PURPOSE OF DOCUMENTATION - Cloud Object Storages3.amazonaws.com/western-pdfdocs-download/N1266_1.pdf · ing documentation is that it may be used in mal-practice cases. The patient’s

CHAPTER OBJECTIVE

After completing this chapter, the reader will beable to identify the importance and purpose of

complete documentation in the medical record.

LEARNING OBJECTIVESAfter studying this chapter, the reader will be

able to

1. explain the beginning of documentation and itsevolution.

2. identify purposes of a health care record.

3. specify ten records one might find in a patient’smedical chart.

4. indicate forms specifically used by nurses indocumenting patient care.

5. identify trends in nursing documentation.

INTRODUCTION

Accurate documentation of patient symptomsand observations is critical to proper treatment

and recovery. Starting on the first day of nursingschool, students are advised about the requirementsfor complete and proper documentation. However,documentation still becomes somewhat burdensomeand time-consuming. Nurses commonly experienceconflict between time spent caring for patients andtime needed to accurately record what care was pro-

vided and patient responses to treatment. When timeis limited, nursing care may take priority and what isdocumented may not tell the whole story.

EVOLUTION OFDOCUMENTATION

Documentation is a vital part of nursing prac-tice. It has been defined as “anything written

or printed that is relied on as a record of proof forauthorized persons” (Daniels, 1997, p. 181). It is therecording of pertinent patient data in a clinicalrecord. Good documentation reflects quality of careand evidence of each health care team member’saccountability in providing care. Written communi-cation must contain (a) appropriate language andterminology; (b) correct grammar, spelling, andpunctuation; and (c) logical organization. Nursingdocumentation is not a new requirement; however,it has become increasingly important in determiningthe quality and cost of patient care.

Documentation has been considered importantsince the days of Florence Nightingale. In her Noteson Nursing, Nightingale indicated nurses need torecord the care provided to patients. Most of thedocumentation during Nightingale’s time was usedfor communication of medical orders and not toobserve, assess, or evaluate patient status. Today,documentation is one of the most critical skills nurs-es perform. Many nurses approach documentationas a chore; however, one’s entire nursing career

C H A P T E R 1

PURPOSE OF DOCUMENTATION

1

Chapter 1—2 Documentation for Nurses

could depend on the accuracy and completeness ofthe charting that has or has not been done.

Nursing documentation was not always thoughtof as a critical part of patient care. In 1951, the JointCommission on Accreditation of HealthcareOrganizations (JCAHO) was established and pro-moted formalization of nursing standards, whichprovided a method by which nursing care could beevaluated. Prior to that time, nursing notes wereremoved from a patient’s chart and destroyed whena patient was discharged. Hospitals are nowrequired by JCAHO to establish quality improve-ment programs to conduct objective, ongoingreviews of patient care. JCAHO has standards inregard to patient records, including information thatmust be present in the record. JCAHO requiresinstitutions to establish quality care and methods tomonitor policies and practice. Nurses must be awarethat JCAHO regulations require completion of thepatient’s records within 30 days following dis-charge. The medical records department may asknurses to remind physicians to complete theirrecords.

In the early 1970s, nursing documentation wasfinally considered an important and legal part of apatient’s chart. With the development of diagnosisrelated groups (DRGs), nursing documentationbecame an important component in determiningmonetary reimbursement for care. DRGs provide amethod for classifying patients into categoriesbased on age, diagnosis, and treatment require-ments. It is the basis for the U.S. Department ofHealth and Human Services’ prospective paymentsystem. The federal Centers for Medicare &Medicaid Services (CMS) (previously Health CareFinancing Administration [HCFA]) requires everypatient be classified into one or more of about 500DRGs. This is necessary for reimbursement for ser-vices provided. The CMS also sets a length of stayfor each DRG, and documentation must be provid-ed if a patient remains hospitalized beyond theestablished time. The key source of information for

determining the patient’s course of treatment andthe correct DRG assignment is the medical record.Because of this reimbursement method, poor docu-mentation may create financial disaster for a hospi-tal. If quality care is provided for fewer expensesthan allotted by the DRG, the hospital is allowed tokeep the difference, thus realizing a profit.

The North American Nursing DiagnosisAssociation (NANDA) is an organization involvedin developing and promoting the use of nursingdiagnoses. The organization formed in 1973 andsince 1975 has continued to develop and refinenursing diagnoses. The diagnoses define problemsnurses are able to treat because they are qualified todo so. They assist nurses with assessing patients’biophysical, psychosocial, psychological, environ-mental, learning, and discharge planning needs.Newly developed components of NANDA addresspatient strengths as well as problems and alsoaddress the move toward wellness.

Even though NANDA is not a regulating body,many admission assessment forms are based onnursing diagnoses. After completing an admissionassessment, the nurse selects the appropriate choicefrom the list of accepted nursing diagnoses to iden-tify actual and potential problems. The identifiedproblems can assist the nurse to develop nursingdiagnoses and a plan of care.

The plan of care should guide patient care anddocumentation in the medical record. Once the planof care is established, it needs to be regularlyreviewed and updated. When a patient’s record isreviewed, the identified nursing diagnoses, inter-ventions, and outcomes should be compared to thedocumentation in the nursing notes. This compari-son can be used to determine whether the patient’shighest priority problems were identified andwhether the nursing interventions were effective.Other parts of the patient’s record may also bereviewed to verify that the nurse carried out the planof care.

Chapter 1—Purpose of Documentation 3

Documentation is the very core of nursing.Nurse practice acts and professional standardsrequire nursing documentation and specify thepatient’s needs that guide the documentation.Through documentation, changes in a patient’s con-dition can be tracked, decisions about the patient’sneeds can be made and recorded, and continuity ofcare can be ensured. Good charting saves time,effort, and money. Effective documentation is a sys-tematic, timely, accurate, well-written account ofnursing care provided for patients. It must complywith standards established by regulatory andaccrediting organizations, insurance companies,and the institution. What is charted may be exam-ined by many reviewers, including accrediting, cer-tifying, and licensing organizations; qualityimprovement professionals; Medicare and insur-ance company reviewers; researchers; and, in somecases, attorneys and judges. Therefore, nursing doc-umentation is a critical part of the complete medicalrecord.

PURPOSE OF MEDICALRECORDS

Amedical record is a valuable source of dataused by all members of a health care team. Its

purposes are to serve as a planning tool for patientcare; to record the course of a patient’s treatmentand changes in medical condition; to documentcommunication between all health care team mem-bers; to protect the legal interests of the patient, theorganization, and health care providers; to provide adatabase for use in statistical reporting, continuingeducation, and research; and to provide informationnecessary for third-party billing and regulatoryagencies. The medical record must be accurate,complete, current, readily accessible, and systemat-ically organized.

Nursing documentation communicates apatient’s assessment to other health care providersand team members. Professional responsibility and

accountability are the most important reasons foraccurate documentation. Nurses are managingpatients with increased complex problems thatrequire increased technology and equipment forcare. Documentation is part of a nurse’s overallresponsibility for patient care because it facilitatescare, enhances continuity of care, and helps coordi-nate treatment and evaluation of the patient.Documentation allows a nurse to take credit for careprovided, the patient’s response, and actions taken.Documentation must clearly communicate thenurse’s judgment and evaluation of a patient’s sta-tus. The patient’s medical record should provideinformation about a specific situation or illness andthe events that occurred during the situation.

Another reason for accurate and complete nurs-ing documentation is that it may be used in mal-practice cases. The patient’s record is considered alegal document that can be used as evidence in alegal action. When a patient makes an accusation ofnegligence or malpractice against a health careprovider, the record becomes a major source ofinformation about the care that the patient received.Many lawsuits are won or lost by the amount of orlack of nursing documentation. Nursing documen-tation provides critical evidence about whether astandard of care was met. The patient’s chart is thebest evidence of what happened to the patient; itbecomes the witness that never lies and never dies.Accurate, timely, and complete charting helps trackquality patient care and protects nurses, physicians,and the hospital from litigation.

The patient’s chart is used for auditing and forquality assurance. It helps organizations review andevaluate the quality of care given in an institution.Hospital accreditation is partially based on nursingdocumentation. The documentation must meet cur-rent requirements and demonstrate compliance withstandards. Current JCAHO standards direct allhealth care facilities to establish policies about thefrequency of documentation and necessary types ofdocumentation. Professional organizations and reg-


ulatory agencies require that documentation includeinitial and ongoing assessments, any variationsfrom the assessment, patient teaching, response totreatment or therapy, and relevant statements madeby the patient and the family.

Managed care has evolved and necessitated theneed to document accurate care for cost contain-ment. Documentation of care helps organizationsreceive reimbursement from third-party payers,including private insurance companies and govern-ment sources of reimbursement, such as Medicareand Medicaid. The complexity of patient problemsand the intensity of patient needs must be docu-mented to ensure complete reimbursement. Eachpatient’s record must provide the DRG code anddocumentation of appropriate care to facilitate thereceipt of appropriate payment.

A patient’s chart may also be used for educationand research. Data gathered from medical recordsof patients may yield a variety of research studies.Students use medical records as educational tools.Patient records provide a comprehensive view ofspecific patients, their health problems, their med-ical treatments, nursing interventions, and theresponse to treatment interventions. Medicalrecords help students understand patients’ individ-ual experiences with specific health problems.

COMMON NURSINGFORMS

Each patient’s medical record may include anumber of specific forms, some of which are

listed in Table 1-1. Although this table is not all-inclusive, it does provide a good representation offorms commonly found in medical records. Formsallow for quick, easy, and comprehensive documen-tation, and they are more accessible than long,detailed progress notes. Nurses are the primary peo-ple documenting on these forms. Discussion ofsome common nursing forms follows.

Nursing History FormsThe nursing history form, or admission assess-

ment form, must be completed by a registered nursewithin a specified time frame from the time of apatient’s admission, usually within 24 hours. Theform contains basic biographical data such as thepatient’s age; method of admission; physician; the

Medical records vary by institution and the ser-vices provided. All records should contain someor all of the following basic information, ifapplicable to the patient:

• Patient identification and demographic data

• Informed consent for treatment and proce-dures

• Medical history, physical, and diagnosis

• Initial nursing admission assessment

• Anesthesia assessment

• Nursing diagnosis or problems

• Nursing or multidisciplinary care plan

• Record of nursing treatments and evaluations

• Diagnostic and therapeutic orders

• Health care providers’ progress notes

• Medication and treatment records

• Results of diagnostic studies

• Operative reports

• Delivery records

• Nurses’ notes of nursing observations

• Vital sign graphs or records

• Consultation notes and reports

• Reports from other disciplines (social ser-vices and recreational, occupational, andactivity therapy)

• Physical therapy reports

• Nutritional notes and reports

• Fluid intake and output charts

• Patient education

• Discharge plan and summary(Daniels, 1997; Pozgar, 2002)

TABLE 1-1: COMMON FORMS THAT MAYBE FOUND IN A PATIENT’S CHART


admitting medical diagnosis or chief complaint; abrief medical-surgical history, including medicationand drug allergies; the patient’s perceptions about ill-ness or hospitalization; and a review of health riskfactors. A nursing physical assessment of all bodysystems may also be included on the form or on adifferent form.

The data collected serves as a baseline withwhich changes in the patient’s status may be com-pared. Baseline data is very important. The exactform may differ by institution and is dependent uponstandards of practice and the institution’s nursingcare philosophy. A sample nursing history form isfound in Figure 1-1 on pages 6 to 8.

Graphic Sheets and Flow SheetsGraphic sheets and flow sheets allow nurses to

readily see and assess changes in patient status.They provide a quick, efficient method to recordinformation about vital signs and routine patientcare. When a significant change is observed, thenurse may further document the assessment, inter-vention, and evaluation of that change in a narrativeor progress note. The graphic sheet or flow sheetprovides a quick, easy reference that all health careteam members can use in assessing a patient’s sta-tus. A sample graphic flow sheet is found in Figure1-2 on page 9.

Nursing KardexDaily patient care is commonly recorded on a

flip-over card that is kept in a portable index file ornotebook at the nurses’ station. Most Kardex formshave an activity and treatment section with a nurs-ing care plan section. Referral to the Kardexthroughout the shift helps a nurse organize informa-tion and plan care. The up-to-date Kardex reducesthe need for continual referral to the patient’s chartfor routine information. Depending on the institu-tion’s requirements, the Kardex may become part ofthe patient’s permanent record. The Kardex pro-vides the nurse an opportunity to communicate use-ful information to the nursing team about a patient’s

unique needs. A sample Kardex form appears inFigure 1-3 on pages 10 and 11.

Even though the Kardex is helpful, it does havedisadvantages. Access is limited to nurses and doesnot allow space for writing an extensive plan formultiple complex patient problems. In suchinstances, the nurse should consult the care plan.Another disadvantage is that the Kardex may not beupdated routinely and thus a nurse may miss a cur-rent or active order.

24-Hour Patient Care Records andAcuity Charting System

Twenty-four hour patient care records eliminateunnecessary record-keeping. Accurate assessmentinformation is documented on a flow sheet inchecklist format. The form is the basis for the acu-ity charting system, which requires nurses to docu-ment interventions used to identify patient acuity.The acuity rating compares patients with one anoth-er and provides a system for determining staffingpatterns. See Figure 1-4 on pages 12 to 14 for anexample of a 24-hour patient care record.

Standardized Care PlansStandardized care plans have simplified nursing

documentation by providing preprinted, establishedguidelines to be used for patient care for specificproblems. After the initial nursing assessment iscompleted, the nurse selects the appropriate stan-dardized care plan and individualizes it to meet thepatient’s specific needs. Many standardized careplans provide spaces for writing specific outcomesof care and recording the dates by which the out-comes should be achieved. A major advantage isthat specific standards of care have been establishedand can easily be adapted to specific patients. Theeducational needs of the patient can easily be iden-tified and addressed. Standardized care plansimprove continuity of care and decrease documen-tation time.

A major disadvantage of standardized care plansis the risk of not taking the time to individualize the

text continues on page 10

FIGURE 1-1: SAMPLE NURSING HISTORY FORM (1 OF 3)






Reprinted with the permission of WellStar Health System, Marietta, GA.

FIGURE 1-2: SAMPLE GRAPHIC FLOW SHEET


Reprinted with the permission of St. Joseph Hospital, Augusta, GA.

plan of care. In addition, plans must be formallyupdated and kept current and the costs of printingand storing the forms may become problematic.Standardized care plans are not designed to replacethe nurse’s professional judgment and decision-making process. See Figure 1-5 on pages 15 and 16for an example of a standardized care plan.

Medication Administration RecordThe medication administration record (MAR)

provides a list of the patient’s medications, dosages,routes, and times for administration, and it includesspaces for indications by the nurse if the medicationhas been given. Accurate documentation is crucial sothat patients receive the appropriate drug, dose, androute of administration. If a patient refuses a drug oris off the unit for a specific diagnostic reason, thenurse should document in the nurses’notes the reasonthe medication was not given. Some notation (such asan asterisk or the space circled) is made on the MARto indicate that the medication was not given. SeeFigure 1-6 on pages 17 and 18 for a sample MAR.

Discharge Summary FormTo insure that the patient’s discharge results in

desirable outcomes, discharge planning begins atadmission. These outcomes may be documented onthe discharge summary form. Revisions to the careplan provide evidence of patient and family involve-ment in the discharge-planning process. Dischargesummary forms make the summary concise andinformative. A copy of the form is usually senthome with the patient. The form may include infor-mation about the patient; identification of possibleproblems; names and phone numbers of people tocontact if problems or questions arise; teaching,activity, diet, medication, wound care, and specialinstructions; and the date and time of the next physi-cian’s visit. The information provides for continuityof self-care upon discharge. See Figure 1-7 on page19 for an example of a discharge summary form.

FIGURE 1-3: SAMPLE KARDEX FORM (1 OF 2)


FIGURE 1-3: SAMPLE KARDEX FORM (2 OF 2)



FIGURE 1-4: SAMPLE 24-HOUR PATIENT CARE RECORD (1 OF 3)






Reprinted with the permission of Piedmont Hospital, Atlanta, GA.

FIGURE 1-5: SAMPLE STANDARDIZED CARE PLAN (1 OF 2)



FIGURE 1-5: SAMPLE STANDARDIZED CARE PLAN (2 OF 2)

Reprinted with the permission of St. Joseph’s Hospital, Atlanta, GA.


FIGURE 1-6: SAMPLE MEDICATION ADMINISTRATION RECORD (1 OF 2)

FIGURE 1-6: SAMPLE MEDICATION ADMINISTRATION RECORD (2 OF 2)


Reprinted with the permission of Medical College of Georgia Children’s Medical Center, Augusta, GA.

FIGURE 1-7: SAMPLE DISCHARGE SUMMARY FORM




TRENDS IN CHARTING

In the past, documentation was process-orientedand emphasized tasks performed by health care

providers. Today, increased consumer awareness,increased acuity of the patient, and increasedemphasis on health care outcomes has created theneed for changes in nursing documentation.Consumers expect nurses to be knowledgeable,competent, and caring while providing high-quality,highly technical care. This care must be recorded inthe patient’s chart. Complex health problems,decreased lengths of stay, and increased patient acu-ity require documentation systems that reflect safe,efficient, and effective care.

Significant trends in documenting patient carehave been observed. Trends include changes in tra-ditional care planning and efforts to meet the needfor increased documentation and improved commu-nication while making charting less time consuming.Beginning in the 1990s, handwritten care plans werereplaced with standardized care plans that requireindividualization to meet specific patient needs.Another trend at that time was the use of criticalpathways, or care maps.

Increasing documentation efficiency is anothertrend. Methods have been developed to reduce theamount of time required for nursing documentation.Emphasis is being placed on documenting patientcare outcomes, especially those that influence dis-charge planning. Trends aimed at improving com-munication through documentation involve usingnursing diagnoses. A shift is also occurring fromnarrative and problem-oriented documentation toFocus charting and charting by exception.Furthermore, computerized documentation isbecoming the primary means of documenting carein the 21st century. Some of these trends will be dis-cussed in more detail throughout this course.

CONCLUSION

Nursing documentation is a critical componentof nursing practice. It allows nurses to protect

their careers by bringing together the best availableevidence about nursing diagnoses, interventions,and outcomes about the care provided. It also pro-tects nurses from inaccurate claims of malpracticeand negligence.

The purpose of this course is to provide informa-tion to help nurses explore the professional and regu-latory requirements for the documentation process;review documentation processes and systems; beaware of the impact of nursing documentation onpatient care, the nursing career, and reimbursement;and learn steps to avoid litigation.

Nursing documentation methods must changeto keep pace with rapid changes in the health caresystem. Patient outcomes are the latest trend fordocumenting patient care. The transition to out-come charting is not easy. It is now critical for nurs-es to document nursing judgments rather than tasks.Different forms used for nursing documentationvary from institution to institution. Representativeforms a nurse may encounter were presented in thischapter. There are numerous charting methods thathelp nurses document outcomes and communicatecomplete, accurate, and clearly understood healthcare interventions and will be discussed further inthe course.

CHAPTER 1Questions 1-6

E X A M Q U E S T I O N S

21

1. Documentation is a critical factor in patientcare because it

a. encourages lawsuits and disciplinaryactions.

b. provides the patient with a method torecord his or her care.

c. provides proof of the type of care rendered.

d. underwrites the cost of patient care.

2. Nursing documentation is thought to havebegun with the need for nurses to record theiractions initiated by

a. Virginia Henderson.

b. JCAHO.

c. Florence Nightingale.

d. DRGs.

3. The purpose of a medical record is to

a. serve as a planning tool for patient care.

b. serve as a method to blame others for notproviding appropriate care.

c. collect data against insurance claims.

d. increase nurses’ work by requiring nonsense notes.

4. When reviewing Mr. Jim Jones medicalrecord, a nurse would probably find which ofthe following forms?

a. Medical history, operative report, and delivery record

b. Physical therapy report, PAP smear report,and graphic record

c. Medication record, nurses notes, andpatient education

d. Consultation notes, progress notes, andbirth weight record

5. Effective documentation encompasses

a. entries into patient records to show lack ofthe need for care.

b. entries of nursing activities performed onbehalf of the patient.

c. oral communication of nonessential factsgiven during the shift report.

d. scratch notes that can be discarded oncethe patient is discharged.

6. Increased consumer awareness, increased acuity of the patient, and increased emphasison health care outcomes has created the needfor such changes in nursing documentation as

a. increased length of stay.

b. continued use of handwritten care plans.

c. reintroduction of the exclusive use of narrative notes.

d. increased documentation efficiency.

THIS IS PAGE 22IT IS BEING LEFT BLANK INTENTIONALLY.

PLEASE DO NOT PRINT THIS MESSAGE.

PURPOSE OF DOCUMENTATION - Cloud Object Storages3.amazonaws.com/western-pdfdocs-download/N1266_1.pdf · ing documentation is that it may be used in mal-practice cases. The patient’s

Documents