Chapter 16 Documentation and Reporting. 16-2 Copyright 2004 by Delmar Learning, a division of...

Chapter 16

Documentation and Reporting

16-2Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.

Documentation as Communication

Communication is a dynamic, continuous, and multidimensional process for sharing information.

Reporting and recording are the major communication techniques used by health care providers.



The medical record serves as a legal document for recording all client activities by health care practitioners.



Documentation is defined as written evidence of:• The interactions between and among health

professionals, clients, their families, and health care organizations

• The administration of tests, procedures, treatments, and client education

• The results or client’s response to these diagnostic tests and interventions



Nurses rely on charting, records, and systems that support the implementation of the nursing process.

Systematic documentation is critical to presenting the care administered by nurses in a logical fashion.



Critical thinking skills, judgments, and evaluation must be clearly communicated through proper documentation.


Purposes of Health Care Documentation

Professional Responsibility and Accountability

Communication Education Research Legal and Practice Standards



Recording provides written evidence of what was done for the client, the client’s response, and any revisions made in the care plan.



Recording documents compliance with professional practice standards and accreditation criteria.

Written records are a resource for review, audit, reimbursement, and research.

Documentation provides a written legal record to protect the client, institution and practitioner.



Education• Health care students use the medical record

as a tool to learn about disease processes, diagnoses, complications, and interventions.

• Clinical rounds and case conferences rely heavily on information contained in the medical record.



Research• Researchers rely heavily on medical records

as a source of clinical data.• Documentation can validate the need for

research.



Legal and Practice Standards• In 80% to 85% of malpractice lawsuits

involving client care, the medical record is the determining factor in providing proof of significant events.


Legal and Practice Standards

Informed Consent Advance Directives American Nurses Association (ANA)

Standards of Care State Nurse Practice Acts Joint Commission on Accreditation of

Health Care Organizations (JCAHO)



Informed consent means that the client understands the reasons and risks of the proposed intervention.

Witnessing confirms that the person who signs the consent is competent.



An advance directive allows the client to participate in end-of-life decisions.

The Patient Self-Determination Act of 1990 requires health care facilities to document whether the client has such a directive.



American Nurses Association Standards of Care make explicit the role of data collection and documentation in nursing practice.



State Nurse Practice Acts have established guidelines to ensure safe practice.

Require evidence of compliance through documentation.



The Joint Commission on Accreditation of Health Care Organizations (JCAHO) requires documentation of compliance with its standards of care requirements.



Reimbursement• Peer review organizations (PROs) are

required by the federal government to monitor and evaluate care.

• Medical record documentation is the mechanism for the PRO review.



Reimbursement • Diagnosis-Related Groups (DRG)

- The medical record must provide documentation that supports the DRG and appropriateness of care.

- If nurses fail to document the equipment or procedures used daily, reimbursement to the facility can be denied.



Reimbursement • Consolidated Omnibus Budget (COBRA)

Reconciliation Act- Any COBRA client receiving care in an

emergency room must be stabilized before being transferred to another facility.

- Facilities in violation of COBRA laws are fined and may lose their eligibility for Medicare and Medicaid funding.


Principles of Effective Documentation

Nursing notes must be logical, focused, and relevant to care, and must represent each phase of the nursing process.

Nursing documentation based on the nursing process facilitates effective care.


Elements of Effective Documentation

Use of Common Vocabulary Legibility Abbreviations and Symbols Organization Accuracy Documenting a Medication Error Confidentiality



Use of Common Vocabulary• Enhances the quality of documentation.• Supports the efforts of research.• Improves communication and lessens the

chance of misunderstanding between members of the health team.



Legibility• Print if necessary.• Do not erase or obliterate writing.• Draw one line through an erroneous entry.• State the reason for the error.• Sign and date the correction.



Correcting a documentation error



Abbreviations and Symbols• Always refer to the facility’s approved listing.• Avoid abbreviations that can be

misunderstood.



Organization• Start every entry with the date and time.• Chart in chronological order.• Chart in a timely fashion to avoid omissions.• Chart medications immediately after

administration.• Sign your name after each entry.



Charting a late entry



Charting a prn medication



Accuracy• Use factual, descriptive terms to chart

exactly what was observed or done.• Use correct spelling and grammar.• Write complete sentences.• Maintain continuity of care by recording with

respect to notes made on previous shifts.



Documenting a Medication Error• Chart the medication on the MAR.• Document in the nurses’ progress notes:

- Name and dosage of the medication- Name of the practitioner who was notified of the

error- Time of the notification- Nursing interventions or medical treatment- Client’s response to treatment



Confidentiality• The nurse is responsible for protecting the

privacy and confidentiality of client interactions, assessments, and care.

• The client’s significant others, insurance companies, or other parties not directly involved in care provided by the health team may not have access to clients’ records.


Methods of Documentation

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• Describes the client’s status, interventions

and treatments; response to treatments is in story format.

• 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.



Problem-Oriented Charting (POMR)• Uses a structured, logical format called

S.O.A.P.- S: subjective data- O: objective data- A: assessment (conclusion stated in form of

nursing diagnoses or client problems)- P: plan


Problem-Oriented Charting (POMR)

Uses flow sheets to record routine care. A discharge summary addresses each

problem. SOAP entries are usually made at least

every 24 hours on any unresolved problem.

SOAP was developed on a medical model.



SOAPIE and SOAPIER refer to formats that add:• I: Intervention• E: Evaluation• R: Revision



PIE Charting• P: Problem• I: Intervention• E: Evaluation

Key components are assessment flow sheets and the nurses’ progress notes with an integrated plan of care.

PIE charting is a nursing model.



Focus Charting• A method of identifying and organizing the

narrative documentation of all client concerns.

• Includes data, action, response.• Uses a columnar format within the progress

notes to distinguish the entry from other recordings in the narrative notes.



Charting by Exception (CBE)• The nurse documents only deviations from

preestablished norms.• Avoids lengthy, repetitive notes.• Enables the identification of trends in client

status.



Computerized Documentation• Increases the quality of documentation and

save time.• Increases legibility and accuracy.• Enhances implementation of the nursing

process. Enhances the systematic approach to client care.

• Provides clear, decisive, and concise key words (standardized nursing terminology).



Computerized Documentation• Provides access to other data, enhancing

critical thinking.• Information is quickly coordinated and

integrated by other departments.• Facilitates statistical analysis of data.



Point-of-Care System• A handheld portable computer is used for

inputting and retrieving client data at the bedside.

• Provides each health care practitioner with all pertinent client data to ensure continuity of care without duplication.

• Provides crucial client information in a timely fashion.



Case Management Process• A methodology for organizing client care

through an illness, using a critical pathway.• A critical pathway is a monitoring and

documentation tool used to ensure that interventions are performed on time and that client outcomes are achieved on time.


Forms for Recording Data

Kardex Flow Sheets Nurses’ Progress Notes Discharge Summary



The Kardex is used as a reference throughout the shift and during change-of-shift reports.• Client data• Medical diagnoses and nursing diagnoses• Medical orders• Activities



Flow sheets reduce the redundancy of charting in the nurses’ progress notes.

The information on flow sheets can be formatted to meet the specific needs of the client.



Nurses’ progress notes are used to document the client’s condition, problems and complaints, interventions, responses, achievement of outcomes.

Progress notes can be completely narrative or incorporated into a standardized flow sheet.



Discharge Summary• Client’s status at admission and discharge• Brief summary of client’s care• Interventions and education outcomes• Resolved problems and continuing need• Referrals• Client instructions


Trends in Documentation

Standardized data bases are required to ensure accuracy and precision in nursing information systems.


Trends in Documentation

Nursing Minimum Data Set (NMDS) Nursing Diagnoses (Taxonomy II) Nursing Intervention Classification (NIC) Nursing Outcomes Classification (NOC)


Reporting

Verbal communication of data regarding the client’s health status, needs, treatments, outcomes, and responses

Summary of current critical information to facilitate clinical decision making and continuity of client care


Reporting

Reporting is based on the nursing process, standards of care, and legal and ethical principles.

Reports require participation from everyone present.


Reporting

Summary Reports Walking Rounds Telephone Reports and Orders Incident Reports


Summary Reports

Commonly occur at change of shift (or when client is transferred).• Assessment data• Primary medical and nursing diagnoses• Recent changes in condition, adjustments in

plan of care, and progress toward expected outcomes

• Client or family complaints


Walking Rounds

Nursing, physician, interdisciplinary Occur in the client’s room and include the

client


Telephone Reports and Orders

Report transfers, communicate referrals, obtain client data, solve problems, inform a physician and/or client’s family members regarding a change in the client’s condition.

Telephone orders are documented in the nurses’ progress notes and the physician order sheet.


Documenting a Telephone Order


Incident Reports

Used to document any unusual occurrence or accident in the delivery of client care.

The incident report is not part of the medical record, but it may be used later in litigation.

Chapter 16 Documentation and Reporting. 16-2 Copyright 2004 by Delmar Learning, a division of...

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