Mrs. Yeager's Homepage
Nursing 205 Homepage
Nursing 215 Homepage
Nursing 230 Homepage

Lecture Notes

Documenting, Reporting, and Conferring 

  1. Nine purposes of patient records
    1. planning patient care
    2. communicate
    3. legal documentation
    4. research
    5. education
    6. quality assurance monitoring
    7. statistics
    8. accrediting and licensing
    9. reimbursement
  2. Three types of patient records
    1. source-oriented medical records
      1. data about the patient is arranged according to the source of the patient data
      2. each person or department makes notations in separate section(s) of the patient's chart
        1. e.g., a physician makes notations on a physician's order sheet, progress notes, doctor's history and physical sheet
        2. e.g., a nurse makes notations on nurses notes
        3. e.g., a physical therapist makes notations on physical therapy notes
      3. eleven components of source-oriented medical records
        1. admission (face) sheet
        2. initial nursing assessment
        3. flowsheets
        4. nurses notes
        5. medical history and examination
        6. physician's order sheets
        7. physician's progress notes
        8. consultation records
        9. diagnostic reports
        10. consultation reports
        11. patient discharge plan and referral summary
    2. problem-oriented medical records (POMRs)
      1. data about the patient is arranged according to patient health problems
      2. each person or department makes notions that are integrated throughout the patient's chart
      3. four components of POMRs
        1. baseline data
          1. all information known about the patient
        2. problem list
          1. problems identified by different team members as they occur or are discovered
        3. initial list of orders or care plans
          1. initial medical and nursing plans of care
        4. progress notes
          1. patient status in areas indicated on the problem list
    3. computer records
      1. data about the patient is arranged according to a computer program
      2. pros of computer records
        1. storage and retrieval of information is fast and simple
        2. links various sources of patient information
        3. patient information, requests, and results are sent and received quickly
        4. bedside terminals can synthesize information from monitoring equipment
        5. facilitates patient outcomes
        6. information is legible
        7. reinforces standards of care
        8. standard terminology improves communication
        9. bedside terminals eliminate need to take notes on a worksheet before recording
        10. beside terminals permit the nurse to check an order immediately before administering a treatment or medication
      3. cons of computer records
        1. patient's privacy may be infringed on if security measures are not used
        2. during breakdowns more information temporarily unavailable
        3. system is expensive
  3. Eight formats for nursing documentation
    1. nursing care plans
      1. individual
      2. standardized
      3. computerized
    2. case managment care plans
    3. kardex
      1. series of cards in a portable index file
      2. usually includes the following:
        1. pertinent information about the patient:
          1. e.g., name, age, room number, religion, marital status, admission data, physician's name, diagnosis, type of surgery, date of admission, occupation, next of kin
        2. list of medications
        3. list of intravenous infusions
        4. list of daily treatments and procedures
        5. allergies
        6. specific data on how patient's physical needs are to be met
          1. e.g., type of diet, assistance needed with feeding, elimination devices, activity level, hygienic needs, safety precautions
        7. problem list
      3. only as good as how well the nurses keep them up to date
    4. progress notes
      1. four methods used to write on progress notes
        1. narrative charting
        2. problem-oriented charting
          1. SOAP
            1. Subjective
            2. Objective
            3. Assessment
            4. Plan
          2. SOAPIER
            1. Subjective
            2. Objective
            3. Assessment
            4. Plan
            5. Intervention
            6. Evaluation
            7. Revision
          3. APIE
            1. Assessment
            2. Plan
            3. Intervention
            4. Evaluation
        3. PIE charting
          1. Problem
          2. Intervention
          3. Evaluation
        4. flowsheet charting, e.g.:
          1. clinical records
            1. e.g., body temperature, vital signs, weight
          2. 24-hour fluid balance record
          3. medication record
          4. nursing care records
    5. focus charting
      1. uses keywords that describe what is happening to the patient
      2. the focus is not limited to clinical problems
      3. the focus could denote any of the following:
        1. a current patient concern
        2. a significant change in patient status or behavior
        3. a significant event in patient therapy
      4. typically uses three columns
        1. date/hour
        2. focus
        3. progress notes
          1. progress notes entries are organized by DAR
            1. data
            2. action
            3. response
    6. charting by exception (CBE)
      1. documentation system in which only significant findings or exception to norms are recorded
      2. three components of CBE charting
        1. unique flowsheets that highlight significant findings and define assessment parameters and findings
        2. documentation by reference to Standards of Nursing Practice which eliminates much of the repetitive charting of routine care
          1. e.g., for the two standards "the nurse shall ensure that the patient has a complete linen change every three days and as needed" and "the nurse shall ensure that the patient is offered oral care tid"
          2. the documentation according to these specified standards involves only a check mark in the routine standards box on the graphic record
          3. and if all the standards are not implemented, an * with reference to the nurses notes is made
          4. and all * exceptions to the standards are closely outlined in narrative form on the nurse's notes
        3. bedside accessibility of documentation forms
    7. discharge note and referral summary
      1. completed when a patient is being discharged and transferred to another institution or to a home setting
      2. discharge summaries usually include the following:
        1. description of the patient's condition at discharge
        2. current medications
        3. treatments
        4. diet
        5. activity level
        6. restrictions
      3. referral summaries usually include the following:
        1. any active health problems
        2. current medications
        3. current treatments that are to be continued
        4. eating and sleeping habits
        5. self-care abilities
        6. support networks
        7. lifestyle patterns
        8. religious preferences
    8. discharging a patient against medical authority (AMA)
      1. procedure to follow when discharging a patient AMA
        1. ascertain why the patient wants to leave AMA
        2. notify the physician
        3. offer the patient the appropriate form to complete
        4. if the patient refuses to sign the form, document this fact on the form and have another health professional witness this
        5. provide the patient with the original of the signed form and place a copy in the record
        6. when the patient leaves the agency, notify the physician, nurse in charge, and agency administration as appropriate
        7. assist the patient to leave as if this were a usual discharge from the agency (the agency is still responsible while the patient is on the premises)
  4. Eleven elements of effective charting
    1. timing
      1. document date/time of the recording, assessment, or nursing strategy (intervention)
      2. follow policy with regard to frequency of charting
        1. adjust according to the patient's condition
      3. document as soon as possible after an assessment or nursing strategy (intervention)
      4. do not document prior to an assessment or nursing strategy (intervention)
      5. document in conventional or military time
        1. whatever one the agency uses
    2. confidentiality
      1. access to medical record is restricted
        1. available to the following:
          1. health care professionals providing patient care
          2. for the purposes of education and research
          3. those individuals whom the patient specifically gives permission
        2. not available to the following:
          1. insurance companies
          2. significant others
        3. all health care professionals are bound by an ethical code to maintain patient confidentiality
    3. permanence
      1. all charting should have the following two qualities:
        1. be legible
        2. be done in dark, colored ink
    4. signatures
      1. all signatures should include the following:
        1. name
        2. title
    5. accuracy
      1. chart facts and observations, rather than opinions or interpretations of an observation
      2. avoid general words, such as large, good, or normal
      3. spell correctly
      4. how to deal with a recording error
        1. draw a line through the error
        2. write the word error above it
        3. do not erase or blot out the error
        4. initial the corrected recording error
      5. how to deal with blanks
        1. draw a line through the blank space so no additional information can be recorded at any other time or by any other person
        2. sign the notation
    6. sequence
      1. document events in the order in which they occurred
    7. appropriateness
      1. only information that pertains to the patient's health problems and care should be recorded
      2. invasion of privacy to record anything else
    8. completeness
      1. all data must meet the following criteria:
        1. be complete
        2. must be helpful to the patient and health care professionals
    9. use of standard terminology
      1. use commonly accepted abbreviations, symbols, and terms that are specified by the agency
    10. brevity
      1. all recordings must meet the following criteria:
        1. be brief
        2. but be complete
    11. legal awareness
      1. clinical record is a legal document
      2. accurate, complete documentation should give legal protection to the nurse, the patient's significant others, other caregivers, the health care agency, and the patient
  5. Three types of reporting
    1. change-of-shift reports
      1. an oral report given two or three times a day by nurses to all nurses on the next shift
      2. important for continuity of care
      3. three formats for reporting
        1. face-to-face
        2. audiotape recording
        3. combination of the two
      4. ten key elements of a change-of-shift report
        1. follow a particular order
        2. provide basic identifying information for each patient
        3. provide the reason for admission of a new patient or medical diagnosis, surgery, diagnostic tests, and therapies in the past 24 hours
        4. include significant changes in the patient's condition and present information in order
        5. provide direct information about patient care
        6. report patients who may require special emotional support
        7. include nurse prescribed and physician prescribed orders
        8. provide a summary of newly admitted patients
        9. report patients that have been transferred or discharged
        10. clearly state priorities of care
    2. telephone reports
      1. include the following when documenting a telephone report:
        1. date and time
        2. the name of the person giving the information
        3. what information was received
        4. name of the person receiving the information
      2. include the following when giving a telephone report to a physician:
        1. patient's name
        2. medical diagnosis
        3. changes in nursing assessment
        4. vitals signs related to baseline vital signs
        5. significant laboratory data
        6. related nursing strategies (interventions)
    3. telephone order
      1. include the following when documenting and writing a telephone order:
        1. write the order down
        2. repeat it back to the physician to ensure accuracy
        3. transcribe the telephone order onto the physician's order sheet in the following manner
          1. "Start IV of D5W at 100 ccs per hour. Dr. John Doe, TO" for a telephone order
        4. physician must countersign the telelphone order within a specified time period according to agency policy
    4. verbal order
      1. include the following when documenting and writing a verbal order:
        1. write the order down
        2. repeat it back to the physician to ensure accuracy
        3. transcribe the verbal order onto the physician's order sheet in the following manner
          1. "Insert nasogastric tube to low constant suction. Dr. Susan Smith, VO" for a verbal order
        4. physician must countersign the verbal order within a specified time frame according to agency policy
  6. Two types of conferring
    1. nursing conferences
      1. a meeting of a group of nurses to discuss possible solutions to certain problems of a patient
      2. best in a climate that promotes the following:
        1. respect
        2. nonjudgmental attitude
        3. open-mindedness
        4. freedom of risk-taking
    2. nursing grand rounds
      1. a procedure in which a group of nurses visits all or selected patients at each patient's bedside to do the following:
        1. obtain information that will help plan nursing care
        2. provide the patient with the opportunity to discuss their care
        3. evaluate the nursing care the patient has received
  7. Referring
    1. sending or directing a patient to another person, or agency, for help or treatment

Return to Top

This page was last modified on 6/1/03