g

, MNS
ntation and
Kedokteran Universitas Brawijaya

Documenta

Efective communication vital

Record
Discussion

Charting
Report
Recording
Documenting
Legal document

Communicati

Communication is a dynamic, continuous,

multidimensional process for sharing infor
Reporting and recording are the major
communication techniques used by health
Documentati
providers.

e interactions between and among health profession

education
practitioners.
rnts,
clients
response
these
diagnostic
tests and
their
families, to
and
health
care organizations

Documentation as
The medical
record serves as a legal d
Communication
Documentation
is
defned as
written evide
ministration
of tests,
procedures,
treatments,
and
recording
all client
activities
by health

interventions

ystematic documentation is critical to prese

ommunicated
proper
documentati
dministered
bythrough
nurses in
a logical
fashion.

Documentati
urses rely on charting, records, and system
Communicati
thinking
skills, judgments,
and evaluation
he implementation
of the nursing
process.m

Purposes of Clien
Records

th care
analysis
Research

Education
care
bursement Planning
Communication

l documentation
Auditing health agencies

He

g provides written evidence of what was

Communication
the client,
the clients response, and any
made in the care plan

Care
ProfessionalDocumentation
Responsibility and Acc

Purposes
Legal and Practice
Standardsof

Research
Education

Purposes of Hea
Care
t, institution and practitioner.
Documentation

Written records are a resource for review,

Recording documents
compliance with
reimbursement,
and research.
ntation
provides
a written
legal
record to cri
practice
standards
and
accreditation

Education

Purposes of Hea
Care
Documentation

Health care students use the medical record as a t

about disease
processes,
diagnoses,
complications,
l rounds
and case
conferences
rely heavily
on inform
interventions.
ned
in the medical record.

Research

Purposes of Hea
Researchers rely heavily on medical records as a sou
Care
data.
Documentation

Documentation can validate the need for resear

Purposes of Hea
Care
Documentation

In 80% to 85% of malpractice lawsuits involving clie

medical record is the determining factor in providin
signifcant events.

Legal and Practice Standar

Legal and Practice

Standards

nesian National Nurses Association (INNA) S

re

State Nurse Practice Acts

Informed
Consent
Advance
Directives

Legal and Practice

Standards

Informed consent means that the client u

essing
confrms
thatof
the
person
who interve
signs t
reasons
and risks
the
proposed
mpetent.

Documentation
Systems

Charting bySource-oriented
exception
recor
puterized documentation
e management
Problem-oriented medical record
Problems, interventions, evaluation (
Focus charting

Documentatio

Nursing
notes must
be logical,
an
ing
documentation
based
on thefocused,
nursing
pr
Principles
of
care,efective
and must
represent each phase of th
itates
care.
Efective
process.

Elements of
Efective
Documentatio

Abbreviations and Symbols

Use of Common
cumenting
a Medication
Error Vocabulary
Organization
nfdentiality

Legibility
Accuracy

Improves communication and lessens the chance of

misunderstanding between members of the health
team.

Elements of
Efective
Documentatio

Enhances the quality of documentati

Supports the eforts of research.

Use of Common Vocabular

Legibility

Elements of
Efective
Documentatio

Sign and date the correction.

Do not erase or obliterate
Draw onewriting.
line through an erroneous entry.
State the reason for the error.

Print if necessary.

a documentation

Elements of
Efective
Documentatio

Elements of
Efective
Documentatio

Always refer to the facilitys approved

Avoidlisting.
abbreviations that can be misundersto

Abbreviations and Symbol

Organization

Elements of
Efective
Documentatio

Start every entry with the date and

time.
Chart in a timely
fashion to avoid omissions.
Chart medications immediately after
administration.
Sign your name after each entry.

Chart in chronological order.

ng a late

Elements of
Efective
Documentatio

Elements of
Efective
Documentation

medication
Charting a prn

Accuracy

Elements of
Efective
Use factual,
descriptive
terms
to chart
exactly
what
ntinuity
of care
by recording
with
respect
to notes
m
done.
s or
shifts.
Documentatio

Use correct spelling and grammar.

Write complete sentences.

Elements of
Efective
Documentatio

Documentorinmedical
the nurses progress notes:
Nursing interventions
treatment
Name and dosage of the medication
Clients response to treatment
Name of the practitioner who was notifed of the
error
Time of the notifcation

Documenting
a Medication
Chart
the medication
on the MAR.E

The nurse is responsible for protecting the priva

clients signifcant others, insurance companies, or o
confdentiality of client interactions, assessment
ies not directly involved in care provided by the healt
not have access to clients records.

Elements of
Efective
Documentatio

Confdentiality

Record

Notations for each discipline in separ

Source-Oriente
of
chart
information
in clear,
coherent mann

Being replaced or augmented

Convenient
Scattered
Narrative charting

Figure 36-8

An example of na

 Dailyplan
care record
Discharge
Special fow sheet
Medical H&P

Components of
Source Initial
nursing
Consultation
assessment
records
Oriented Recor

Physicians order sheet

Referral summary

Graphic
record
notes
Nurses
Progress notes
Admission sheet
MAR

Diagnostic reports

Record

Encourages collaboration
Arranged according to client probl
Problem-oriented medical recor
Advantages
n
ability
to usecaregivers
format
lem list alerts
to clients
Problem-Oriente
ain up-to-date problem
list

needs
Disadvantages

POMR Compo

Listed
in order
identifed
Derived
from
database
sheet for all notes
Updated

Database
Problem
list
Plan of care
Progress notes

POMR Progres
Notes

SOAPIER

valuation Objective
Subjective
Assessment
Interventions
evision
Plan
SOAP format frequently us

Problems
Interventions
Groups information

ts, incorporates ongoing care plan

nt establishes, records problem
or develop problem statement

PIE Syste

Evaluation of nursing care

us: condition, nursing diagnosis, beha

/symptom

Focus Chart

Three columns usually us

Data
Action
ProgressDate
noteand time
icResponse
perspective

Figure 36-11
system.

Example of the focus

Exception

n of lengthy, repetitive notes

Charting
ion that nurse did assess
clientby

Charting
by exception
Standards
of nursing
care (C
Bedside access to chart forms

Advantages
Flow sheets

nformation
between
settings format
Information
easily retrieved,
variety
ized
lists, add narrative information
Can generate
work list for shift
ecognition
technology
Relatively easy

Computerized
Manage hugeDocumentation
volume of information

MDS

Computerize
Documentati
Pros

focus
client ou
forFacilitates
notes
kneed
various
sources,
links
toon
monitors
mediate
order checking
dside
terminals

Fast, efcient use of time

Synthesize
information
Legible

Computerized
Documentatio
Cons

System expensive
Client privacy concer
nded training periods
Breakdowns make informati
unavailable

nt unexpected event
orated
graphics and
fow cost-efecti
sheets
Emphasizes
quality,
not
met
is variance
Multidisciplinary
approach
Planning
and documenting
client ca
Case

Management

Critical pathway

nexpected outcome

Figure 36-16
form.

Excerpt from a critical path

Example of Critical

Figure 36-17

continued

Case Managemen

nts with one or two diagnoses

Helps to decrease length of stay

Efcient use of time

Promotes collaboration

Advantages
Disadvantages
Goal-focused

Documenting Nursi
Activities

ursing discharge/referral summaries

Admission nursing assessm

Flow sheet

Progress
notescare plans
Nursing
Kardexes

Admission Nursing
Assessment

systems
Body
Functional abilities
Health
and risks
Type of
healthproblems
care setting
Nursing model
Can be organized by health pa

Evidence of client assessments

Client outcomes

Nursing Care
Plans

JCdiagnoses
requires and/or
clinical
record
incl
Nursing
client
needs
Evidence
of a written
current
nursing
careclient
plan
ional
care Nursing
plan
for each
interventions
ardized care plans save time

reco
Kardexes
May/may not be part of permanent
May be in pencil

List ofPertinent
treatments,
procedures
information,
May orders
be organized into sections
allergies
Procedures
Concise method
Medications,
IV fuids for organizing,

Activity

continued

data on
how physical
need
list withSpecifc
stated goals,
nursing
approaches
Kardexes,
isual guide

Diet,
assistance
with feeding
Hygienic
needs,
safetyneeded
precautions
Elimination devices

Flow Sheet & Prog

Notes

Medication administration record (MAR)

Skin assessment
record
ress, interventions,
re/assessment
data

Input and output (I &

O)
Record data quickly, concisely

Progress

Flow sheet
notes
Graphic record

cility

Nursing
ansferred within facility,Discharge
to/from long-term

with client
for continuity
ClientsReport
status goes
description,
resolved
problemsof
careIf given to client, family understandabl
terms

Completion on discharge/tra

Usually includes:

Usually include:

Referral
Summaries

Unresolved continuing health problems

Restrictions
related to to
activity,
diet,
Treatments
be continued
bathing
Current medications
Activities of daily living (ADL) abilities
Comfort level

Support networks

Disease process

continued

Referral Summari

ischarge destination and mode

Activities
and exercise, special diet
Follow-up
appointments
eferrals
Medications
Client education provided in rel
to

Specialized care or treatment

Facility Specifc
Documentation

Long-term care documentati

Home care documentation

Long-Term Care
Documentation

Medicare and Medicaid requirements

Federal, state
regulations
intermediate

Two types of care

Requirements
Skilledstandards
or based on
Professional

HCFA
OBRA law

continued

Long-Term Car
Documentatio

Medications, treatments
ADLs, hydration,
nutrition
status
Every 2 weeks
for
intermediate care
Once
a
week
for
skilled-care
clients
Specifc
problems
noted in care
plan
measures
needed
haviorSafety
modifcation
assessments
Summary addresses:
Nurse
Mental
status completes nursing care s

continued

Long-Term Car
Documentatio

ument and
report
systems
Requirements
MDS
andany
plan
of care change
within time

ocument interventions, progress

When
clients
health
status changes
Primary
care
provider,
clients
Keep
record
of visits,
family phone c
family
Review, revise care plan every 3 months

Standardized

Home Care
Documentation

Health Care Financing Administration (H

Home health certifcation/plan of treatment

form
Medical update and client information form

Two records
required
Nurse completes
forms
Medicare and Medicaid

each visit

Home Care F

Comprehensive
nursing assess
thly progress
nursing summary
Plan of care

Interventions
Note changes
Client responses
Progress
note at
Vital signs
as indicated

continued

Home Care Forms

Copy of care plan in clients hom

Document that changes were reported
Notify reimbursers
discontinued
Encourage
client,services
caregiver
record
datat
Report
changes
oftoplan
of care
Write discharge summary for physician

General Guideli
for
Recording

NO recording prior to providing care

t Commission DO NOT USE LIST

Legibility
Date and time
Permanence
Timing
Acceptedbyterminology
Approved
agency

Signature
Correct spelling

General Guideli
for
Recording, cont

w line through it and write mistaken

y

Clients name, identifying

information

Recording a mistake

Observations
and facts
agency policy
Name
or initialsFollow

Accuracy

Figure 36-19
error.

Correcting a ch

Methods of
Documentation

Focus Charting
Narrative Charting
Source-Oriented Charting
Problem-Oriented Charting
PIE Charting
by Exception
(CBE)
erized Documentation
nagement with Critical Paths

Methods of
Documentation

Narrative
charting
now being
replaced
by other
fo
Describes
the is
clients
status,
interventions
and

response to treatments is in story

format.

Narrative Charting

Methods of
Documentation

Narrative recording by each member (source) of th

team on separate records.

Source-Oriented Charting

sessment (conclusion stated in form of

t problems)

Methods nursing
of diagnos
Documentation

Uses a structured, logical format called S.

Problem-Oriented Charting (P

S: subjective data
O: objective data

P: plan

Charting
(POMR)

P entries are usually made at least every 24

Problem-Oriente
unresolved problem.

Uses fow sheets to record routi

OAP was developed on a medical model.
A discharge summary addresses each

Problem-Oriente
Charting
(POMR)

SOAPIE and SOAPIER refer to formats

I: Intervention
E: Evaluation
R: Revision

Delmar

6-70

Problem-Oriente
Charting
(POMR)

I: Intervention
P: Problem
E: Evaluation

PIE Charting

Methods of
Documentation

mponents are assessment fow sheets and t

progress notes with an integrated plan of c

PIE charting is a nursing model.

Methods of
Documentation

Focus Charting

Methods of
Documentation

columnar format within the progress notes to distin

A
of identifying
and
organizing
thenotes.
narrative
trymethod
from other
recordings
in the
narrative
of all client concerns.

Includes data, action, response.

Methods of
Documentation

The nurse documents only deviations from preestab

Avoids lengthy, repetitive notes.

Enables the identifcation of trends in client

status.

Charting by Exception (CB

he systematic approach to client care.

Provides clear, decisive, and concise key words

(standardized
nursing
terminology).
Increases
the quality
of documentation and s
legibilityofand
nhancesIncreases
implementation
theaccuracy.
nursing process. Enh

Methods of
Documentation

Computerized Documenta

Methods of
Documentation

Information
quicklytocoordinated
integrated
Providesisaccess
other data, and
enhancing
critic
departments.

Facilitates statistical analysis of data.

Computerized Documentati

Methods of
Documentation

A handheld
portable
computer iswith
usedall
forpertinent
inputtingc
ides
each health
care practitioner
client
data at the
bedside.
sure
continuity
of care
without duplication.

ovides crucial client information in a timely fashion.

Point-of-Care System

Methods of
Documentation

ical pathway is a monitoring and documentation tool

A
for organizing
clienton
care
through
an
e methodology
that interventions
are performed
time
and that
critical
mes arepathway.
achieved on time.

Case Management Proces

Forms for Recor

Data

Discharge Summary
Nurses Progress Notes

Flow Sheets

Kardex

Data

The Kardex is used

as a reference
through
Forms
for Recor

Medical diagnoses and nursing diagnoses

during change-of-shift reports

Client data
Medical orders
Activities

Data

Flow sheets reduce the redundancy of c

information
on fow notes.
sheets can be formatte
nurses progress
specifc needs of the
client. for Recor
Forms

Data

Progress notes can be completely narrative

incorporated into a standardized fow sheet.
Nurses progress notes are used to docume
condition, problems and complaints, interv
Forms
for Recor
responses, achievement
of outcomes.

Summary

Forms for Recor

Data

Brief summary of clients care

Interventions and education outcomes
Clients
statusand
at admission
discha
Resolved
problems
continuingand
need
Referrals

Client instructions
Discharge

Documentation

Standardized data bases are required to e

Trends
in
and precision in nursing
information
syste

Trends in
Documentation

Nursing Diagnoses (Taxonomy II

Nursing Minimum
Data Set
(N
Nursing Intervention
Classifcation
(NIC)
Nursing Outcomes Classifcation (NOC)

Reportin
mary
current critical of
information
to facili
Verbalofcommunication
data regarding
th
ical
status, needs, treatments, outcomes, and
ision making and continuity of client care

Reportin
Reports
require
participation
from everyone
Reporting
is based
on the nursing
process
care, and legal and ethical principles.

Reportin

Telephone Reports and Orders

Incident Reports

Walking
Rounds
Summary
Reports

written or computer based, the

aking an entry on a clients
lled
recording,
charting,
orco
Report:
Is oral,
written, or
ing.
A clinical record,
also to co
communication
intended
rtinformation
or client record
is a formal,
to others.
ent that provides evidence of
re.

Assessment data

progress toward expected outcomes

Summary
Commonly
occur adjustments
at change of
shiftof(or
w
nt changes
in condition,
in
plan
care,
Reports
transferred).

Primary medical and nursing diagnoses

Client or family
complaints

Occur in the clients Walking

room and include
Rou
client

Nursing, physician, interdiscip

Telephone Reports
Orders

Report transfers, communicate referrals, obt

hone orders
are inform
documented
in theand/or
nursescl
solve
problems,
a physician
members regarding a change in the clients

notes and the physician order sheet.

Documenting a Tele
Order

the delivery of client care.

y be used later in litigation.

Incident
Reports
Used toreport
document
unusual
occurrenc
incident
is notany
part
of the medical
re

General Guideli
for
Recording, cont

Omitted care must also be recorded

Refect nursing process

What, why, who

Sequence
Conciseness
Appropriateness
Completeness

And client

Legal Prude

Admissible in court as legal document

Adhere to professional standards
Follow
agency
policy and
procedures
Legal
protection
to nurse,
caregive

 Alter record

Chart in advance
Use vague terms
or
Leave blank spaces
Use patient
Record
assumptions
client Chart for others

Dont

Dos and Do

Do

Objective, factual

Show
follow-up
sponses
Correct errors
Chart
changes

Read
prior
notes
Chart teaching
timely
Be
Quotes

g Skills in

INTRODUCTI
d nurse needs to have great
reporting skills.
time to develop great reporting skills, you s
n this area if you're trying to land a job as a
l nurse or manager.

Reporting Skills
Nursing

Don't Be Afraid of
Silences
Be Prepared, But Not
Rigid

Be Prepared

re- and Post-

e Health Alliance of MidAmerica LLC

Objective
State the benefts of clinical
conferences.

e strategies to promote student

Explain the purposes of pre-clinical and po
pation
conferences.
ical conferences.

Discuss ways to prepare for clinical c

Objective

ist methods to conduct successful clinical pr

onferences.

Pair: with the person next to you

Think-Pair-S

Share: ideas generated with the group

Think: your own clinical conference exp

Planning for C
Conferences

Method for Conference Evaluation

Purpose
Process

Topic
Strategies

Debriefng
Strengthen
skills
Learn by using student
Vent feelings
assignments as case
studies

Purposes
of

Conferences
Post-conference

Pre-conference
Review daily
expectations
Validate student
Help
set
Link theory to priorities
clinical
practice assignment preparation

Promote interactive
Develop problem-solving,
learning, collaboration,
decision-making,
and
and teamwork
critical thinking skills

Benefts of Clinical

Conferences

Benefts of Clinical
Conferences

Develop oral communication skills

Link
theory to practice
Provide
opportunity
for self-refection

Sharing of student learning/skill maste

Develop
nursing attitudes
and values
Benefts
of Clinical
AssessConferences
own learning

Diferent Approaches f
of
Students

Advanced Students

Beginning Students

process
Able to see things in shades of
gray

Diferent Approach
Advanced
Levels
Students
use of medical
Active role inMore
leading
terminology
conferences

Greater understand nursing

of Students
Externally focused

Specifc directions Beginning

Inner focused
Concrete material students
Limited understanding
Black & white terms
of
Highly critical of staf
nursing process
execution
of nursing care
Skill reinforcement
Need to learn medical
terminology

Skill building with

equipment
Strengthening
skills
Clinicaldocumentation
pathways

system

Conference

how to operate a clinical

agencysActiviti
compute
Possible
Case study analysis with student assigned
Rounds)
a

Discussion of role transition issues

Topic of the week

a
Conference

Clarifying
assisting
students
with writt
riefng
of theand
days
experience
(post-confere
clinical
Possible Activiti
ing
process activities
assignments

Sharing personal accomplishments

Conference

Analyzing staf performance in nursing car

Processing legal and
ethical issues
that ari
Possible
Activiti
g the
health
carewith
system
& delivery
of healt
Guest
speaker
expertise
aspecial

Conference

Linking personal experiences

health
Possiblewith
Activiti
ofered as studentsa

Cyber clinical conference

8-122

Faculty Role in
Conferences

sent problem, issues and cases for discussi

Plan discussion and learning activiti

Create questions and cases

8-123

Faculty Role in
Conferences

Support shared information and ideas

Be fexible

Keep time

p Create
students
relationships,
patterns,
a
anidentify
environment
conducive
to discu
mes

Conferences

Provide
non-threatening
Faculty
Role infeedbac

Facilitate group process

Likely to occur with groups exceeding 5 me

Invite involved persons to share conversatio

Outline conference time frame and goals

Managing side conversatio

Faculty Role in
Conferences

discussion and use silence until all

become attent
n student seating if becomes a chronic problem

Start conference only when all members have arri

Hold to the allotted time frame for the conference

Faculty Role in
Conferences

Handling Tardiness

8-127

Faculty Role in
Conferences

Handling Dysfunctional Group Memb

Monopolizer

Know-It-All
Complainer
Playboy/Playgirl
Quiet One

Student Role in
Conferences

Work collaboratively with group

Examine diferent point of
views

Prepare for discussion

Arrive on time

Support shared information

Ask questions

Student Role in
Conferences

focused on conference deliberations

ipate
actively
Modify
own perspectives and opinions to
consensus

Start
on time role
evaluation
Maintain group focus
Assure
a comfortable
End on time
Stay
OUT of
the student and
private setting

Tips for Efective

Implementation

Tips for Efective

Implementation

Conduct
conference
a private
location
Create
a safe in
climate
for
discussi
Suggested seating arrangements
Faculty taking notes

Positive feedback
Open-ended
questions
Pledge of
confdentiality

Ask for volunteers to speak

Target students
sensitivity
More with
Tips
to Facilitat
Phrase
open
Student
students
time
to ended
answerquestions
questionscarefully
(5-10
nds)
Participation

Check out

Use of Wheeler & Chins Feminis

More Tips to Facilitat

Student
Person holding object speaks
Participation

Circling
Check in

Develop
a feedback form
Direct student
conversations
Note cards

Conference
Evaluation

Have students complete a feedback f

Faculty self-refection
e item on clinical faculty evaluation

Summary

8-135

Not all conferences will be perfect.

ccessful conferences require planning.
Things happen that disrupt the schedul
ays room for improvement.
Be open to student cues.

regnant woman in labour

mergency patient in hospital settings
mergency patient in pre hospital settings
ivide yourpatient
class into 10 small groups
ischarged
LETS
PRACTI
ach
group
must
present
of patients
in di
ental
health
patient
ups
should
prepare
their CASES
own cases
rup patient
1 : fractures
porting
ead
rup 2 : Infectious disease
rup 3 : Pediatric patient

Grup 4 : Gerontology patient

play.

In the next 2x50, report your work in yo

ake a pair in your group. One does the reporting and
role taking
oes note

LETS PRACTI

Change the turn.

Discuss in pair.

REFERENC

Lhynnely. (2012). Nursing Abbreviations

, E.2008.
Fundamental
of Nursing.
5th
Editio
Version].
Retrieved June
4, 2012,
from
cott:
William Wilkins
http://nursingcrib.com/nursing-notesewer/fundamentals-of-nursing/nursing-abbr

Questions? Com

KS A LOT