Documentation

• Documentation


  • Must be clear, accurate, concise, and accessible
  • Should provide a clear understanding and picture of the client
  • Allows the interprofessional team to communicate with each other
• PIE Model

  • Problem
  • Intervention
  • Evaluation
• SOAP Note


  • Subjective: Symptoms are what the client describes
  • Objective: Clinical impression the health care provider sees, hears, touches, measures, or smells
  • Assessment: Combines the subjective and objective information to arrive at a nursing diagnosis
  • Plan: Details steps to treat clients and suggests the need for consultation or additional testing to address client needs
• Source-oriented medical record


  Traditional format for documenting within a medical record for all disciplines, usually divided into specific sections
• Focus charting


  • Centers on specific health care problems and changes in condition, client events, and concerns
  • Three items must be documented: Data, Action, Response
• Charting by Exception


  Focuses on documenting only unexpected or unusual findings, a shorthand method of documenting routine and normal findings
• Problem-Oriented Medical Records


  Stages include: 1) Developing a database, 2) Identifying and numbering specific problems, 3) Formulating a plan of action for each problem, 4) Noting ongoing progress for each problem
• FACT


  Factual, Accurate, Complete, Timely
• Correcting Errors in Documentation

  1. Keep the original document

  2. Draw a single line through the entry and write "error" along with your initials

  3. Record the date and time of when the correction was entered

  4. Do not obscure the original entry

  5. Document the correct information

  
• Guidelines for Making a Late Charting Entry

  1. Identify the entry as a "late entry"

  2. Identify which event the late entry is for

  3. Make sure all new entries are signed and dated

  4. Identify which event or previous note the new note is referencing

  5. Make sure there are no blank lines
• Electronic Health Records (EHRs)


  • A systemic, digitized documentation system to improve client care
  • Provides comprehensive records of a person's health history as well as a means of communication for all health care providers
  • Accounts for every treatment, diagnosis, and provider visit for billing, all components can be used in a court of law
• Electronic Documentation Guidelines


  1. Never use anyone else's login information

  2. Password must be strong, unique, and should be changed frequently

  3. Log off when documentation is complete

  4. Never leave a computer station without logging off first

  5. Computer monitor/screen should be protected

  6. If an electronic signature is used, ensure your name is correct and professional credentials are noted
• The Institute for Safe Medication Practices (ISMP) compiles a list of abbreviations that are appropriate to use with documentation, helping to reduce confusion and errors