Healthcare Core Curriculum Competency 5: Report & Documentation Dede Carr, BS, LDA Karen Neu, MSN, CNE, CNP 1

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Communications in Health Care

Healthcare Core CurriculumCompetency 5: Report & Documentation

Dede Carr, BS, LDAKaren Neu, MSN, CNE, CNP

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Explain the components of accurate and appropriate documentation and reporting including common medical abbreviations

Competency 5: Report & Documentation

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Report: An oral, written or computer-based communication intended to convey information to others (Ramont & Niedringhaus, p. 85)

Record: Written or computer-based collection of data (Ramont & Niedringhaus, p. 85)

Medical or Clinical Record:◦ Collection of all documents that are filed together to form

a complete chronological health history of a particular patient (Juliar)

◦Formal, legal document that provides evidence of the client’s care (Ramont & Niedringhaus, p. 85)

Charting/Recording/Documenting: Process of making an entry into the client’s clinical record

(Ramont & Niedringhaus, p. 85)

Definitions of Terms

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Notes and documents that health care workers add to the medical records

Medical documentation is crucial for medical care and health care services.

Aids in standard of care. Allows proper reimbursement for

treatment. Neglecting to document a patient’s

condition or treatment may have serious consequences in the future.

“If it is not documented, it didn’t happen.”(Juliar)

Purposes of Client’s Records

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Communication Planning client care Legal documentation Education, research, & healthcare analysis Auditing Reimbursement (Ramont & Niedringhaus,

p. 86, 88)


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Communication Vehicle or way by which different healthcare

professional who interact with the client communicate with each other

Prevents fragmentation, repetition, and delays in client care

Record also provides a central location for notifying health professionals of the client’s needs, progress, & current status (Ramont & Niedringhaus, p. 85)


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Planning Client Care Each healthcare professional uses data from

client’s record to plan care for the client Example: Physician may determine that

laboratory values indicate presences of certain microorganisms causing infection so orders an antibiotic

Nurses use baseline & ongoing assessments to determine effectiveness of interventions & the nursing care plan

Record provides a base from which all healthcare disciplines (workers) may coordinate client’s care (Ramont & Niedringhaus, p. 85)


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Legal Documentation Record is a legal document & admissible in

court In some jurisdictions, it may be

inadmissible in court if the client objects, because information given to a physician or nurse practitioner is confidential



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Education, Research, & Healthcare Analysis Students use client’s records as an essential educational

tool Record can be a comprehensive view of the client, illness,

treatment strategies, & factors that affect outcome of illness

Record information can be valuable source of data for research

Review of treatment plans for clients with similar health problems can yield helpful information when treating new patients with same problem

May assist healthcare planners to identify agency needs (can highlight overused or underused services

Can identify services that cost agency money & those that generate revenue (Ramont & Niedringhaus, p. 85)


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Auditing An audit is a review of records Client’s records are audited for quality

improvement Example: Joint Commission (JCAHO) may

review client's records to determine if a particular health agency is meeting its stated standards


Purposes of Client’s Record

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Reimbursement Documentation helps a facility receive

reimbursement (payment) from the federal government

Example: For a facility to obtain payment through Medicare, client’s clinical record must contain certain diagnosis-related group (DRG) codes & reveals that the appropriate care was given


Purposes of Client’s Record

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History, Physical, and Consultations◦Report on the initial finding of all physicians

seeing the patient. Includes personal, family and social history of the patient.

Physician’s Orders◦Written record of all medications & treatments

prescribed for the patient. Diagnostic Tests◦Any report that includes findings in an attempt to

diagnosis the patient(Juliar)

Contents of Medical (Clients’ Clinical) Records

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Admissions◦Completed forms and consent

Surgical Procedures◦Consents for and reports related to any surgical

procedures performed. Medication Record◦ Includes all the medications that the patient is

taking Progress Notes◦A written chronological statement about a

patient’s care(Juliar)

Contents of Medical (Clients’ Clinical) Records

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Because client’s record is legal document & may be used to provide evidence in court must consider many factors in recording.

Health care workers must maintain ◦Confidentiality of clients’ record◦Legal standards in process of recording


Guidelines for Recording

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Recording/Documentation Guidelines Date and time Timing of

documentation Legibility Permanence Accepted Terminology Correct spelling Signature Accuracy

Sequence Continued notes Appropriateness &

completeness Conciseness Legal prudence Additional tips for

documentation(Ramont & Niedringhaus, p. 85)

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Date & Time Document date & time with each entry Make entries as soon as possible after

performing observation/assessment; task/intervention

Record time using either conventional time denoting AM or PM, or using 24-hour clock (military time)

Avoid block-style charting in which an entire shift is documented under one date & time


Recording/Documentation Guidelines

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Timing of Recordings Follow agency policy regarding frequency of

documenting Adjust frequency of documentation as client’s

condition indicates--an unstable client requires more frequent observation & documentation (client in restraints needs frequent checking, observation, & documenting)

NEVER record nursing care before it is provided



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Legibility Make all entries legible & easy to read to

prevent interpretation errors Print your entries if cursive writing is difficult to

read Follow agency policy regarding handwritten

recording of healthcare worker’s notesPermanence Make all entries on client’s chart permanent,

non-erasable blue or black ink according to policy

Ensure record is permanent & changes can be identified (Ramont & Niedringhaus, p. 86)


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Accepted Terminology Use commonly accepted abbreviations, symbols,

& terms specified by agency policy Write a term out in full if in doubt about whether

to use an abbreviationCorrect Spelling Use correct spelling to ensure accuracy in

documentation Look words up in a dictionary or other resource

book if unsure of correct spelling Spell similar medication names correctly to

avoid medication errors (Ramont & Niedringhaus, p. 86)


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Signature Sign entries made in notes at the time you make the

entry Use name & title in the signature-Example: J. Green,

CNA would be correct, depending on facility policy Full signature should appear at least once on each

page Use correct title abbreviations: RN=registered

nurse; LPN=licensed practical nurse; SN=student nurse in RN program; SPN=student nurse in practical nurse program

(Ramont & Niedringhaus, p. 86, 88)


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Accuracy Check that you have correct chart by verifying

client’s name & identification information stamped or written on each page before making an entry or filing a report

Make accurate notations—ones that consist of facts or observations rather than opinions or interpretations

[Describe what you see & hear, not what you think or interpret for client actions]

Quote client directly in client’s exact words when documenting client’s concerns



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Accuracy Chart specific data rather than using general

terms, such as large, good, or normal that can be misinterpreted [Example: “2 cm by 3 cm bruise”]

Document a description of behavior you observed rather than using terms such as anxiety or agitation

Document objectively-what you see, hear, feel by touch, smell

Correct an error in documentation by drawing a single line through it & writing the word error above it, with your initials, or name, depending on agency policy

(Ramont & Niedringhaus, p. 86, 88)


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Accuracy Do not erase, overwrite, blot out, or use

corrective fluid Write on every line but never between lines Draw a line through any blank space & sign

the notation. In this way no additional information can be recorded at any other time or by any other person

Never leave a blank lines about your entry or between your entries (Ramont & Niedringhaus, p. 86, 88)


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Sequence Document events in order in which they

occur: observations, tasks/interventions, & client’s responses

Make a late entry by clearly labeling your entry as late according to facility policy ◦Example: “Late entry [date] [time]” or ‘[date] [time]

Late entry” Do not make a late entry more than 24 hours

after the event. This is usually not permitted (Ramont & Niedringhaus, p. 86, 88)


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Continued Notes Continue entries to another page by indicating

that note continues & signing the entry. On next page, enter date/time of note & start it by indicating that it is a continuation

Appropriateness & Completeness Record only information that pertains to client’s

health problems & care Record all observations, dependent &

independent interventions, client’s problems, progress toward goals, & communication with other disciplines



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Appropriateness & Completeness Document any care that was omitted & include why it

was omitted & who was notified Use descriptions that are appropriate & accurate [avoid

stereotyping]Conciseness Do not use client’s name when charting [since this is

client’s chart you do not need to use terms such as client, resident, & patient (Check facility’s policy & procedures

End each thought or sentence with a period; it is not necessary to use full sentences

Write notes so that data that follows comma is associated with data that preceded it (Ramont & Niedringhaus, p. 88-89)


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Legal Prudence Document accurately & completely to protect

healthcare staff, the facility, & client Clinical record is legal document that provides

proof of the quality of care given to the client Follow general principle, “If its not charted, it’s

wasn’t done.” Follow agency policy & procedures for

intervention & documentation in all situations, especially high-risk situations (Ramont & Niedringhaus, p. 89)


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Client’s clinical record is legal document & admissible in chart which can be scrutinized by attorneys,

Client may object because of confidential information

Client’s record is property of facility Client has right to a copy of information, but will

need to make a written request & pay for copying

When charting, be sure to use objective, factual information rather than opinions & interpretations


Legal & Ethical Aspects of Documentation

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When charting, be sure to use objective, factual information rather than opinions & interpretations

Not all data about a client should be recorded; any personal information that client shares & does not pertain to health problems or cares is inappropriate for the record

Documentation is the determining factor in a great percentage of malpractice cases involving client care

Important that you document client care clearly, concisely, & accurately (Ramont & Niedringhaus, p. 90)

Legal & Ethical Aspects of Documentation

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Accuracy – Just the facts. Only the facts and not opinions or feelings.

Legible – Make sure that whatever is charted can be clearly read

Date – Be aware of what format is to be used. Example: 01/25/11 or 25/01/11

Time – 12 hour clock or 24 hour clockFull signature and titleCorrect spellingBecause each healthcare facility may have their

own abbreviations, avoid using them (Juliar)

Keys to Accurate & Appropriate Documentation--Summary

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Never erase, use white out, or corrective tape Draw a single line through the error Write in the correct information Date and initial the correction (Juliar)

Making Corrections

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Client’s record private & access restricted to health professionals directly involved in giving care to client

Insurance companies have not legal right to demand access to medical records, even though they may be determining compensation to client.

Therefore a client who is making a claim for compensation may ask to have medical history as evidence.

In order for an agency to provide requested information, client must sign an authorization for review, copying, or release of information from the record. This form must specifically indicate what information is to be released & to whom


Confidentiality of Client’s Records

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Each healthcare worker has a password to enter & sign computerized files [Do not share these]

After logging on, never leave a computer terminal unattended [If handheld, do not leave either]

Do not leave client information on monitor where others can see it

Follow agency procedures for documenting sensitive material

Conditions for confidentiality same for computer records as they are for paper


Confidentiality in Computerized Records

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Either oral or written Purpose: to communicate specific information to

person or group of people Report should be concise with only pertinent

information Change-of-Shift Report: report given to all nurses

on next shift—To provide continuity of care for clients to provide new caregivers with quick summary of clients’ needs & detail of care given

May be written or oral, either face-to-face exchange or by audiotape recordings; sometimes given at bedside so all can participate (Ramont & Niedringhaus, p. 90)

Reporting

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Health professionals give reports about clients to healthcare providers and visa versa, to family members, and patients

When receiving a telephone message, one should document:

Date & time Name of person giving the information What information was received Sign notationPerson receiving the message should repeat

the information back to the sender to ensure accuracy

Telephone Reports

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Juliar, K. (2003) Minnesota Healthcare Core Curriculum (2nd ed.). Clifton Park, NY: Delmar Publishers

Ramon, P.R. & Niedringhaus, D. M. (2008). Client communication. Fundamental nursing care (2nd ed.). (pp. 226-242). Upper Saddle River, NJ: Person Prentice Hall

References

Documents

Healthcare Core Curriculum Competency 5: Report & Documentation Dede Carr, BS, LDA Karen Neu, MSN, CNE, CNP 1