Chapter 37 Documenting and Reporting

Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Chapter 37

Documenting and Reporting

Chapter 37

Documenting and Reporting


The Health RecordThe Health Record

• The health record is a manual or electronic account of a client’s relationship with a healthcare facility.

• The nurse, being the primary caregiver, must record client information clearly, accurately, and frequently.

• The commonly used term for documentation is “charting.”

• The client’s health record is usually called the “chart.”


The Health Record (cont’d)The Health Record (cont’d)• Accurate and complete documentation in the client’s

health record is an essential communication tool.

• It is used:

– To maintain effective communication among all caregivers

– To provide written evidence of accountability

– To meet legal, regulatory, and financial requirements

– To provide data for research and educational purposes

– To document health status*


CommunicationCommunication

• The health record is a communication tool:

– Helps caregivers to exchange information with one another

– Offers the client documentation and verification of his or her own health status

• It includes information about the client’s condition, treatments, responses to treatments, and plans and instructions for treatment of the client.


AccountabilityAccountability• The health record is documented evidence that the

healthcare agency and providers have acted responsibly and effectively.

• Legal requirements and protection

– It is a legal record.

• Regulatory requirements

– To prove the agency has met standards of care

• *Financial accountability

– Enables third-party payers to reimburse the facility

– Record all treatments given, examinations administered, and special equipment used


Research and EducationResearch and Education

• Healthcare planners examine health records of individuals and groups to determine patterns of illness, trends, or effective treatment strategies.

• Health records, particularly those kept in computer databases, provide excellent research opportunities in healthcare.

• It is also an excellent educational tool.


Documentation SystemsDocumentation Systems

• The health record is either a manual (paper) document, an electronic document, or a combination of both.

• Electronic documents are located in a medical information system (MIS), which is housed in a computer network.

• Another documentation system is referred to as electronic medical records (EMRs).


Manual and Computerized DocumentationManual and Computerized Documentation• Manual records

– Can be kept at the client’s bedside for convenience; documents all important data

– *Documents assessment data, care plans, medications, treatments, vital signs

• Computer records

– Can simultaneously be transmitted to a physician’s office or to a distant location for interpretation

– All information included in the MIS or EMR is similar to that found in the manual record.

– Requires knowledge of use of the computer system

– Speed and convenience in data entry *


Contents of the Health RecordContents of the Health Record• The health record contains four general categories of

information.

– Assessment documents

• RAP’s, MDS*

– Plans for care and treatment

– Progress records

• Describes clients treatments, responses to treatments and unusual events

– Plans for continuity of care

• Review health record

• Document appearance, behavior and response

• A client’s healthcare information should be confidential.


Contents of the Health Record (cont’d)Contents of the Health Record (cont’d)

• Formats of written documentation are based on assessment, nursing diagnosis, planning and goal setting, implementation/interventions, and evaluation.

– Flow sheet

– Medication administration record


Contents of the Health Record (cont’d)Contents of the Health Record (cont’d)

• Plans for continuity of care forms are used to ensure that the client’s care is consistent and effective.

– Teaching record

– Transfer form/screen

• Summarizes clients condition and responses to treatment to prepare for transfer to another unit, facility or community agency

– Discharge/transfer summary


Documentation FormatsDocumentation Formats

• Narrative–chronological

– Progress notes, nurses’ notes, narrative charting

• Usually done every 2 hours or more

• Problem-oriented (focus)

– Focuses on specific problems*

– SOAP, SOAPIER, APIE, PIE, DAPE, DARP, and DARE

• Discipline area documentation

• Charting by exception (CBE)

– Ex. Lung sounds


Documentation Formats (cont’d)Documentation Formats (cont’d)

• System flow sheet

– *list most common normal and abnormal findings, less chance of leaving out info

• Case management

– Critical pathway

– Collaborative pathway

– Care mapping

• Graphic flow sheet

• Medication administration record (MAR)


Advantages and Disadvantages Advantages and Disadvantages

• Narrative charting

– Very thorough and detailed

– Time-consuming

• Documentation by discipline

– Helps providers in each subspecialty find their own forms quickly and follow the progress of their therapies without having to read notes from other disciplines

– Can be difficult to monitor data as a holistic view of the client


Advantages and Disadvantages (cont’d) Advantages and Disadvantages (cont’d)

• Charting by exception

– Efficient, especially for the client who is physically stable with an uncomplicated care plan

– May be a disadvantage when a legal defense claim, such as negligence, is necessary

• Case management or critical pathways

– Client is the focus of case study, achieves specific outcomes identified in a multidisciplinary team approach, may not be suitable for a client with special or complex individual needs.


Advantages and Disadvantages (cont’d)Advantages and Disadvantages (cont’d)

• *Medication administration record (MAR)

– Lists all medications that the physician has ordered for the client, as well as other information

– Used by nonlicensed personnel as well as licensed nurses


Data Commonly Found on a Flow SheetData Commonly Found on a Flow Sheet

• Vital signs, intake and output

• Activities of daily living (ADLs)

• Dietary or eating patterns

• Neurologic checks (“neuro checks”)

• Restraint observation and documentation

• Frequent blood sugar monitoring

• Postoperative records

• Wound care and monitoring


Guidelines for Documentation**Guidelines for Documentation**• Document what you see.

• Be specific.

• Use direct quotes.

• Be prompt.

• Be clear and consistent.

• Record all relevant information.

• Respect confidentiality.

• Record documentation errors.

• SEE Table 37-4, 37-5


Recording Documentation ErrorsRecording Documentation Errors

• In case of an error in documenting, the nurse should cross out the incorrect statement with a single line, enclose it in parentheses, and write ERROR and initials next to it.

• Some agencies recommend using recorded in error (RIE) instead. Other agencies use the term “mistaken entry.”

• After filling in the term that the agency uses, record the correct statement.

• The EMR has a mechanism for “late entries,” in which the nurse may identify an earlier error.


Reporting of InformationReporting of Information

• “Report-off”—the nurse summarizes the activities and conditions of assigned clients because he or she is leaving the unit for a break or at the end of a shift.

– May be very brief or quite detailed

• *Change-of-shift reporting is a means of exchanging information between the outgoing and incoming staff on each shift.

• In walking rounds, caregivers move from client to client, discussing pertinent information.