Communication of the Nursing

Process: Documentation
Pamela Fowler, MS, RNC
Assistant Professor
Rogers State University
Why Document?
Professional responsibility
Legal protection
Regulatory standards
Reimbursement
Societal Factors Affecting
Nursing Documentation
Increased consumer awareness
Increased acuity of hospitalized patients
Increased emphasis on outcomes
Trends in Charting
Reduction in duplicate charting
Bedside charting
Multidisciplinary charting
Clinical paths
More uniformity in documentation
Computerized documentation
Fax machines
Desired outcomes for
documentation
The chart is legally sound
The chart reflects the nursing process
The chart describes the patients ongoing
status from shift to shift
The plan of care and the chart complement
one another
The documentation system is designed to
facilitate retrieval of information for quality
improvement activities and research.
The documentation system supports the
staffing mix and acuity levels in the current
healthcare environment
Charting systems
Effective and efficient charting has been an
issue to nursing throughout history.
Numerous methods of charting have
evolved over time.
More are evolving every day.
Narrative
A diary or story like approach to the
recording of patient care
Are more efficient if used in combination
with flowsheets for recording some
repetitive data
Narrative
Advantages
familiar to most nurses
can be easily combined with other methods
if done correctly contains the complete NP
especially useful in emergent situations

Narrative
Disadvantages
lack of structure
task oriented and time consuming
information may be difficult to retrieve
does not always reflect critical thinking,
decision making and analysis
SOAP charting
A problem oriented charting method
Subjective data
Objective data
Assessment
Plan

SOAP charting
Has been expanded to include
SOAPIE
add Interventions
add Evaluation
SOAPIER
add Revision

SOAP, SOAPIE, SOAPIER
Advantages
well structured
reflects the nursing process
easier to track particular problems for QI
can be used effectively with standard careplans
frequently used in the integrated plans
SOAP, SOAPIE, SOAPIER
Disadvantages
requires rethinking documentation process
seldom in its original form
can be redundant
not the most efficient for nurses
has met some resistance
PIE charting
Also problem oriented
Problem
Intervention
Evaluation
Originally designed to eliminate the
traditional care plan and to integrate an
ongoing care plan into documentation

PIE
Advantages
simplifies charting by using flow sheets
eliminates the traditional separate care plan
encourages use of some of NP
each problem identified is evaluated q shift
lends itself well to primary nursing
enhances professional credibility
PIE
Disadvantages
outcomes may not be prominently addressed
assumes all nurses practice at same level of
sophistication and knowledge
how to incorporate the LPN as documentor
not well-suited to LTC or terminally ill
can create lengthy documentation if the patient
has numerous problems
Focus charting
A method for organizing the narrative
documentation to include data, action and
response for each identified concern.
Focus
Advantages
provides structure
promotes documentation of NP
increases ease of locating information
encourages identification of patient concerns,
not just problems
promotes analytical thinking
Focus
Disadvantages
can become a narrative note
requires a change in thinking
can be difficult to construct accurately and
logically
Computerized Charting
One of the strongest trends in nursing
documentation throughout the US and
Canada.
Very common in the larger facilities in this
area.
Smaller facilities may have no computer
charting or may have only a portion of
charting computerized.
Computerized charting
Advantages
Legible records
Readily available records
Improved nursing productivity
Reduction in record tampering
Support of use of the NP
Reduction in redundant documentation
Clinical prompts, reminders, and warnings
Computerized charting
Advantages, cont
Categorized nursing notes
Automatically printed reports
Documentation according to standards of care
Improved recruitment and retention of nurses
Improved knowledge of outcomes
Availability of data
Prevention of medication errors
Computerized charting
Disadvantages
Unfamiliar to users
Lack of portability
Problems with security and confidentiality
Disruptive computer downtime
Size of the record
Erroneous acceptance of information
Limitation of format
Computerized charting
Disadvantages, cont
Resistance
Inadequate numbers of terminals
Computer lag during peak usage time
Nurses difficulty in giving up worksheets
Cost
Charting by exception
Includes flowsheets, documentation by
reference to standards of practice, protocols,
a nursing data base, nursing diagnosis based
care plans and SOAP progress notes
Charting by exception
Advantages
most current data available at bedside
flowsheets eliminate need for worksheets
guidelines can be printed on back of forms
trends are easily discerned
normal findings are precisely defined
repetitive charting of routine care eliminated
charting time is decreased
easily adapted to documentation on clinical paths
Charting by exception
Disadvantages
can require duplication of charting
works best with all RN staff
requires a major change in systems
requires a major educational effort
may impact reimbursement
may have legal ramifications
Legal Aspects of Charting
Document the clinically significant details
Sign every entry
Write neatly and legibly
Use proper spelling, grammar, and
appropriate medical phrases
Document in blue or black ink and use
military time
Legal
Use authorized abbreviations
Use graphic records to record vital signs
Record the patients name on every page
Chart promptly
Avoid block charting
Chart after delivery of care
Fill in blanks on chart forms
Legal
Document exact quotes
Eliminate bias from written descriptions of
patients
Chart only care you provide or supervise
Do not tamper with records
Correctly identify late entries
Record only accurate information
Legal
Do not omit significant information from
the chart
Correct mistaken entries properly
Do not rewrite the record
Do not lose or destroy medical records
Do not add to the notes of others
Do not use the medical record to criticize
others
The Incident/Variance Report
Should be completed when any unusual
occurrence warrants documentation
Record the details in objective terms
Do not admit liability of blame
Chart only what is observed firsthand
Describe actions taken to provide care
Do not include names/addresses of
witnesses
Incident/Variance reports
Document time of incident, names of
physician, supervisor and family members
notified
Send the report to the persons designated by
policy to review them
If additional information is found after
filling out the form, file an amendment
properly dated and signed.
Incident/Variance reports
What to put in the chart
factual, honest and objective description of the
incident
Do not mention the incident/variance report in
the charting
Include any statements made by patients or
family particularly if the statements indicate
that their actions contributed to the
incident/variance.