Documentation and Reporting

1. Documentation and Reporting Teresa V. Hurley MSN,RN

2. 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

3. 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

4. Charting • Legal Requirements -regulated by state laws -professional standards -Joint Commission on Accreditation of Health Care Organizations [JCAHO]

5. 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

6. Charting Specifics • Each entry is signed with your first initial, last name and status • J. Smith, SN • R. Jones, RN • Script not printing is used for the signature and it should appear at the right hand margin of the narrative note.

7. 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 period Does not have to be complete sentences

8. 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

9. 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

10. 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+;

11. 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

12. 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

13. Narrative Charting • Used with flow sheets and other systems • Chronological data quickly documented • Familiar form • Used in all types of settings

14. 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

15. 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

16. Problem-Oriented Medical Records POMR • 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

17. POMR: SOAP or SOAPIE • Subjective • Objective • Assessment • Plan • Implementation • Evaluation

18. 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

19. 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

20. 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

21. 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

22. 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

23. REPORT to NURSING ADMINISTRATORS • Written or Verbal each shift • Data on critically ill clients • Unusual occurrences • Problems with clients, families or other disciplines

24. 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