Stephanie Talbot 1 NSG 126:Documenting and Reporting I. Purpose of Client records: a.

Communicate to other professional who care for the client b. Planning client care c. Auditing- review of client records for quality assurance d. Research- data recorded is a valuable source of data for research e. Education- students use them as an educative tool f. Reimbursement- helps facilities receive reimbursement from federal government (Medicare, DRG) g. Legal documentation- clients record is a legal document admissible in court h. Health care analysis- information can assist health care planners to identify agency needs ex. Overutilization and underutilization of hospital services Documentation Systems: a. Source oriented record- each department makes notations in a separate section or sections of the client record. This type of charting allows HCP to easily locate forms to record data, and to trace information specific to ones discipline. b. Problem oriented record- data arranged according to problem client has rather than the source of the information. 4 components: i. Database ii. Problem list iii. Plan of care iv. Progress notes- use of the SOAP (subjective data, objective data, assessment and planning) method or PIE (problem interventions and evaluation of nsg care) c. Focus charting- client and client concerns and strengths are the focus of care. Consist of 3 columns: date and time, focus, progress notes (organized into DAR--data, action and response) d. Chart by exception (CBE)- only significant findings or exceptions are recorded. Three components: i. Flowsheet highlighting significant findings and defined assessment parameters ii. Documentation by reference to the agencies printed standards iii. Bedside accessibility e. FACT- designed to eliminate redundant and irrelevant data and inconsistencies in recording. Elements: i. Flowsheets that are individualized ii. Assessment sheets that are standardized iii. Concise integrated progress notes and flowsheets that are used to document the clients condition and response iv. Timely entries that are recorded after care is given f. CORE- documentation system focuses on nursing process. Consists database, plan of care, flowsheets, progress notes, and discharge summary. CORE calls for assessing client s functional and cognitive status within 8hrs of admission. Progress note uses the DAE---data, action, evaluation.

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Stephanie Talbot 2 NSG 126:Documenting and Reporting III. Guidelines for Recording: a. Date and time of each recording b. Frequency of documenting- always done after performing nursing care c. Legibility- must be legible d. Permanence- entries made in black ink e. Accepted terminology- only use those commonly accepted. f. Correct spelling g. Signature- always sign ex. Stephanie Talbot, RN h. Accuracy- clients name and identifying information should be stamped on each page. if make an error, draw a line through it, write error above on the line below and sign it i. Sequence- document all events in order in which they occurred j. Appropriateness- record only information that pertains to the clients health problems and care. k. Completeness- notes need to reflect the nursing process l. Conciseness- recordings should be brief as well as complete m. Legal prudence- notes should give legal protection to nurse through being complete, accurate, legible etc. Guidelines for Reporting: reports can be written or oral a. Follow a particular order ex. Based on room numbers in the hospital b. Provide only basic identifying information for each client c. For new clients provide reason admitted, any surgeries, medical diagnosis, diagnostic tests or therapies d. Include significant changes in a clients condition e. Provide exact information ex. Mr. Jones received Demerol 100mg IM at 2000 hrs f. Report clients need for emotional support g. Include current nurse-prescribed and physician prescribed orders h. Provide a summary of newly admitted clients i. Report clients that have been transferred or discharged from the unit j. Clearly state the priorities of care and care that is due after the shift begins k. Be concise and do not elaborate on background data or routine care.

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