documentation

• Documentation


  The recording of client's data by the nurse to complete the assessment phase
• Accurate documentation is essential and should include all data collected about the client's health status
• Data are recorded in a factual manner and not interpreted by the nurse
• Nurse's recording of client's breakfast intake

  • Coffee 240 ml, Juice 120 ml, 1 pc. egg
• Documentation


  Serves as a permanent record of client information and care
• Reporting


  Takes place when two or more people share information about client care
• Nursing documentation


  The charting of documents, the professional surveillance of the patient, the nursing action taken in the patient's behalf, and the patient's programs with regards to illness
• Purposes of client's record/chart

  • Communication
  • Legal documentation
  • Research
  • Statistics
  • Education
  • Audit and quality assurance
  • Planning client care
  • Reimbursement
• Guidelines for documentation

  • Document legibly or print neatly in inerasable ink
  • Use correct grammar and spelling
  • Avoid wordiness that creates redundancy
  • Use phrases instead of sentences to record data
  • Record data findings, not how they were obtained
  • Write entries objectively without making premature judgments or diagnosis
  • Record the client's understanding and perception of problems
  • Avoid recording the word "normal" for normal findings
  • Record complete information and details for all client symptoms or experiences
  • Include additional assessment content when applicable
• Source oriented medical record


  The "traditional client record"
• Five basic components of source oriented medical record

  • Admission sheet
  • Physician's order sheet
  • Medical history
  • Nurse's notes
  • Special records and reports
• Kardex

  A quick reference, changed as needed, not part of permanent record; a concise method of organizing and recording data, readily accessible to health care team, a series of flip cards to ensure continuity of care, a tool for change of shift report, and for planning & communication purposes
• Characteristics of good recording

  • Brevity
  • Use of ink / permanence
  • Accuracy
  • Appropriateness
  • Completeness & chronology / organization / sequence / timing
  • Use of standard terminology
  • Signed
  • In case of error
  • Confidentiality
  • Legal awareness
  • Legible
  • Do not use the word "patient" or "pt" in the chart
  • A horizontal line drawn to fill up a partial line
• Types of reporting

  • Change-of-shift reports or endorsement
  • Telephone reports
  • Telephone orders
  • Transfer reports
• Problem oriented record

  Commonly referred to as POR, organized according to problem, with four parts: database, problem list, initial plan, and progress notes
• SOAP


  A method used for problem-oriented charts, with S for subjective, O for objective, A for assessment, and P for plan
• Focus charting

  • D - Complaining of pain at incision site on level #7

  A - Repositioned for comfort; Demerol 50mg IM given

  R - (Charted at a later date.) States a decrease in pain, "feels much better."
• PIE charting

  Similar to SOAP charting, but comes from the Nursing Process, with P for problem, I for intervention, and E for evaluation
• Narrative charting

  Chronological, baseline charted every shift, lengthy and time-consuming, with separate pages for each, source-oriented
• Charting by exception

  Uses flowsheets, emphasis on abnormal (what is abnormal for this patient), although it may be abnormal for the "normal" person, if it is abnormal for your patient on a consistent basis, it is no longer considered an "exception"
• Correcting errors

  • If 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

  Avoid using "error" or "wrong patient" when making correction

  Follow your facilities policy

  Do not alter charting, it is a legal document
• Incident reports

  Objective, do not blame or admit liability, document what you did, do not include names/addresses of witnesses, document time/name of doctor, do not file in chart, do not write "incident report made"