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Elsevier items and derived items 2009 by Saunders, an imprint of
Elsevier Inc.
Documentation of Nursing Care
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Th eory` Identify t h ree purposes of documentation` Correlate
nursing process wit h th e process of c h arting` Discuss
maintaining confidentiality of medical records` Compare and
contrast 5 main met h ods of written
documentation` Compare and contrast t h e five main met h ods of
written
documentation` List legal guidelines for recording on medical
records` Relate t h e approved way to correct entries in medical
records
th at were made in error
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Clinical Practice` Correctly make entries on a daily care flow s
h eet` Use a systematic way of c h arting to ensure t h at all
pertinent informationh
as been included` Document t h e c h aracterization of a sign or
symptoms in
a sample c h arting situation` Apply t h e general c h arting
guidelines in t h e clinical
setting
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` Provides a written record of t h e h istory, treatment,care,
and response of t h e patient w h ile under t h e
care of a h ealt h care provider ` Is a guide for reimbursement
of costs of care` May serve as evidence of care in a court of law`
S h ows t h e use of t h e nursing process`
Provides data for quality assurance studies
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` Is a legal record t h at can be used as evidenceof events t h
at occurred or treatments given
` Contains observations by t h e nurses about t h epatients
condition, care, and treatmentdelivered
` S h ows progress toward expected outcomes
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` W ritten nursing care plan or interdisciplinarycare plan is
framework for documentation
` Ch arting organized by nursing diagnosis or problem`
Implementation of eac h intervention
documented on flow s h eet or in nursing notes` Evaluation
statements placed in nurses
notes and indicate progress toward t h e statedexpected outcomes
and goals
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` Contains data about patients stay in a facility` Only h ealt h
care professionals directly caring for
th e patient, or t h ose involved in researc h or teac h ing, s
h ould h ave access to t h e c h art` Patient information s h ould
not be discussed wit h
anyone not directly involved in t h e patients care
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` Source-oriented (narrative) c h arting` Problem-oriented
medical record (POMR)
ch arting` Focus c h arting` Ch arting by exception`
Computer-assisted c h arting` Case management system c h arting
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` Organized according to source of information` Separate forms
for nurses, p h ysicians, dietitians,
and ot h er h ealt h care professionals to documentassessment
findings and plan t h e patient's care` Narrative c h arting
requires documentation of
patient care in c h ronologic order
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` AdvantagesInformation in c h ronologic order Documents
patients baseline condition for eac h s h iftIndicates aspects of
all steps of t h e nursing process
` DisadvantagesDocuments all findings: makes it difficult to
separatepertinent from irrelevant informationRequires extensive c h
arting time by t h e staff Discourages p h ysicians and ot h er h
ealt h teammembers from reading all parts of t h e c h art
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` Focuses on patient status rat h er t h an onmedical or nursing
care
` Five basic parts: database, problem list, plan,progress notes,
and disc h arge summary
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` AdvantagesDocuments care by focusing on patients
problemsPromotes problem-solving approac h to careImproves
continuity of care and communication bykeeping relevant data all in
one place
Allows easy auditing of patient records in evaluatingstaff
performance or quality of patient careRequires constant evaluation
and revision of careplanReinforces application of t h e nursing
process
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` DisadvantagesResults in loss of c h ronologic c h arting
More difficult to track trends in patient statusFragments data
because more flow s h eets required
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` Pproblem identification` Iinterventions` Eevaluation
` Follows t h e nursing process and uses nursingdiagnoses w h
ile placing t h e plan of care wit h inth e nurses progress
notes
` TH IS IS TH E TY PE OF C H AR T ING W ET EAC H Y OU T O DO
BASED ON ICPs mixedin wit h focus c h arting.
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` Directed at nursing diagnosis, patient problem,concern, sign,
symptom, or event
` Th ree components:D: data, A : action, R : response (DAR)x O R
D: data, A : action, E : evaluation (DAE)
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` AdvantagesCompatible wit h th e use of t h e nursing processS
h ortens c h arting time: many flow s h eets,ch ecklistsNot limited
to patient problems or nursingdiagnoses
` DisadvantagesIf database insufficient, patient problems
missedDoesnt ad h ere to c h arting wit h th e focus onnursing
diagnoses and expected outcomes
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` Based on t h e assumption t h at all standards of practice are
carried out and met wit h a normal
or expected response unless otherwisedocumented
` A long h and note is written only w h en t h estandardized
statement on t h e form is not met
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` AdvantagesH igh ligh ts abnormal data and patient trends
Decreases narrative c h arting timeEliminates duplication of c h
arting` Disadvantages
Requires detailed protocols and standardsRequires staff to use
unfamiliar met h ods of recordkeeping and recordingNurses so used
to not c h arting t h at important datasometimes omitted
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` Electronic h ealt h record (E H R)Computerized record of
patient's h istory and careacross all facilities and admissions
` Computerized provider order entry (CPOE)Provides efficient
work flow
Automatically routs orders to appropriate clinicalareas
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` Documentation done as interventions areperformed using bedside
computers
` Variations depending on t h e system` Some produce flow s h
eets wit h nursing
interventions and expected outcomes` Ot h ers use a POMR format
to produce a
prioritized problem list
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` AdvantagesDate and time of t h e notation automatically
recordedNotes always legible and easy to readQuick communication
among departments about patient needsMany providers h ave access to
patients information at onetimeCan reduce documentation
timeElectronic records can be retrieved very quicklyReimbursement
for services rendered is faster and completeCan provide a complete
record of t h e patient's medical h istoryCan reduce errors
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` DisadvantagesSop h isticated security system needed to
prevent
unaut h orized personnel from accessing recordsInitial costs are
considerableImplementation can take a long timeSignificant cost and
time to train staff to use t h e
systemComputer downtime can create problems of input,access,
transfer of information
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` A met h od of organizing patient care t h roug h anepisode of
illness so clinical outcomes are
ac h ieved wit h in an expected time frame and ata predictable
cost
` A clinical pat h way or interdisciplinary care plantakes t h e
place of t h e nursing care plan
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` Be specific and definite in using words or ph rases t h at
convey t h e meaning you wis h
expressed` W ords t h at h ave ambiguous meanings and
slang s h ould not be used in c h arting
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` Sentences not necessary Articles (a, an, t h e) may be
omittedTh
e word patient omitted wh
en subject of sentence` Abbreviations, acronyms, symbols
acceptable to
th e agency used to save time and space` Ch oose w h ich be h
aviors and observations are
notewort h y
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` If writing not legible, misperceptions can occur `
Completeness is more important t h an brevity
(see Boxes 7-1 t h roug h 7-3 for c h artingguidelines)` Record
information about t h e patients needs
and problems and specify nursing care given for th ose needs or
problems
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` Not a part of t h e permanent medical record` A quick
reference for current information about
th e patient and ordered treatments` Usually consists of a
folded card for eac h patient
in a h older t h at can be quickly flipped from onepatient to
anot h er
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` Room number, patient name, age, sex, admittingdiagnosis, p h
ysicians name
` Date of surgery` T ype of diet ordered` Sc h eduled tests or
procedures` Level of activity permitted` Notations on tubes, mac h
ines, ot h er equipment in use` Nursing orders for assistive or
comfort measures` List of medications prescribed by name` IV fluids
ordered
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` h ttp://www.twlk.com/ h ealt h care/422-0002.pdf
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` Scenerio: 1 day post-op knee surgery` Pain r/t surgical
manipulation of rt knee AEB subj
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and 8/10 wit h ROM.
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33
