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