Doc and Report

Documentation and Reporting

Teresa V. Hurley MSN,RN

Charting

The process of recording vital information that is communicated to others.– Facts and figures that are specific, clear and

precise– Contains correct language, medical terms and

abbreviations– Observations, interventions and communications– Reports to authorities as child or elder abuse

Charting

Assessment of quality and effectiveness of nursing care

Permanent record Assessment of quality and effectiveness of

nursing care Legal Document in the event of litigation or

prosecution If not charted, legally it was not done

Charting

Legal Requirements-regulated by state laws

-professional standards

-Joint Commission on Accreditation of Health Care Organizations [JCAHO]

Charting Specifics

Black ball point pen because it microfilms best Errors are corrected by drawing a single line through

the error. Above write “Mistaken Entry” [ME] and your initial.

No white-out, erasers, eradicators, covering-up materials

Error no longer written. Juries associate it with an actual nursing mistake

Charting Specifics

Each entry is signed with your first initial, last name and status

J. Smith, SNR. Jones, RN

Script not printing is used for the signature and it should appear at the right hand margin of the narrative note.

Charting Specifics

Notes are written on each succeeding line Lines are not omitted A horizontal line is drawn to “fill up” a partial

line Each entry is dated and timed Begin with a Capital letter End with a periodDoes not have to be complete sentences

Charting Specifics

Be accurate Describe behaviors Use approved abbreviations and symbols Spell correctly Used correct terminology and grammar Write legibly [Printing is acceptable] Chart only what you have done Do not double chart [data appears on a flow sheet]

except when the patient has a change in their condition

Charting Specifics

If you forgot to chart something do so on the next available line putting the time of the event and not the time you are actually charting it

Physician visits Time client left and returned to unit including

transportation and destination Medications: dosage, route, site, pain relieved, time

worked, and/or side effects Treatments

Charting Specifics

Chart objective facts

-ate 100% and not “good appetite”

-client/patient c/o placed in quotes

“stabbing; “chest pain”; “going down” his “left arm”

-objective observations

-skin cold and clammy; diaphoretic,

-v/s B/P 70/40; Pulse 122 bpm, irregular, 1+;

Charting Format

Assessment at the start of the shift Changes in mental, psychological,

physiological conditions Reactions to procedures or medications Teaching

-Document what was taught

and the client’s response

Charting Systems

Source-oriented– Data entered according to the source [i.e. nurse,

MD, social worker, respiratory therapy etc.]– Form of charting is a narrative– Overall picture is difficult to ascertain

Narrative Charting

Used with flow sheets and other systems Chronological data quickly documented Familiar form Used in all types of settings

Narrative Charting Disadvantages

Lack of a systematic structure hinders making relationships between data

Requires time May lack information concerning client

outcomes Quality Assurance monitoring more difficult Relevant data found in several places

Charting Systems

Problem-oriented

-Data organized based on problems

-Each member of the health team documents on the same problem

-The overall picture can be seen easily

-Focus is on the client and not on the person or department reporting

Problem-Oriented Medical RecordsPOMR

Focus is on the client One set of progress notes is used by all

persons caring for the client Format is called SOAP or SOAPIE

POMR: SOAP or SOAPIE

Subjective Objective Assessment Plan Implementation Evaluation

Charting Systems

Computer-Assisted -Data legible

-Quick access to data and information between departments

-Easily retrievable

-Quick assess to data

-Confidentiality maintained

-Bedside computers increase accuracy and speed of charting

-Meet JCAHO standards

-Increase speed and completeness of reimbursement

Disadvantages of Computer-Assisted Charting

Expensive to purchase and update Problems with “downtime” interfere in

charting and receiving information Increase charting time if not enough

terminals Reliance on technology instead questioning

data which may be wrong

REPORTING: INTRASHIFT

Verbal reports during your shift to other team members

-Significant changes in Vital signs

-Unusual reactions to treatments, procedures, medications

- Changes in physical or psychological condition

Reporting

Intershift– Verbal or tape recorded– Client’s Name, Age, Room Number, MD,

Diagnosis, Date of Surgery– Changes or unusual occurrences – Laboratory results, studies, tests to be done on

next shift– Physical or psychological problems

REPORTING: MD NOTIFICATION

Significant changes in physical assessment, abnormal laboratory findings, test results

Identify self to MD by name, status, unit and client’s name

State exact reason why you are calling Current vital signs, laboratory results,

medications etc. should be available

REPORT to NURSING ADMINISTRATORS

Written or Verbal each shift Data on critically ill clients Unusual occurrences Problems with clients, families or other

disciplines

INCIDENT REPORT

Unusual Occurrence, Variance or Incident Report [IR]

Helps to document quality care Identify areas where staff development is

needed Maintain detailed record of incident for

possible legal action