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Documenting and Reporting

Guidelines for Good Documentation and Reporting 

1. Fact – information about clients and their care must be factual. A record should contain descriptive, objective            information about what a nurse sees, hears, feels and smells
2. Accuracy – information must be accurate so that health team members have confidence in it
3. Completeness – the information within a record or a report should be complete, containing concise and thorough            information about a client’s care. Concise data are easy to understand
4. Currentness – ongoing decisions about care must be based on currently reported information.
At the time of occurrence include the following:
a. Vital signs
b. Administration of medications and treatments
c. Preparation of diagnostic tests or surgery
d. Change in status
e. Admission, transfer, discharge or death of a client
f. Treatment fro a sudden change in status
5. Organization – the nurse communicate in a logical format or order
6. Confidentiality – a confidential communication is information given by one person to another with trust and                confidence that such information will not be disclosed

Image: http://magazine.nursing.jhu.edu

Documentation

  • Anything written or printed that is relied on as a record of proof fro authorized persons.

Purposes of Records 

  1. Communication
  2. Planning Client Care
  3. Auditing Health Agencies
  4. Research
  5. Education
  6. Reimbursement
  7. Legal Documentation
  8. Health Care Analysis

Documentation Systems 

1. Source – Oriented Record 

a. The traditional client record
b. Each person or department makes notations in a separate section or sections of the client’s chart
c. It is convenient because care providers from each discipline can easily locate the forms on which to record           data and it is easy to trace the information
d. Example: the admissions department has an admission sheet; the physician has a physician’s order sheet, a           physician’s history sheet & progress notes
e. NARRATIVE CHARTING is a traditional part of the source-oriented record

2. Problem – Oriented Medical Record (POMR)

a. Established by Lawrence Weed
b. The data are arranged according to the problems the client has rather than the source of the information.

The four (4) basic components:

i. Database – consists of all information known about the client when the client first enters the health care     agency. It includes the nursing assessment, the physician’s history, social & family data

ii. Problem List – derived from the database. Usually kept at the front of the chart & serves as an index to       the numbered entries in the progress notes. Problems are listed in the order in which they are identified &    the list is continually updated as new problems are identified & others resolved

iii. Plan of Care – care plans are generated by the person who lists the problems. Physician’s write                physician’s orders or medical care plans; nurses write nursing orders or nursing care plans

iv. Progress Notes – chart entry made by all health professionals involved in a client’s care; they all use the     same type of sheet fro notes. Numbered to correspond to the problems on the problem list and may be        lettered for the type of data

Example: SOAP Format or SOAPIE and SOAPIER

S – Subjective data
O – Objective data
A – Assessment
P – Plan
I – Intervention
E – Evaluation
R– Revision

 

                Advantages of POMR:

  • It encourages collaboration
  • Problem list in the front of the chart alerts caregivers to the client’s needs & makes it easier to track the status of each problem.

                     Disadvantages of POMR:

  • Caregivers differ in their ability to use the required charting format
  • Takes constant vigilance to maintain an up-to-date problem list
  • Somewhat inefficient because assessments & interventions that apply to more than one problem must be repeated.

3. PIE (Problems, Interventions, and Evaluation)

a. Groups information in to three (3) categories
b. This system consists of a client care assessment floe sheet & progress notes
c. FLOW SHEET – uses specific assessment criteria in a particular format, such as human needs or functional            health patterns
d. Eliminate the traditional care plan & incorporate an ongoing care plan into the progress notes

4. Focus Charting

a. Intended to make the client & client concerns & strengths the focus of care
b. Three (3) columns fro recording are usually used: date & time, focus & progress notes

5. Charting by Exception 

a. Documentation system in which only abnormal or significant findings or exceptions to norms are recorded
b. Incorporates three (3) key elements:
i. Flow sheets
ii. Standards of nursing care
iii. Bedside access to chart forms

6. Computerized Documentation

a. Developed as a way to manage the huge volume of information required in contemporary health care
b. Nurses use computers to store the client’s database, add new data, create & revise care plans & document client progress.

7. Case Management

a. Emphasizes quality, cost-effective care delivered within an established length of stay
b. Uses a multidisciplinary approach to planning & documenting client care, using critical pathways.

Nursing Care Plan (NCP)

Two Types:

1. Traditional Care Plan – written fro each client; it has 3 columns: nursing diagnoses, expected outcomes &            nursing interventions.
2. Standardized Care Plan – based on an institution’s standards of practice; thereby helping to provide a high            quality of nursing care

KARDEX 

  • Widely used, concise method of organizing & recording data about a client, making information quickly accessible to all health professionals. Consists of a series of cards kept in a portable index file or on computer generated forms.

Information may be organized into sections:

    1. Pertinent information about the client
2. List of medications
3. List of IVF
4. List of daily treatments & procedures
5. List of Diagnostic procedures
6. Allergies
7. Specific data on how the client’s physical need is to be met
8. A problem list, stated goals & list of nursing approaches to meet the goals

Nursing Discharge / Referral Summaries 

  • Completed when the client is being discharged & transferred to another institution or to a home setting where a visit by a community health nurse is required. Regardless of format, it includes some or all of the following:
1. Description of client’s physical, mental & emotional state
2. Resolved health problems
3. Unresolved continuing health problems
4. Treatments that can be continued (e.g. wound care, oxygen therapy)
5. Current medications
6. Restrictions that relate to activity, diet & bathing
7. Functional/self-care abilities
8. Comfort level
9. Support networks
10. Client education provided in relation to disease process
11. Discharge destination
12. Referral Services (e.g. social worker, home health nurse)

References:
FEU In House Review Handout

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