Chapter 16

Documenting, Reporting,
Conferring, and Using Informatics
 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
 DOCUMENTING

• is written or computer-based.
• All personnel involved in a patient’s health care contribute to the
medical record by documenting on the health agency’s forms.
– Each institution has specific documentation requirements
Medical record, also called a chart or client record, is a formal, legal
document that provides information about a person’s health
problems, the care provided by health practitioners, and the
progress of the patient.
Although health care organizations use different systems and forms
for documentation, all client records have similar information.
Principles of Effective Documentation
• Nursing notes must be logical, focused, and
relevant to care, and must represent each
phase of the nursing process.
• Nursing documentation based on the nursing
process facilitates effective care.
Guidelines for Documentation: Written
Format
• Use forms as per agency policy (i.e. flow sheets,
graphic sheet, NCP, progress notes)
• Follow agency guidelines regarding color ink,
approved abbreviations, format of time (i.e.
military/standard)
• Write LEGIBLY-questionable info implies doubt,
suggests you lack reasonable knowledge
• NEVER skip lines!!
• Never chart PRIOR to doing something.
• Chart as you go—stay current.
Using the 24-hr Cycle Military Clock for
Documenting Times
 Documenting
General Guidelines for Recording
Because the client’s record is a legal document and may be
used to provide evidence in court, many factors are
considered in recording.
1. Data & Time: Documenting the date and time of each
recording. This is essential not only for legal reasons
but also for client safety. Record the time in the
conventional manner (e.g. 9:00 am or 3:20 pm) or
according to the 24-hours clock (military clock).
2. Timing: follow the agency’s policy about the
frequency of documenting, and adjust the frequency
as a client’s condition indicates; for example, a client
whose blood pressure is changing requires more
frequent documentation than a client whose blood
pressure is constant. You don’t need an order to
apply nursing judgment!
3. Legibility: all entries must be legible and easy to read
to prevent interpretation errors.
 Documenting
General Guidelines for Recording
4. Performance: all entries on the client’s record are
made in dark ink so that the record is permanent and
changes can be identified.
5. Accepted Terminology: use only commonly accepted
abbreviations, symbols, and terms that are specified
by the agency.
Box 17-3 has a list that you will learn. We’ll add others.
6. Correct Spelling: correct spelling is essential for
accuracy in recording. If unsure how to spell a word,
look it up in a dictionary. Credibility!
7. Signature: each recording on the nursing notes is
signed by the nurse making it. The signature includes
the name and title; for example, “Susan J. Green, RN”
or “SJ Green, RN”
You will write “S. Green, HUSN,” and your instructor will cosign.
 Documenting
General Guidelines for Recording
8. Sequence: documenting events in the order
in which they occur; for example, record
assessments, then the nursing interventions,
and then the client’s responses.
Out-of-sequence entries must be acknowledged. See next slide.

9. Accuracy: the client’s name and identifying

information should be written on each page
of the clinical record. Accurate notations
consist of facts or observations rather than
opinions or interpretations. It is more
accurate, for example, to write that the
client “refused medication” (fact) than to
write that the client “was uncooperative”
(opinion). A legal nightmare!
 Charting a late entry

• Date and time your entry on the next available

line.
• Refer to the time the documented event
happened in the narrative.
• Example:
– 3/12/13 1400 Late entry: The patient was noted
to have bilateral 2+ pretibial edema @ 0900.
 Documentation
• Chart facts, not your opinion
• Use quotations if the patient said it.
• Be specific! Using nonspecific terms implies
doubt about your knowledge. i.e.
appears/seems/tolerated well etc.
• ABC’s: Accuracy/Brevity/Completeness
Guidelines for Documentation: Timing
• Chart as soon as possible
after care/observations
• Important to document
changes in the patient’s
condition, but also what
you did about it.
• NEVER chart what you
plan to do
• Date & time each entry
in the margin
 Guidelines for Documentation:
Accountability
• Record is permanent
• Sign full name and title
• No erasures
• Do Not write ERROR for a mistake
• Single line thru mistake, print “Mistaken
Entry” or ME (if acceptable) above or next
to mistake, enter correction, initial & date
per policy. Other methods—Single strike
through, put in parentheses, initials.
Correcting errors
 Guidelines for Documentation:
Accountability
• IF IT ISN’T DOCUMENTED, IT WASN’T DONE
• Document all physician visits and phone calls,
and what was discussed.
• If you call the physician to report something,
document it.
– “Dr. Smith notified of 8 cm. area of sanguinous
drainage on dressing.”
• Unusual incidents must be recorded on
incident reports or similar forms.
 Incident Reports
• Used to document any unusual occurrence or
accident in the delivery of client care.
– Falls, medication errors
• The incident report is not part of the medical
record, but it may be used later in litigation.
 Guidelines for Documentation:
Confidentiality
• Students are permitted access to charts for
educational purposes
• Students use only patient initials on all
assignments, in every class.
• Only caregivers need to know info in chart
• Follow facility policy for pt. review of chart.
 PRACTICE AND
LEGAL STANDARDS
– In 80% to 85% of malpractice lawsuits involving client care,
the medical record is the determining factor in providing
proof of significant events.

The legal aspects of documentation

require:
• Writing legible and neat
• Spelling and grammar properly used
• Authorized abbreviations used
• Time-sequenced factual and descriptive entries
 Legal and Practice Standards
• Informed Consent
• Advance Directives
• American Nurses Association (ANA) Standards
of Care
• State Nurse Practice Acts
• Joint Commission on Accreditation of Health
Care Organizations (JCAHO)
 Legal & Practice Standards
 Nurses are responsible for assessing and
documenting that the client has an
understanding of treatment prior to
intervention.

 Two indicators of this are Informed Consent

and Advance Directives.
 Legal and Practice Standards
• Informed consent means that the client
understands the reasons and risks of the
proposed intervention.
• Witnessing confirms that the person who
signs the consent is competent.
 Legal and Practice Standards
• An advance directive allows the client to
participate in end-of-life decisions.
• The Patient Self-Determination Act of 1990
requires health care facilities to document
whether the client has such a directive.
 Legal and Practice Standards
• American Nurses Association Standards of
Care make explicit the role of data collection
and documentation in nursing practice.
 ANA documentation standards

Elements of nursing process needed to

be made evident in documentation include:

• Assessment. • Implementation.
• Nursing Diagnosis. • Evaluation.
• Planning and • Revisions of planned
outcome care.
identification.
 Meeting Core Standards

A nurse meets the standards by:

■ documenting an assessment of the client’s health status and

situation/circumstances
■ ensuring that client preferences for care and outcomes guide
the development of any written plan of care
■ documenting consent when the nurse proposes a treatment
or intervention
■ documenting the implementation of the care plan and/or the
action(s) taken
■ documenting an evaluation of nursing strategies and client
outcomes
■ documenting independent and collaborative actions
(e.g., those actions ordered by a physician);
 Legal and Practice Standards
• State Nurse Practice Acts have established
guidelines to ensure safe practice.
• Require evidence of compliance through
documentation.
• To access the Nurse Practice Act, go the OBN
website and select “rule and law”
– http://www.nursing.ohio.gov
 Legal and Practice Standards
• The Joint Commission on Accreditation of
Health Care Organizations (JCAHO) requires
documentation of compliance with its
standards of care requirements.
 Purposes of Health Care
Documentation
• Reimbursement
– Peer review organizations (PROs) are required by
the federal government to monitor and evaluate
care.
– Medical record documentation is the mechanism
for the PRO review.
 REIMBURSEMENT

• The federal government requires monitoring

and evaluation of quality, appropriateness of
care provided.
• Documentation of intensity of services and
severity of illness reviewed.
• Failure to document can result in
reimbursement denied.
 Reimbursement
– Diagnosis-Related Groups (DRG)
• Patients are assigned a DRG based on their admitting
diagnosis
• Each DRG has a clinical pathway—like a recipe—that patients
move along on their way to wellness
• Federally mandated since the 1980’s, determines how much
money hospitals get for each “product,” since patients in
each “product” category are similar and are expected to use
the same level of resources.
• Case Managers (nurses) review charts to assure care is
appropriate and ongoing.
• The medical record must provide documentation that
supports the DRG and appropriateness of care.
• If nurses fail to document the equipment or procedures used
daily, reimbursement to the facility can be denied.
 HIPAA Laws
• Finalized regulations established 2000,
modified by the Bush administration 2002.
• All health agencies have HIPAA training for
workers
• Violations may result in jail/ $25,000 fines.
• PATIENT RECORDS ARE CONFIDENTIAL
 What Is Confidential?
• All information about patients written on
paper, spoken aloud, saved on computer
– Name, address, phone, fax, social security
– Reason the person is sick
– Treatments patient receives
– Information about past health conditions
• HIV status may even be absent from the chart
deliberately. Worried? Then be sure to use standard
precautions on EVERY patient.
 Some real-life examples…
• Don’t talk about patients in the elevator, on the shuttle
bus, or on Facebook.
– Hospitals monitor Facebook
• Don’t let anyone use your computer password—ever!
• Don’t tell patients’ visitors ANYTHING
• Never give phone information
• Don’t copy/take pictures of your patient’s chart for
your care plan.
• Don’t look up anyone else’s test results—even your
own! Don’t try to get into someone’s chart/EHR unless
you are assigned to that patient. This is monitored by
IT!
 Question
Tell whether the following statement is true or
false.
A nurse who fails to log off a computer after
documenting patient care has breached
patient confidentiality.
A. True
B. False
 Answer
Answer: A. True
A nurse who fails to log off a computer after
documenting patient care has breached
patient confidentiality.
 Potential Breaches in Patient
Confidentiality
• Displaying information on a public screen
• Sending confidential e-mail messages via public
networks
• Sharing printers among units with differing functions
• Discarding copies of patient information in trash cans
• Holding conversations that can be overheard
• Faxing confidential information to unauthorized
persons
• Sending confidential messages overheard on pagers
 Patient Rights

• See and copy their health record—hospitals

have policies on this that you must follow.
• Update their health record
• Get a list of disclosures
• Request a restriction on certain uses or
disclosures
• Choose how to receive health information
• Choose who can know about their condition
 Question
Tell whether the following statement is true or
false.
A patient has the right to obtain, review, and
revise the patient information in his or her
health record.
A. True
B. False
 Answer
Answer: B. False
A patient has the right to obtain and review,
but not revise the patient information in his or
her health record.
 Documenting
Purposes of client records
A. Communication: patient’s record serves as the vehicle by
which different members of the health team communicate
and share information with each other.
B. Assessment: nurses and other health team members gather
assessment data from the patient’s record.
C. Planning patient care: the entire health team uses data from
the patient’s record to plan care for the patient.
D. Education & research: nursing students, medical students
and other health team members often use patient record as
an educational tools. It provides a comprehensive view of the
patient’s health status. The information contained in a record
can be a valuable source of data for research.
 Documenting
Purposes of client records

E. Legal documentation: the client’s record is a legal

document and is usually admissible in court as
evidence.
F. Health care analysis: records can be used to
establish the costs of various services and to identify
those services that cost the agency money and those
that generate revenue.
G. Auditing health agencies: patient’s record is used
to monitor the care received by the patient and the
competence of people giving that care.
 Other forms of Communication--
Orders
• The chart is a method of communicating between disciplines
– Diagnostic and therapeutic orders
– Who can write these orders?
• Physicians, dentists, podiatrists, psychologists, PA’s, APN’s who are licensed,
have privileges. (residents and interns count—they are doctors, but medical
students’ orders must be cosigned by a physician.)
– Written orders
• Preferred! Must be signed/dated by the provider.
– Verbal orders
• v.o. Dr. Smith/M. Jones RN
• Only in emergencies, then Dr. (or provider) must co-sign
– Telephone orders
• t.o .Dr. Smith/M. Jones RN
• Read it back
Documenting a Telephone
Order
 Other forms of communication--
Reporting
• Change of shift report
– Summary of patient condition and current status of
care, from off-going nurse to oncoming-nurse
• Types of shift report
– Face-to Face
– Audiotaped
– Walking rounds
• Students will receive report and be expected to
give report when leaving
– Learn to use a report sheet! Examples….
 INFORMATION
FOR SHIFT REPORT

• Name, room and bed, age, • General status, any

gender significant change
• Physician, admission date,
and diagnosis • New or changed
• Diagnostic tests or physician’s orders
treatments performed in • IV fluid amounts, last
past 24 hours (results if PRN medication
ready)
• Concerns about client
• Handout—try it, or make
your own.
 Other reports
• Talking to physicians
– SBAR
• Transfers/Discharge Reports
– Nurse to nurse
• Family condition reports
– HIPAA rules apply
– Do not inform about bad test results—some
things are to be done by physicians
Here is an example of a call to a physician using SBAR:
Introduction:
Dr. Jones, this is Deb McDonald RN, I am calling from ABC Hospital
about your patient Jane Smith.
Situation:
Here's the situation: Mrs. Smith is having increasing dyspnea and is
complaining of chest pain.
Background:
She is 2nd day post op from a total knee replacement. About two hours
ago she began complaining of chest pain. Her pulse is 120 and her
blood pressure is 128/54. She is restless and short of breath.
Assessment:
I think she may be having a cardiac event or a pulmonary embolism.
Recommendation:
I need someone to evaluate her STAT, so I called the 3rd year resident,
because I know you’re in the office. I also started O2 via nasal canula
at 8 liters/min. I can have a STAT EKG done, if you’d like. She has an
IV of NS running at 100 ml/hr and I cancelled her lunch for now and
made her NPO. Is there anything else you want me to do?
 Methods of Documentation
• Narrative Charting
• Source-Oriented Charting
• Problem-Oriented Charting
• PIE Charting
• Focus Charting
• Charting by Exception (CBE)
• Computerized Documentation
• Case Management with Critical Paths
 Methods of Documentation
• Source-Oriented Charting
– Narrative recording by each member (source) of
the health care team on separate records.
 Methods of Documentation
• Narrative Charting
– Describes the client’s status, interventions and
treatments; response to treatments is in story
format.
– Narrative charting is now being replaced by other
formats.
– We’ll look at some examples, but first, let’s look at
some rules of charting…..
 Documenting
Methods of Charting
1. Narrative charting: Narrative charting (style of
documentation generally used in source-oriented records)
involves writing information about the patient and patient
care in chronologic order.

Nursing Notes

Date/time Nurses Remarks

13.30 pm States “I am having chest pain. It’s like an

elephant is sitting on me” B. Zook, RN

13.40 pm Skin is pale & moist. O2 started at 5L/min

Nitroglycerin tablet administered sublingual

Figure 1 Sample of narrative charting

 Procedural narrative notes
• 5/15/13 0900 #16 fr. Foley catheter inserted to closed
drainage. Draining moderate amounts clear straw-
colored urine. Pt. remained stable throughout the
procedure (or pt. tolerated procedure well, if your
institution allows that).----------------------S. Smith RN
• 5/15/13 0900 Right chest tube dressing changed for
small amount of serosanguinous drainage. Site benign.
No crepitus noted. Replaced dressing w/ vasoline gauze
and drain sponges per policy. All tubing checked for air
leaks, no leaks noted. Tubes taped and secured to
body. Pt. remained stable throughout the procedure
(or tolerated well, depending on policy).-----S. Smith
RN
 How do I know what to say?
• Writing a narrative can be hard for beginners.
• You must write the sentences in the
chronological order in which things were
done.
• Don’t use complete sentences or say “I
noted…” Say “thus-and-such noted.”
• You’ve got to know the words! To that end---
here are some handouts you need to
memorize!
 Methods of Documentation
• Problem-Oriented Charting (POMR)
– Has 4 elements: database, problem list, POC, and
progress note, written in SOAP format
– Uses a structured, logical format called S.O.A.P.
• S: subjective data
• O: objective data
• A: assessment (conclusion stated in form of nursing
diagnoses or client problems)
• P: plan
 Problem-Oriented Charting (POMR)
• SOAPIE and SOAPIER refer to formats that
add:
– I: Intervention
– E: Evaluation
– R: Revision
 Problem-Oriented Charting (POMR)
• Uses flow sheets to record routine care.
• A discharge summary addresses each
problem.
• SOAP entries are usually made at least every
24 hours on any unresolved problem.
• SOAP was developed on a medical model.
 Documenting
Types of Patient Records
2. SOAP charting: SOAP charting (documentation style more
likely to be used in a problem-oriented record) acquired
its name from the four essential components included in
a progress note:
* S : subjective data
* O : objective data
* A : analysis of the data
* P : plan for care
SOAP charting helps to demonstrate interdisciplinary
cooperation, because everyone involved in the care of a
patient makes entries in the same location in the chart.
 Documenting
Types of Patient Records

Letter Explanation Nurses Remarks

Subjective Information reported by the patient S – “I don’t feel well”

Objective Information reported by the nurse O - Temperature 38C

Analysis Problem identification A – Fever

Plan Proposed treatment P – Increased fluid intake & Monitor

body temperature. Call Dr. for
acetaminophen order

SOAP charting format

 Methods of Documentation
• PIE Charting
– P: Problem
– I: Intervention
– E: Evaluation
• Key components are assessment flow sheets
and the nurses’ progress notes with an
integrated plan of care.
• PIE charting is a nursing model.
 Documenting
Types of Patient Records
4. PIE charting:
PIE charting is method of recording the patient’s progress under
the headings of problem, intervention, and evaluation.
When the PIE method is used, assessments are documented on
separate form and the patient’s problems are given a
corresponding number.

Date/time Nurses Remarks

6/6 P# 1 crackles heard on inspiration in the bases
of R and L lungs.
8.30 am I# 1 splinted with pillow.
Instructed to breathe deeply, open mouth, and
cough at the end of expiration.
E# 1 Lungs clear with coughing. L Cass, HN

Sample of PIE charting

 Methods of Documentation
• Focus Charting
– A method of identifying and organizing the
narrative documentation of all client concerns.
– Includes data, action, response.
– Uses a columnar format within the progress notes
to distinguish the entry from other recordings in
the narrative notes.
 Documenting
Types of Patient Records
Focus charting: Focus charting (modified form of SOAP Charting)
uses the word focus rather than problem, because some
believe that the word problem carries negative
connotations.
Focus charting used DAR model:
D = data category reflects the assessment phase of the
nursing process
A = action category reflects planning & implementation
phase of the nursing process.
R = response category reflect the evaluation of the nursing
process
DAR notation tends to reflect the steps in the nursing
process.
 Focus charting
Types of Patient Records

6/6/2006 D (data) - Bladder distended 2 fingers above pubis.

Patient states, “I feel like my bladder is full but I can’t go on
this bedpan.”

10.15 am Has not urinated since catheter was removed 6 hours ago

A (action) –Assisted to toilet. Faucet turned on, dangled

fingers in basin of water, provided privacy

R (response)- voided 525ml of clear urine L. Cass, SN

Example of DAR charting

 Question
Which of the following methods of
documentation is unique in that it does not
develop a separate plan of care but instead
incorporates the plan of care into the progress
notes?
A. Source-oriented records
B. Problem-oriented records
C. PIE (problem, intervention, evaluation)
D. Focus charting
 Answer
Answer: C. PIE (problem, intervention, evaluation)
Rationale:
PIE charting incorporates the plan of care into progress
notes in which problems are identified by number.
In source-oriented records, each healthcare group keeps
data on its own separate form.
Problem-oriented records are organized around patient
problems rather than around sources of information.
Focus charting brings the focus of care back to the patient
and the patient’s concerns.
 Methods of Documentation
• Charting by Exception (CBE)
– The nurse documents only deviations from
preestablished norms.
– Avoids lengthy, repetitive notes.
– Enables the identification of trends in client
status.
CBE—old Summa forms (they are now all electronic.) Checkboxes unless something
was out of the ordinary.
 Methods of Documentation
• Case Management Process
– A methodology for organizing client care through
an illness, using a critical pathway.
– A critical pathway is a monitoring and
documentation tool used to ensure that
interventions are performed on time and that
client outcomes are achieved on time.
 Forms for Recording Data
• Kardex
• Nursing Assessment Sheet (covered in previous
chapter)
• Flow Sheets
• Nurses’ Progress Notes (also called nurses’ notes)
• Discharge Summary
• MAR (Medication Administration Record)
(Lorantffy handouts)
 Forms for Recording Data
• The Kardex is used as a reference throughout
the shift and during change-of-shift reports.
– Client data
– Medical diagnoses and nursing diagnoses
– Medical orders
– Activities
 Forms for Recording Data
• Flow sheets reduce the redundancy of
charting in the nurses’ progress notes.
• The information on flow sheets can be
formatted to meet the specific needs of the
client.
 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.
 Forms for Recording Data
• Nurses’ progress notes are used to document
the client’s condition, problems and
complaints, interventions, responses,
achievement of outcomes.
• Progress notes can be completely narrative or
incorporated into a standardized flow sheet.
 Forms for Recording Data
• Discharge Summary
– Client’s status at admission and discharge
– Brief summary of client’s care
– Interventions and education outcomes
– Resolved problems and continuing need
– Referrals
– Client instructions
 Forms
• The MAR is for recording daily and prn
medications
• Used at the bedside as a patient identifier
Charting a prn medication
 COMPUTERIZED DOCUMENTATION

• Reduces time taken, increases accuracy.

• Increases legibility.
• Stores, retrieves information quickly.
• Improves communication among health care
departments.
• Confidentiality and costs can be problems.
 Electronic Documentation
• Bedside data entry
• Abilities of EMR’s
– Retrieval by caregivers, administrators, third-party
payers
– Trending and tracking
• Concerns about EMR’s
– Security of data
– No national standards
– Depersonalization of care
 Electronics in Health Care
• Client monitoring devices have been used for
years
• Telemedicine/telehealth
• Practice management
 Nursing Informatics
According to the ANA, the role of the informatics nurse is
distinguished from other informatics roles by its
association with patient care delivery. ANA provided
the current definition in 2001 as:
• A specialty that integrates nursing science, computer
science and information science to manage and
communicate data, information, and knowledge in
nursing/patient practices.
• Facilitates the integration of data, information,
knowledge to support patients, nurses and other
providers in their decision-making in all roles and
settings.
Components of Practice: Transformation of Data
to Knowledge
• The transformation of data to knowledge is a key
concept of the nursing informatics role and has
the potential to significantly impact nursing
practice.
• It involves three components:
– 1. Data are discrete entities that are described
objectively without interpretation
– 2. Information is data that are interpreted, organized,
or structured
– 3. Knowledge is information that is synthesized so that
relationships are identified and formalized.
 Core Functions of EHR’s
• Health information and data
• Results management
• Order management
• Decision support
• Electronic connectivity
• Patient support
• Administrative processes and reporting
 WHY EHR’s are important
• Historically, there are drawbacks to paper
records.
• Certainly, EHR’s have fixed many of these. But
problems still exist.
• Read “Where’s my Chart?” and answer the
following questions:
– What are the dangers to the client when the provider
has no access to their old charts?
– How would this situation have been improved if the
EHR’s were interconnected?
 Workflows, old and new
• Outpatient settings: Workflows in an office
using paper charts are compared to an office
using EHR. (see handouts)
• Inpatient settings: Significant differences exist
which make EHR more efficient
 Problems of Paper Record

– • Chart is thick
– • Disorganized and illegible
– • Problems in finding data
– • Record fragmentation
– • Archiving issues (space, environmental control)
– • Handling files issues (occupational hazards)
 Benefits of EHR’s
• More time spent with patient and less time at
nurse station
• Reduce paperwork / paper loss
• Automated tools of nursing documentation
• Accurate logging of nurses activities
• Uniform standards of nursing care are
programmed (nursing process)
• Cost reduction (Fewer loss of charges)
• Timely transfer of test results
• Decision support—computer gives you advice
 Point of Care documentation
• Nurse enters data at the
client’s bedside
• Real-time entry makes
data available
immediately
• Can be COWs or fixed
computer workstations
located throughout the
unit
• Tablets with handwriting
or speech recognition
 Guidelines for safe computer charting
• Don’t let anyone use your password
• Always log off when you are done
• Never delete anything. Use error protocols.
• Don’t leave patient info displayed on the
monitor where it can be seen
• Don’t use email to send protected patient
information
 Guidelines for aesthetic use of
computers
• Bedside computers may help us, but don’t
forget to talk to the patient.
• Nurse the patient, not the computer
• Look the patient in the eye when he talks, not
at your computer screen.
• Don’t fiddle around with it in the patient’s
room—if you’re unsure where to find data,
leave the room and do it elsewhere.