Documentation

1. Documentation Recording and Reporting

2. Communication in health care • Discussion • Reporting • Oral • Written • Taped • Charting

3. Recording – The Chart • Patient’s health care information • Purposes • Communication • audit • research • education

4. Recording– The Chart • Nursing documentation • Assessment • Care plan • Narrative notes • Flow sheets • Medication records (MAR) • Discharge summary • Incident report is not part of the chart

5. Guidelines for Documentation • Content • Format • Timing

6. Problem-oriented record • S-O-A-P-I-E-R • A-P-I-E

7. Source-oriented record • Separate form for each group • Nurses notes are usually narrative • Flow sheets used extensively

8. Care Paths • Also known as • Critical paths • MAPS • Charting by exception

9. Computer documentation • Electronic transmission to regulatory agencies • Purchasers of health care demanding evidence of quality • Nursing leaders calling for outcomes database • Managed care organizations want to track the client across continuum of care

10. Reporting • Forms • Change of Shift • Basic Identifying data • Current health status • Orders • Summary • Transfer/DC