Documentation

and Reporting
Maria Katrina L. Costiniano, RN, MAN
 Generally, health personnel communicate Through…

Discussion Report Records

• an informal oral consideration of a • oral, written, or computer-based • also called a chart or client record,
subject by two or more health communication intended to is a formal, legal document that
care personnel to identify a convey information to others. provides evidence of a client’s care
problem or establish strategies to and can be written or computer
resolve a problem. based.
Documentation
• Anything written or printed that is relied on as a record of
proof for authorized persons.
• Documentation and reporting in nursing are needed for
continuity of care it is also a legal requirement showing the
nursing care performed or not performed by a nurse.
 The American Nurses Association Code of Ethics (2001) states that “.
. . the nurse has a duty to maintain confidentiality of all patient
information” (p. 12).

Changes in the laws regarding client privacy became effective on

Ethical and April 14, 2003.

Legal The new HIPAA regulations maintain the privacy and confidentiality
of protected health information (PHI).
considerations
• HIPAA refers to the Health Insurance Portability and Accountability Act of
1996.
It is the responsibility of the student or health professional to
protect the client’s privacy by not using a name or any statements
in the notations that would identify the client.
 1. A personal password is required to enter and sign off
computer files. Do not share this password with anyone,
including other health team members.
2. After logging on, never leave a computer terminal
Ensuring unattended.
3. Do not leave client information displayed on the monitor
Confidentiality where others may see it.
4. Shred all unneeded computer-generated worksheets.
of Computer 5. Know the facility’s policy and procedure for correcting an
entry error.
Records 6. Follow agency procedures for documenting sensitive
material, such as a diagnosis of AIDS.
7. Information technology (IT) personnel must install a
firewall to protect the server from unauthorized access.
 PURPOSES OF CLIENT RECORDS

Planning Client Auditing Health

Communication Research
Care Agencies

Legal Health care

Education Reimbursement
documentation Analysis
 Documentation systems

Source oriented Problem-oriented Problems, interventions,

Narrative charting
record medical record evaluation (PIE) model

Charting by Computerized
Focus charting Case management.
exception (CBE) documentation
Source-Oriented Record
• The traditional client record.
• Each person or department makes notations in a separate
section or sections of the client’s chart.
• In this type of record, information about a particular problem
is distributed throughout the record.
Narrative Charting
• A traditional part of the source-oriented record.
• It consists of written notes that include routine care, normal
findings, and client problems.
• When using narrative charting, it is important to organize the
information in a clear, coherent manner.
• Using the nursing process as a framework is one way to do this.
Problem-Oriented • Established by Lawrence Weed in the 1960s, the
Medical Record data are arranged according to the problems the
client has rather than the source of the
information.
• Members of the health care team contribute to
the problem list, plan of care, and progress notes.
• Plans for each active or potential problem are
drawn up, and progress notes are recorded for
each problem.
Advantages and disadvantages of pomr
Advantages Disadvantages
(a) it encourages collaboration and (a) caregivers differ in their ability to use the
(b) the problem list in the front of the chart alerts required charting format,
caregivers to the client’s needs and makes it (b) it takes constant vigilance to maintain an up-to-
easier to track the status of each problem. date problem list, and
(c) it is somewhat inefficient because assessments
and interventions that apply to more than one
problem must be repeated.
 Database
The POMR has Problem list
four basic
components: Plan of care
Progress notes
 Consists of all information known about the client when the
client first enters the health care agency.

It includes the nursing assessment, the primary care

database provider’s history, social and family data, and the results of
the physical examination and baseline diagnostic tests.

Data are constantly updated as the client’s health status

changes.
Problem list
Problems are listed in the
It is usually kept at the front order in which they are
of the chart and serves as an identified, and the list is
Derived from the database.
index to the numbered continually updated as new
All caregivers may contribute entries in the progress notes. problems are identified and
to the problem list, which others resolved.
As the client’s condition
includes the client’s
changes or more data are
physiological, psychological,
obtained, it may be necessary
social, cultural, spiritual,
to “redefine” problems.
developmental, and
environmental needs.
Plan of care
The initial list of orders or plan of care is made with reference to the active problems.

Care plans are generated by the individual who lists the problems.

Primary care providers write physician’s orders or medical care plans; nurses write nursing orders or
nursing care plans.
The written plan in the record is listed under each problem in the progress notes and is not isolated as a
separate list of orders.
Progress notes
• A progress note in the POMR is a chart entry made by all health
professionals involved in a client’s care; they all use the same type of
sheet for notes.
• Progress notes are numbered to correspond to the problems on the
problem list and may be lettered for the type of data.
• For example, the SOAP format is frequently used. SOAP is an acronym for
subjective data, objective data, assessment, and planning.
S- Subjective data • S—Subjective data consist of information obtained from what the
client says.
• It describes the client’s perceptions of and experience with
the problem.
• When possible, the nurse quotes the client’s words;
otherwise, they are summarized.
• Subjective data are included only when it is important and
relevant to the problem.
O- Objective data
• O—Objective data consist of information that is
measured or observed by use of the senses (e.g.,
vital signs, laboratory and x-ray results).
A- Assessment • A—Assessment is the interpretation or conclusions drawn about the
subjective and objective data.
• During the initial assessment, the problem list is created from the
database, so the “A” entry should be a statement of the problem.
• In all subsequent SOAP notes for that problem, the “A” should
describe the client’s condition and level of progress rather than merely
restating the diagnosis or problem.
P- Plan
• P—The plan is the plan of care designed to resolve the stated
problem.
• The initial plan is written by the person who enters the
problem into the record.
• All subsequent plans, including revisions, are entered into
the progress notes.
soapier
• Over the years, the SOAP format has been modified.
• The acronyms SOAPIE and SOAPIER refer to formats that add
interventions, evaluation, and revision:
I- interventions
• I—Interventions refer to the specific interventions
that have actually been performed by the caregiver.
E- evaluation
• E—Evaluation includes client responses to
nursing interventions and medical treatments.
• This is primarily reassessment data.
R- Revision
• R—Revision reflects care plan modifications suggested
by the evaluation.
• Changes may be made in desired outcomes,
interventions, or target dates.
 • The PIE documentation model groups information

pie into three categories.

• PIE is an acronym for problems, interventions, and
evaluation of nursing care.
• This system consists of a client care assessment
flow sheet and progress notes.
• The PIE system eliminates the traditional care plan
and incorporates an ongoing care plan into the
progress notes.
• A disadvantage is that the nurse must review all
of the nursing notes before giving care to
determine which problems are current and which
interventions were effective.
Pie continuation
• International’s three-part format: client’s response, contributing or probable causes of the response, and
characteristics manifested by the client.
• The problem statement is labeled “P” and referred to by number (e.g., P #5).
• The interventions employed to manage the problem are labeled “I” and numbered according to the problem (e.g., I
#5).
• The evaluation of the effectiveness of the interventions is also labeled and numbered according to the problem (e.g.,
E #5)
Focus charting
• Focus charting is intended to make the client and client concerns and strengths the focus
of care.
• Three columns for recording are usually used: date and time, focus, and progress notes.
• The focus may be a condition, a nursing diagnosis, a behavior, a sign or symptom, an
acute change in the client’s condition, or a client strength.
• The progress notes are organized into (D) data, (A) action, and (R) response, referred to as
DAR.
• The focus charting system provides a holistic perspective of the client and the client’s
needs. It also provides a nursing process framework for the progress notes (DAR).
 dar

The data category reflects the assessment phase The action category reflects planning
of the nursing process and consists of The response category reflects the
and implementation and includes
observations of client status and behaviors, evaluation phase of the nursing process
including data from flow sheets (e.g., vital signs, immediate and future nursing actions. It
may also include any changes to the and describes the client’s response to
pupil reactivity). The nurse records both any nursing and medical care.
subjective and objective data in this section. plan of care.
 Charting by exception (CBE) is a documentation system in
which only abnormal or significant findings or exceptions to
norms are recorded.

Charting by
exception CBE incorporates three key elements (Guido, 2010):

• Flow sheets
• Standards of nursing care
• Bedside access to chart forms
Flow sheets
• Examples of flow sheets include graphic records of a vital
sign sheet
• A head and face assessment in a daily nursing assessments
record and
• A Braden assessment of the skin
 • Documentation by reference to the agency’s printed
standards of nursing practice eliminates much of the
repetitive charting of routine care.
• An agency using CBE must develop its own specific
Standards of standards of nursing practice that identify the minimum
nursing care criteria for client care regardless of clinical area.
• Some units may also have unit-specific standards unique
to their type of client.
• For example, “The nurse must ensure that the unconscious
client has oral care at least q4h.”
Bedside access to chart forms
• In the CBE system, all flow sheets are kept at the client’s
bedside to allow immediate recording and to eliminate the
need to transcribe data from the nurse’s worksheet to the
permanent record.
Computerized documentation
• Electronic health records (EHRs) are used to manage the huge volume of information required in
contemporary health care.
• Nurses use computers to store the client’s database, add new data, create and revise care plans,
and document client progress
• Some institutions have a computer terminal at each client’s bedside, or nurses carry a small
handheld terminal, enabling the nurse to document care immediately after it is given.
Nursing minimum data set
(NMDS)

• An effort to establish uniform definitions

and categories (e.g., nursing diagnoses)
for collecting, essential nursing data for
inclusion in computer databases.
Case management
• The case management model emphasizes quality, cost-effective care delivered within an established
length of stay. This model uses
• A multidisciplinary approach to planning and documenting client care, using critical pathways.
• These forms identify the outcomes that certain groups of clients are expected to achieve on each day of
care, along with the interventions necessary for each day
variance
A variance is a deviation from what was planned on the critical pathway—
unexpected occurrences that affect the planned care or the client’s responses to
care.
The case management model promotes collaboration and teamwork among
caregivers, helps to decrease length of stay, and makes efficient use of time.
DOCUMENTING
NURSING
ACTIVITIES
 A comprehensive admission assessment, also referred to as an initial
database, nursing history, or nursing assessment, is completed when the
client is admitted to the nursing unit.

Admission These forms can be organized according to health patterns, body systems,
functional abilities, health problems and risks, nursing model, or type of
nursing health care setting (e.g., labor and delivery, pediatrics, mental health).

assessment The nurse generally records ongoing assessments or reassessments on

flow sheets or on nursing progress notes.
 There are two types of nursing care plans: traditional and
standardized.

The traditional care plan is written for each client.

• The form varies from agency to agency according to the needs of the
Nursing care client and the department.
• Most forms have three columns: one for nursing diagnoses, a second for
plans expected outcomes, and a third for nursing interventions.
Standardized care plans were developed to save documentation time.
• These plans may be based on an institution’s standards of practice,
thereby helping to provide a high quality of nursing care.
• Standardized plans must be individualized by the nurse in order to
adequately address individual client needs.
kardex
• The Kardex is a widely used, concise method of organizing
and recording data about a client, making information quickly
accessible to all health professionals.
• The system consists of a series of cards kept in a portable
index file or on computer-generated forms.
• The card for a particular client can be quickly accessed to
reveal specific data.
The information on Kardexes may be
organized into sections, for example:

• Pertinent information about the client, such as name, room

number, age, admission date, primary care provider’s name,
diagnosis, and type of surgery and date
• Allergies
• List of medications, with the date of order and the times of
administration for each
• List of intravenous fluids, with dates of infusions
The information on Kardexes may be organized into
sections, for example:
• List of daily treatments and procedures, such as irrigations, dressing changes, postural drainage, or measurement of vital
signs
• List of diagnostic procedures ordered, such as x-ray or laboratory tests
• Specific data on how the client’s physical needs are to be met, such as type of diet, assistance needed with feeding,
elimination devices, activity, hygienic needs, and safety precautions (e.g., one person assist)
• A problem list, stated goals, and a list of nursing approaches to meet the goals and relieve the problems.
 • A flow sheet enables nurses to record nursing data
Flow sheets quickly and concisely and provides an easy-to-read
record of the client’s condition over time.
 • This record typically indicates body
temperature, pulse, respiratory rate, blood
pressure, weight, and, in some agencies,
Graphic record other significant clinical data such as
admission or postoperative day, bowel
movements, appetite, and activity
Input and output record
• All routes of fluid intake and all routes
of fluid loss or output are measured and
recorded on this form.
 Medication flow sheets usually include designated areas
for the date of the medication order, the expiration date,
the medication name and dose, the frequency of
Medication administration and route, and the nurse’s signature.
administration
record Some records also include a place to document the
client’s allergies
 • A skin or wound assessment is often recorded on
Skin a flow sheet.
• This EHR specifically utilizes the Braden
assessment Assessment. EHRs may include categories related
record to stage of skin injury, drainage, odor, culture
information, and treatments.
Progress notes
• Progress notes made by nurses provide information about the progress a client is
making toward achieving desired outcomes.
• Therefore, in addition to assessment and reassessment data, progress notes include
information about client problems and nursing interventions.
• The format used depends on the documentation system in place in the institution.
 A discharge note and referral summary are completed when the
client is being discharged and transferred to another institution or
to a home setting where a visit by a community health nurse is
Nursing required.
discharge/
referral Many institutions provide forms for these summaries.

summaries • Some records combine the discharge plan, including instructions for care,
and the final progress note.
• Many are designed with checklists to facilitate data recording.
 • Description of client’s physical, mental, and emotional
discharge and status at discharge or transfer

referral • Resolved health problems

• Unresolved continuing health problems and continuing care
summaries needs; may include a review-of-systems checklist that
considers integumentary, respiratory, cardiovascular,
usually include neurologic, musculoskeletal, gastrointestinal, elimination,
and reproductive problems
some or all of • Treatments that are to be continued (e.g., wound care,
oxygen therapy)
the following: • Current medications
 • Restrictions that relate to (a) activity such as lifting, stair
discharge and climbing, walking, driving, work; (b) diet; and (c) bathing
such as sponge bath, tub, or shower
referral • Functional/self-care abilities in terms of vision, hearing,
summaries speech, mobility with or without aids, meal preparation
and eating, preparing and administering medications, and
usually include so on
• Comfort level
some or all of • Support networks including family, significant others,
religious adviser, community self-help groups, home care
the following: and other community agencies available, and so on
 • Client education provided in relation to disease
discharge and process, activities and exercise, special diet,
referral medications, specialized care or treatments, follow-
up appointments, and so on
summaries • Discharge destination (e.g., home, nursing home) and
usually include mode of discharge (e.g., walking, wheelchair,
ambulance)
some or all of
• Referral services (e.g., social worker, home health
the following: nurse).
Long term documentation
 Specific problems noted in the care plan
Mental status
Activities of daily living

Summaries Hydration and nutrition status

Safety measures needed
should address Medications
the following: Treatments
Preventive measures
Behavioral modification assessments, if pertinent (if client is taking
psychotropic medications or demonstrates behavioral problems).
Home care documentation
GENERAL GUIDELINES FOR
RECORDING: 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
GENERAL GUIDELINES FOR
RECORDING: timing
• 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.
• As a rule, documenting should be done as soon as possible after
an assessment or intervention. No recording should be done
before providing nursing care.
GENERAL GUIDELINES FOR
RECORDING: legibility
• All entries must be legible and easy to read to prevent
interpretation errors.
• Hand printing or easily understood handwriting is usually
permissible.
• Follow the agency’s policies about handwritten recording.
 • All entries on the client’s record are made in dark ink so that
the record is permanent and changes can be identified.
GENERAL • Dark ink reproduces well on microfilm and in duplication
processes.
GUIDELINES FOR • Follow the agency’s policies about the type of pen and ink
used for recording.
RECORDING: • In regards to EHRs, changes are made in accordance with the
software guidelines.
permanence • It is important for the nurse to understand the policies and
procedures of the health care institution regarding
documentation
GENERAL • Abbreviations are used because they are short, convenient,
and easy to use.
GUIDELINES • Abbreviations are convenient; however, they are often
ambiguous.
FOR • It is important to use only commonly accepted abbreviations,

RECORDING: symbols, and terms that are specified by the agency.

• Many abbreviations are standard and used universally;
accepted others are used only in certain geographic areas.
• Many health care facilities supply an approved list of
terminology abbreviations and symbols to prevent confusion.
GENERAL GUIDELINES FOR RECORDING: correct spelling

• Correct spelling is essential for accuracy in recording.

• If unsure how to spell a word, look it up in a dictionary or other resource book.
• Two decidedly different medications may have similar spellings; for example, Fosamax and
Flomax.
 • Each recording on the nursing notes is signed by the
GENERAL nurse making it.

GUIDELINES • The signature includes the name and title; for example,
“Susan J. Green, RN” or “SJ Green, RN.”
FOR • Some agencies have a signature sheet and after signing
this signature sheet, nurses can use their initials.
RECORDING: • With computerized charting, each nurse has his or her

signature own code, which allows the documentation to be

identified.
 signature
• The following title abbreviations are often used, but nurses need to follow
agency policy about how to sign their names:
 GENERAL GUIDELINES FOR
RECORDING: accuracy
• The client’s name and identifying information should be stamped or written on each
page of the clinical record.
• Notations on records must be accurate and correct. Accurate notations consist of facts
or observations rather than opinions or interpretations.
• 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).
• 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.
GENERAL GUIDELINES FOR RECORDING: sequence

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

Update or delete problems as needed.

 • Record only information that pertains to the client’s health
problems and care.
GENERAL • Any other personal information that the client conveys is
inappropriate for the record.
GUIDELINES FOR • Recording irrelevant information may be considered an
RECORDING: invasion of the client’s privacy and/or libelous.
• A client’s disclosure that she was addicted to heroin 15
appropriateness years ago, for example, would not be recorded on the
client’s medical record unless it had a direct bearing on the
client’s health problem.
GENERAL GUIDELINES FOR
RECORDING: completeness
• 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.
• Care that is omitted because of the client’s condition or
refusal of treatment must also be recorded.
• Document what was omitted, why it was omitted,
and who was notified.
 Recordings need to be brief as well as complete
to save time in communication.
GENERAL
GUIDELINES FOR The client’s name and the word client are
omitted. For example, write “Perspiring profusely.
RECORDING: Respirations shallow, 28/min.”

conciseness
End each thought or sentence with a period.
GENERAL GUIDELINES • Accurate, complete documentation should give
FOR RECORDING: legal protection to the nurse, the client’s other
caregivers, the health care facility, and the client.
legal prudence
• Admissible in court as a legal document, the
clinical record provides proof of the quality of care
given to a client.
• Documentation is usually viewed by juries and
attorneys as the best evidence of what really
happened to the client.
reporting
 • 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,

reporting including pertinent information but no extraneous detail.

• In addition to change-of-shift reports and telephone
reports, reporting can also include the sharing of
information or ideas with colleagues and other health
professionals about some aspect of a client’s care.
Hand off report
• Incomplete handoff communication is associated with sentinel events that will result in adverse health
care outcomes or death (Criscitelli, 2013).
• As a result, a hospital is required to implement a standardized approach to “handoff” communication,
which is defined as a process in which information about patient/client/resident care is communicated in
a consistent manner including an opportunity to ask and respond to questions (Riesenberg, Leitzsch, &
Cunningham, 2010, p. 24).
 • The handoff communication or change-of-shift report is given to
all nurses on the next shift. Hill and Nyce (2010) identified three
important features in an effective change-of-shift report.
• These are: “two way, face-to-face communication; written support
Change-of- tools; and content in handover which captures intention” (p. 44).
• Face-to face communication allows the oncoming nurse the ability
shift report to ask questions and gain confidence to care for the client. The
incoming and departing nurses establish priorities for the care of
the client in the upcoming hours by reviewing checklists and the
client’s medical record. Content of the handover, which captures
intention, includes client problems and interventions to care for the
client’s problems.
Sbar tool • The Institute for Healthcare Improvement
(2013) states that “the SBAR allows for an
easy and focused way to set expectations for
what will be communicated and how
between members of the team, which is
essential for developing teamwork and
fostering a culture of patient safety”
Telephone reports
• Health professionals frequently report about a
client by telephone.
• The nurse receiving a telephone report should
document the date and time, the name of the
person giving the information, and the subject of
the information received, and sign the notation.
• For example: 6/6/14 1035 G Messina, laboratory
technician, reported by telephone that Mrs. Sara
Ames’s hematocrit is 39%. _____B. Ireland RN
Telephone reports
• The person receiving the information should repeat it back to the sender to ensure accuracy.
• When giving a telephone report to a primary care provider, it is important that the nurse be concise and
accurate.
• The SBAR communication tool is often used for telephone reports. Begin with name and relationship to the client
(e.g., “This is Jana Gomez, RN; I’m calling about your client, Dorothy Mendes. I’m her nurse on the 7 pm to 7 am
shift”).
• Telephone reports usually include the client’s name and medical diagnosis, changes in nursing assessment, vital
signs related to baseline vital signs, significant laboratory data, and related nursing interventions.
• The nurse should have the client’s chart ready to give the primary care provider any further information.
Telephone • After reporting, the nurse should document the
date, time, and content of the call. For example:
reports 1200—Admitted from ED. c/o burning upper right
quadrant abdominal pain. Rates pain at 6/10. BP
115/80, P100, R15. Demerol 100 mg given IM per
order. 1300—BP 100/40, P115, R30. Pain
unchanged. Color pale and diaphoretic. Reported
by telephone to Dr. Burns at 1305.
_____________ TS Jones RN
 • Primary care providers often order a therapy (e.g., a medication) for a
client by telephone.
• Most agencies have specific policies about telephone orders. Many
agencies allow only registered nurses to take telephone orders.
Telephone • While the primary care provider gives the order, write the complete
order down on the physician’s order form and read it back to the

orders primary care provider to ensure accuracy.

• Question the primary care provider about any order that is ambiguous,
unusual (e.g., an abnormally high dosage of a medication), or
contraindicated by the client’s condition.
• Have the primary care provider verbally acknowledge the read-back of
the verbal/telephone order.
Telephone orders
• Then indicate on the physician’s order form that it is a verbal order (VO) or telephone order
(TO).
• Once the order is written on the physician’s order form, the order must be countersigned by
the primary care provider within a time period described by agency policy. Many acute care
hospitals require that this be done within 24 hours.
Care conference
• A care plan conference is a meeting of
a group of nurses to discuss possible
solutions to certain problems of a client,
such as inability to cope with an event
or lack of progress toward goal
attainment.
 • Nursing rounds are procedures in which two or
more nurses visit selected clients at each client’s
bedside to:
Nursing rounds • Obtain information that will help plan nursing care.
• Provide clients the opportunity to discuss their care.
• Evaluate the nursing care the client has received.
Group work
• Mr. Anderson, an 80-year-old male, was admitted for back pain. He has a past medical history of hypertension. He told
the admitting nurse that he has lost interest in many of his normal activities because of the constant pain. You read the
following documentation entry by a previous nurse:
8—Client is a complainer. I listened to him for 15 minutes with no success. BP 210/90 and 180/70. P 72, R 18.
12—Refused lunch.
2—Client fell out of bed.
Case study
1. What guidelines were not used in
this documentation?
2. The nursing diagnosis for Mr.
Anderson is Acute Pain. What
would you expect to document?
3. Sort the following pieces of data for Mr. Anderson into
a SOAP note:
a. “I didn’t sleep last night” g. Heating pad applied to lower back
b. Positioned on side with pillows behind back h. BP 210/90, P 72, R 18
c. Continues to need narcotic medication to progress i. Add to plan of care to offer analgesic around the
toward goal of pain relief clock q4h versus prn
d. States pain is 8 out of 10 j. 6/6/15 #1 Pain
e. “I feel better” (after interventions) k. “Sharp, stabbing pain in lower back that radiates to
f. Last medicated 5 hours previously left leg”
l. Medicated with ordered analgesic
Case study
4. Sort the pieces of data from Question 3 into a
DAR note.
Thank
you!