The plans, based on the institution’s
standards of nursing practice, are pre-printed,
established guidelines used to care for
patients who have similar health problems.
• After completing a nursing assessment, the
nurse identifies the standard care plans that
are appropriate for the patient and places the
plans in his or her medical record. The nurse
modifies the plans to individualize the
therapies.

• Progress Notes
• Progress notes made by nurses provide
information about the progress a client is
making toward achieving desired
outcomes.

• Discharge Summary Forms
Discharge documentation includes
• Medications
• Diet
• Community resources
• Follow-up care
• Who to contact in case of an emergency
or for questions

• ACUITY RECORDS
• Although acuity records are not part of a
patient’s medical record, they are useful for
determining the hours of care and staff required
for a given group of patients.
• A patient’s acuity level, usually determined by
a computer program, is based on the type and
number of nursing interventions required over a
24-hour period.
• The patient-to-staff ratios established for a unit
depend on a composite gathering of 24-hour
acuity data

Most Common Documents
In Patient Record:
• Admission sheet
• Physician’s order sheet
• Nurse’s admission assessment
• Graphic sheet and flow sheet- vital signs, I/Ochart
• Medical history and examination
• Nurses’ notes
• Medication records
• Progress notes
• results from diagnostic tests
• consent forms
• Discharge summary
• Referral summary

Common types of records to be kept
in an educational institution
• Admission register
• Attendance register
• Clinical experience records
• Common health record
• Internal assessment register
• External marks register
• Reports of various committee
• Other regulatory and affiliating bodies
correspondence

Common types of records to be kept
in an educational institution
• Cumulative Records: It is otherwise called as
continuous records. It is economical and time-
saving. It contains the complete information of
the individual and helpful in the long term
evaluation.
• Anecdotal Record: An anecdotal record is a
simple statement of an incident prepared by the
observer, which seems to be significant with the
pertaining incident. In elaboration, it is the
recording of all incidents in an organization
concerning a particular event or person.

Computerized documentation
• Nurses use computers to store the
client’s database, add new data, create
and revise care plans, and document
client progress.

• ADVANTAGES
– Increases the quality of documentation and
save time.
– Increases legibility and accuracy.
– Facilitates statistical analysis of data.
– The system links various sources of client
information.

• DISADVANTAGES
• Client’s privacy may be infringed on if security
measures are not used.
• Breakdowns make information temporarily
unavailable.
• The system is expensive.
• Extended training periods may be required
when a new or updated system is installed.

• PRECAUTIONS
• Password. Never share. Change frequently.
• Make sure terminal cannot be viewed by
unauthorized persons.

Methods Of Recording /
Documentation Systems

Methods Of Recording
• There are several documentation systems
for recording patient data.
• Regardless whether documentation is
entered electronically or on paper, each
health care agency selects a documentation
system that reflects its philosophy of
nursing.

• Narrative Charting
• Source-Oriented Charting
• Problem-Oriented Charting
• PIE Charting
• Focus Charting
• Charting by Exception (CBE)
• Computerized Documentation
• Case Management with Critical Paths

• Narrative Charting
The traditional methods of nursing
documentation.
– Describes the client’s status, interventions
and treatments; response to treatments is in
story format or paragraph in chronological
order.
– Narrative charting is now being replaced by
other formats.

• Source-Oriented Charting
Narrative recording by each member (source)
of the health care team on separate records.
– For example the admission department has
an admission sheet, nurses use the nurses’
notes, physicians have a physician notes,
etc….
It is otherwise called narrative charting.

• Problem-Oriented Charting (POMR)
Uses a structured, logical format called
S.O.A.P. / I.E.R.
• S: subjective data
• O: objective data
• A: assessment (conclusion stated in a form
of nursing diagnoses or client problems)
• P: plan

• Problem-Oriented Charting (POMR)
• Recently S.O.A.P. format is modified as S.O.A.P.I.E.R
for better reflecting the nursing process
• S: subjective data
• O: objective data
• A: assessment (conclusion stated in a form of
nursing diagnoses or client problems)
• P: plan
• I : intervention (specific interventions implemented).
• E: evaluation. Pt response to interventions
• R: revision. Changes in treatment.

• PIE Charting
PROBLEM
INTERVENTION
EVALUATION
Example:
– P: Patient reports pain at surgical incision as
7/10 on 0 to 10 scale
– I : Given morphine 1mg IV at 23:35.
– E : Patient reports pain as 1/10 at 23:55.

• Focus Charting
– A method of identifying and organizing the
narrative documentation of all client concerns.
– Uses a columnar format within the progress notes
to distinguish the entry from other recordings in
the narrative notes (Date & Time, Focus, Progress
note)
– The progress notes are organized into: Data (D),
Action (A), Response (R) (DAR)

• Focus Charting
• DATA – SUBJECTIVE OR OBJECTIVE
THAT SUPPORTS THE FOCUS
(CONCERN)
• ACTION – NURSING INTERVENTION
• RESPONSE – PT RESPONSE TO
INTERVENTION

DATE & TIME FOCUS
PROGRESS
NOTE
28/11/2017 AT
23:35 Hrs
Acute pain
related to
surgical incision
D: Patient
reports pain as
7/10 on 0 to 10
scale at 23:30
Hrs.
A: Given
morphine 1mg
IV at 23.35 Hrs.
R: Patient
reports pain as
1/10 at 23.55

• Charting by Exception (CBE)
– The nurse documents only deviations from
pre-established norms (document only
abnormal or significant findings).
– Avoids lengthy, repetitive notes.

• Computerized Documentation
– Increases the quality of documentation
and save time.
– Increases legibility and accuracy.
– Facilitates statistical analysis of data.

• Case Management Process
– A methodology for organizing client care
through an illness, using a critical pathway/
standardized care plan.
– A critical pathway is a multidisciplinary plan or
tool that specifies assessments, interventions,
treatments and outcomes of health related
problems a cross a time line

Report
• A report is oral, written, or computer-based
communication intended to convey information
to others.
The purpose of reporting is to communicate
specific information to a person or group of
people.
• A report, whether oral or written, should be
concise, including pertinent information but no
extraneous detail

Reports commonly used by nurses
include
• Hand off report
A. Change of shift report
B. Transfer report
• Telephone reports
• Incident reports
Types of reports:

• Hand off report
Hand-off reports happen any time one
health care provider transfers care of
a patient to another health care
provider.
• The hand off report may be change
of shift report or transfer report
Types of reports:

• Hand off report
The purpose of hand-off reports is to provide
better continuity and individualized care for
patients.
For example, if you find that a patient breathes
better in a certain position, you relay that
information to the next nurse caring for the
patient.
Hand off report can be given face-to-face, in
writing, or verbally such as over the telephone or
via audio recording
Types of reports:

• Hand off report
A. Change of shift report
It is given to all nurses on the next shift.
It includes up-to date information
about a patient’s condition, required
care, treatments, medications, and any
recent or anticipated change.
Types of reports:

• Hand off report
B. Transfer report
Transfer report is given whenever the patient
is transferred to other health care unit.
It can happen between:
• Nursing unit-to-nursing unit transfer
• Nursing unit to diagnostic area.
• Special settings (operating room,
emergency department).
• Discharge and inter-facility transfer
Types of reports:

Health professionals frequently report about
a client by telephone.
• A registered nurse makes a telephone
report when significant events or changes
in a patient’s condition have occurred.
• Nurses inform primary care providers
about a change in a client’s condition; a
radiologist reports the results of an x-ray
study
Types of reports:

Guidelines for Taking/ Recording Telephone Orders
• Write down the time and date on the physicians’
order sheet.
• Write down the order exactly as given by the
physician.
• Read the order back to the physician to ensure it
is accurately recorded.
• Record the physician’s name on the order sheet,
state “telephone order”, print your name and sign
the entry, along with your designation (e.g.,
“RN”).
Types of reports:

• Telephone Orders & Verbal Orders:
• A Telephone Order (TO) occurs when a
health care provider gives an order over the
phone to a registered nurse.
• A Verbal Order (VO) involves the health
care provider giving orders to a nurse while
they are standing near each other.
• TOs and VOs usually occur at night or
during emergencies and frequently cause
medical errors.
Types of reports:

• To ensure that a verbal or telephone order is complete,
registered nurses should check the following:
• client’s name
• medication name
• dosage form (e.g., tablet, inhalant)
• route of administration
• exact strength of concentration
• dose (in unit of measurement)
• frequency of administration
• quantity and duration
• purpose or indication for the medication (i.e., appropriate
for client’s treatment plan)
• prescriber’s name and designation.
Types of reports:

An incident or occurrence is any event that is not
consistent with the routine operation of a health
care unit or routine care of a patient.
• Examples of incidents include
• Patient falls,
• Needle stick injuries,
• A visitor having symptoms of illness,
• Medication administration errors,
• Accidental omission of ordered therapies, and
• Circumstances that lead to injury or a risk for
patient injury
Types of reports:

Incident (or occurrence) reports are an important
part of the quality improvement program of a
unit.
• Always contact the patient’s health care
provider whenever an incident happens
• In the incident report form document an
objective description of what happened, what
you observed, and the follow-up actions taken.
Types of reports:

Incidents are generally recorded in two places, in
the client’s medical record and in an incident
report, which is separate from the chart.
The nurse should avoid using the words “error”,
“incident” or “accident” in the documentation. It
is recommended the nurse first document an
incident in the health record to ensure continuity
and completeness, and then complete an
incident report in accordance with facility
policies and procedures (Grant & Ashman, 1997).
Types of reports:

The purpose of a health record and occurrence/
incident report diﬀers. Therefore, for the sake
of clarification, the nurse should avoid
documenting “refer to incident report”
in a client’s health record.
It is separate from the patient record and are used
by organizations for risk management, to
track trends in systems and client care and to
justify changes to policy, procedure and/or
equipment
Types of reports:

Minimizing Legal Liability Through
Effective Record Keeping

As the records are the proof of care and legal
documents the records have to be maintained
appropriately to avoid legal complications. The
nurse has to take the following measures:
• Keep the records under safe custody of
nurses.
• No individual sheet should be separated.
• Maintain the confidentiality of the information
• Don’t make accessible to other patients and
visitors.
• Strangers are not permitted to read records.

• Records are not handed over to the legal
advisors without written permission of the
administration.
• Handed carefully, not destroyed
• Identified with bio-data of the patients such
as name , age, admission number,
diagnosis, etc.
• Never sent outside of the hospital without
the written administrative permission.
• Send the records to medical record
department (MRD) for the further usage.

• You spill something on the chart, do not
discard notes. Recopy, put original and
copied sheets in chart. Write “copied” on
copy.
• Do not scribble out charting.
• Follow your facilities policy.
• Do not alter charting, it is a legal document.

Maintenance Of Computerized
Records:
• Maintain the confidentiality of the information.
• Never disclose the password to any others
• Don’t delete any information from the system
unless you are authorized to do.

Conclusion
• Quality documentation is an integral part of
professional RN practice. It reﬂects the
application of nursing knowledge, skills and
judgment, the clients’ perspective and
interdisciplinary communications. These
guidelines will support RN’s to contribute to the
development of agency policy and promote
evidence informed practice, which enables RNs
to meet the Standards of Practice for Registered
Nurses every day in client care.

Babitha's Note on documentation

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