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Basic Nursing: Foundations of Skills & Concepts Chapter 10. DOCUMENTATION. Documentation. Written evidence of: The interactions between and among health care professionals, clients, their families, and health care organizations.

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documentation
Documentation

Written evidence of:

  • The interactions between and among health care professionals, clients, their families, and health care organizations.
  • The administration of tests, procedures, treatments, and client education.
  • The results of, or client’s response to, diagnostic tests and interventions
purposes of documentation
Professional responsibility

Accountability

Communication

Education

Research

Satisfaction of Legal and Practice standards

Reimbursement

Purposes of Documentation
documentation as communication
Documentation as Communication
  • Documentation is a communication method that confirms the care provided to the client.
  • It clearly outlines all important information regarding the client.
documentation as education
Documentation as Education
  • The medical record can be used by health care students as a teaching tool.
  • It is a main source of data for clinical research.
documentation research
Documentation & Research
  • The medical record is a main source of data for clinical research.
legal practice standards
Legal & Practice Standards
  • Nurses are responsible for assessing and documenting that the client has an understanding of treatment prior to intervention.
  • Two indicators of the above are Informed Consent and Advance Directives.
informed consent
Informed Consent
  • A competent client’s ability to make health care decisions based on full disclosure of the benefits, risks, and potential consequences of a recommended treatment plan.
  • The client’s agreement to the treatment as indicated by the client’s signing a consent form.
advanced directives
Advanced Directives
  • Written instructions about a client’s health care preferences regarding life-sustaining measures. (e.g. living will and durable power of attorney for health care).
  • Allows clients, while competent, to participate in end-of-life decisions.
documentation reimbursement
Documentation & Reimbursement
  • Accreditation and reimbursement agencies require accurate and thorough documentation of the nursing care rendered and the client’s response to interventions.
principles of effective documentation
Assessment.

Nursing Diagnosis.

Planning and outcome identification.

Implementation.

Evaluation.

Revisions of planned care.

Principles of Effective Documentation

Elements of nursing process needed to

be made evident in documentation include:

elements of effective documentation
Use a common vocabulary.

Write legibly and neatly.

Use only authorized abbreviations and symbols.

Employ factual and time-sequenced organization.

Document accurately and completely, including any errors.

Elements of Effective Documentation

To ensure effective documentation, nurses should:

methods of documentation
Narrative Charting

Source-oriented charting

Problem-oriented charting

PIE charting

Focus charting

Charting by exception

Computerized documentation

Critical pathways

Methods of Documentation
narrative charting
Narrative Charting
  • This traditional method of nursing documentation takes the form of a story written in paragraphs.
  • Before the advent of flow sheets, this was the only method for documenting care.
source oriented charting
Source-Oriented Charting
  • A narrative recording by each member (source) of the health care team on separate records.
problem oriented charting
Problem-Oriented Charting
  • Focuses on the client’s problem and employs a structured, logical format called SOAP charting:
  • S: Subjective data (what the client states)
  • O: Objective data (what is observed/inspected)
  • A: Assessment
  • P: Plan
pie charting
PIE Charting
  • PROBLEM
  • INTERVENTION
  • EVALUATION
focus charting
Focus Charting
  • A documentation method that uses a column format to chart data, action, and response (DAR).
charting by exception
Charting by Exception
  • A documentation method that requires the nurse to document only deviations from pre-established norms.
charting by exception20
Charting by Exception
  • A documentation method that requires the nurse to document only deviations from pre-established norms.
computerized documentation advantages
Decreased documentation time.

Increased legibility and accuracy.

Clear, decisive, and concise words.

Statistical analysis of data.

Enhanced implementation of the nursing process.

Enhanced decision making.

Multidisciplinary networking.

Computerized Documentation:Advantages
critical pathways
Critical Pathways
  • A comprehensive, standard plan of care for specific case situations.
  • The pathway is monitored to ensure that interventions are performed on time and client outcomes are achieved on time.
forms for recording data
Forms for Recording Data
  • Kardex
  • Flow Sheets
  • Nurse’s Progress Notes
  • Discharge Summary
kardex
Kardex
  • A summary worksheet reference of basic information that traditionally is not part of the record. Usually contains:
    • Client data (name, age, marital status, religious preference, physician, family contact).
    • Medical diagnoses: listed by priority.
    • Allergies.
    • Medical orders (diet, IV therapy, etc.).
    • Activities permitted.
flow sheets
Flow Sheets
  • Vertical or horizontal columns for recording dates and times and related assessment and intervention information. Also included are notes on:
    • Client teaching.
    • Use of special equipment.
    • IV Therapy.
nurse s progress notes
Nurse’s Progress Notes
  • Used to document:
    • Client’s condition, problems, and complaints.
    • Interventions.
    • Client’s response to interventions.
    • Achievement of outcomes.
discharge summary
Discharge Summary

Highlights client’s illness and course of care. Includes:

  • Client’s status at admission and discharge.
  • Brief summary of client’s care.
  • Intervention and education outcomes.
  • Resolved problems and continuing care needs.
  • Client instructions regarding medications, diet, food-drug interactions, activity, treatments, follow-up and other special needs.
trends in documentation
Trends in Documentation
  • Nursing Minimum Data Set.
  • Nursing Diagnoses.
  • Nursing Intervention Classification.
  • Nursing Outcomes Classification.
nursing minimum data set
Nursing Minimum Data Set
  • The elements that should be contained in clinical records and abstracted for studies on the effectiveness and costs of nursing care. Focuses on:
    • Demographics.
    • Service.
    • Nursing care.
nursing diagnoses
Nursing Diagnoses
  • A clinical judgment about individual, family, or community responses to actual or potential health problems or life processes.
nursing intervention classification
Nursing Intervention Classification
  • A comprehensive standardized language for nursing interventions organized in a three-level taxonomy.
nursing outcomes classification
Nursing Outcomes Classification
  • A classification system that comprises 190 outcome labels and corresponding definitions, measures, indicators, and references.
summary reports
Summary Reports
  • The outlining of information pertinent to the client’s needs as identified by the nursing process.
  • Commonly given at end-of-shift.
walking rounds
Walking Rounds
  • A reporting method used when the members of the care team walk to each client’s room and discuss care and progress with each other and with the client.
telephone reports and orders
Telephone Reports and Orders
  • Telephone communications are another way nurses:
    • Report transfers.
    • Communicate referrals.
    • Obtain client data.
    • Solve problems.
    • Inform a client’s family members regarding a change in client’s condition.
incident reports
Incident Reports
  • The documentation of any unusual occurrence or accident in the delivery of client care, such as falls or medication errors.