Chapter 37: Documenting and
Reporting
Sasha Persaud
Homework
• Assignment due on Day 10 by 9:00 am
Learning Objectives #1
• State the reasons for maintaining a written and continuous health record.
• List the categories of information that are included in the health record.
• Discuss the advantages and disadvantages of both manual and computerized
documentation.
• Discuss the rationale for use of accountability (core) measures, how these
measures are integrated with the documentation of interventions, and
outcomes of client care standards.
• Differentiate among the following types of charting in progress notes:
narrative, SOAP, SOAPIER, APIE, PIE, DAPE, DARP, DARE, and CBE.
Learning Objectives #2
• State the advantages and disadvantages of the following types of documentation:
narrative, problem-oriented, discipline area, charting by exception, case
management, critical pathways, and medication administration records.
• Identify the data that are commonly found on a flow sheet.
• State eight guidelines that are generally accepted for documentation.
• Practice using descriptive terms, abbreviations, and acronyms commonly used in
charting.
• Identify and differentiate the regulations and method of documenting for the
following: an error in charting, a late entry, and an error that occurred regarding
care for a client.
• Describe the process and content of reporting information to nurses. Discuss how
this type of report differs from communicating to other members of the healthcare
team.
Documentation
• Health record: manual or electronic account of client relationship
with a healthcare facility
• All information is recorded chronologically and systematically
regarding client’s health, past and current problems, diagnostic
tests, treatments, responses to treatments, discharge planning
• Must record information clearly, accurately, and frequently
• Charting: the term used for documentation
• Chart: the client’s health record
Purposes of the Health Record
• To maintain effective communication among all caregivers
• To provide written evidence of accountability
• To meet legal, regulatory, and financial requirements
• To provide data for research and educational purposes
• **the health record is a legal document**
Communication #1
• Health record is a communication tool all caregivers use to exchange
information
• Enables all healthcare providers to remain in touch about the nature of
the client’s health problems, possible treatments, treatments given,
and client responses
• Provides documentation and verification of client’s own health status
which they may require for a specific reason
Communication #2
• Nurses facilitate communication by
Accountability #1
• Responsibility for actions
• Health record is documented evidence that healthcare agency and
providers have acted responsibly and effectively
• Required for legal, regulatory, and financial reasons
• The Joint Commission and Centers for Medicare and Medicaid Services
(CMS) developed core measures (accountability measures) that provide
standards of care. https://www.jointcommission.org/resources/news-and-multimedia/fact-sheets/facts-about-accountability-
measures/
• Required to meet standards
• Specifications Manual for National Hospital Inpatient Quality measures
https://www.jointcommission.org/measurement/specification-manuals/
Accountability #2
• Major issues
o Legal requirements and protection: mandate
that states all businesses and corporations that
provide public services must keep a record of
their interactions with clients. Health record is a
legal document
o Documentation criteria: must meet standards of
care established by governmental or voluntary
regulatory agencies. https://wpcdn.ncqa.org/www-prod/wp-
content/uploads/2018/07/20180110_Guidelines_Medical_Record_Documentation.pdf
o Financial accountability: a complete list of of
services and products are required for insurance
reimbursement
Accountability #3
vMajor issues (cont)
o Research and education: healthcare record is
reviewed for EBP research in the pattern of
illness, trends, or effective treatment strategies.
If it was not documented,
it was not done!
Question #1
Is the following statement true or false?
If a nursing action is not documented in the medical record, in the
eye of the law, the nurse is not responsible for the action.
Answer to Question #1
False
If health records are audited, if it was not documented, it was not
done in the eyes of the law. This does not exempt the nurse who
makes an error.
Documentation Systems #1
• Manual, electronic, or combination of both
• Medical information system (MIS): electronic document housed in
computer network
• Electronic medical records (EMR)
• Manual records
o Collection of various forms and documents
o May keep some at bedside for convenience
o Due to computers becoming bedside tools, manual
records may be phased out or eliminated
o See Table 37-1
Documentation Systems #2
• Computer Records
o Electronic medical recordkeeping for all information
o Enables bedside practitioners to store, process, and
transmit information
o EMR systems use networks of terminals, at client
bedside, nursing stations, computer on wheels
(COW), or workstation on wheels (WOW)
o Internet access allows healthcare providers to access
information without being next to client
o Each healthcare facility’s computer system is unique
to their own needs
o Orientation, refresher courses offered for training
Forms in the EMR
Contents of the Health Record #1
• Assessment documents
o All information about client
o Admission record, medical history and physical;
nursing admission history; minimum data set or
resident assessment protocol (RAP); laboratory
record; consultation
• Plans for care and treatment
o Problem list, healthcare provider’s orders,
nursing care plan, teaching plan, clinical care
path, consent for treatment
Contents of the Health Record #2
• Formats of documentation
o Using a progress note entry format
§ Establish a baseline of data
§ Document the accountability (core) measures
of admission
§ Enter data at regular intervals
§ Summarize the client’s condition
§ Document changes in the client’s condition
§ Document a response to treatment
Contents of the Health Record #3
• Formats of documentation (cont.)
o Narrative–chronological: summarizes progress of
client toward goals; nurses’ notes; documents
what is happening throughout day; very
thorough and detailed, time-consuming
o Area charting: focus on specific problem rather
than general assessment data; problem-oriented
medical records (POMR); focused charting;
different types of charting; delineate subjective,
objective, approach, analysis, plan,
interventions, response, education, evaluation
Contents of the Health Record #4
• Formats of documentation (cont.)
Contents of the Health Record #5
Contents of the Health Record #7
• Formats of documentation (cont.)
o Discipline Area (Multidisciplinary) Documentation:
separate notes for healthcare providers, nurses,
other healthcare team members; allows each
subspecialty to find their documents quickly;
information may be missed due to not seeing notes
o Charting by Exception: narrative charting uses flow
sheet listing body systems and typical findings; make
notation about abnormal findings in nurses’ note
o Case Management: emphasis is on quality care
delivered in most cost-effective manner; client is
focus; case studies, care mapping, collaborative
pathways, critical pathways; team shares information
Contents of the Health Record #8
• Formats of documentation (cont.)
o Graphic Flow Sheet: medical administration
record (MAR) lists all medications, usually kept
separate from rest; common for vital signs,
intake and output, ADLs, dietary or eating
patterns, neurologic checks, restraint
observation and documentation, frequent blood
sugar monitoring, postoperative records, wound
care and monitoring
Contents of the Health Record #9
• Plans for continuity of care
o Length of stay varies
o Specific forms are used to ensure client’s care is
continuous, consistent, and effective
o Teaching plans, transfer notes, discharge
summaries contain information to enable
continuity of care
Question #2
Is the following statement true or false?
Charting by exception (CBE) uses a SOAPIER or a system flow sheet
format for certain progress notes.
Answer to Question #2
True
Charting by exception (CBE) uses a SOAPIER or a system flow sheet
format for progress notes where abnormal signs or symptoms (the
“exception” to normal status) are specifically identified, assessed,
and interventions are documented.
Guidelines for Documentation #1
• Document what you see
o Describe exactly what is observed, document what
you see, describe assessments objectively, do not
give opinions or interpretations, be specific; identify
client’s reaction to your actions
• Be specific
o Avoid ambiguous statements and generalizations;
avoid judgmental words: well, fair, poor, good
• Use direct quotes
o Directly quote the client, differentiate client’s words
from your observations, enclose client’s statements
in quotation marks
Guidelines for Documentation #2
• Be prompt
o Document immediately after giving all care,
medications, and treatments; never document
before; if forget to document something, must
identify entry as “late entry”
• Be clear and concise
o Correct spelling, punctuation, and sentence structure
essential; if manual, print or write neatly in black
ink; use 24-hour clock; only standard abbreviations;
use correct signature; do not leave blank lines
o See Boxes 37-2 and 37-3; Tables 37-3, 37-4, 37-5,
and 37-6
12 Hour vs 24 Hour clock
Guidelines for Documentation #3
• Record all relevant information
o Read healthcare provider’s notes; document all
communication with other members of team
• Respect confidentiality
o Only share information with appropriate healthcare
team member and in proper setting; do not talk
about client when bystander is near; do not allow
others to see computer screen
• Record documentation errors
o Illegal to use correction fluid or erase errors; cross
out error with one line, write ERROR and your initials
next to it, and record correct statement; computer
also has system for correcting
Reporting
• “Report off” to other nurses
• Change-of-shift reporting
o May be given in person, in writing, or by tape
recorder
o May be very brief or quite detailed
o May be given in walking rounds
o Outgoing nurse introduces incoming nurse
o See Nursing Care Guidelines 37-1
Reporting Guidelines
Sample Shift report form
SBAR
• SBAR (situation, background, assessment, recommendations) method of
communication is used to organize information when calling a primary
provider.
Question #3
What methods may be used for change-of-shift reporting? (Select
all that apply.)
a. Team leader reports to the entire incoming shift
b. One caregiver reports to another caregiver
c. Written report from one caregiver to another
d. Verbal report is given to the caregiver at client’s bedside
e. Report may be recorded on a tape recorder
Answer to Question #3
a. Team leader reports to the entire incoming shift
b. One caregiver reports to another caregiver
c. Written report from one caregiver to another
e. Report may be recorded on a tape recorder
A change-of-shift report may be given in person, in writing, or by
tape recorder. If the report is verbal, it is given in a location where
clients and visitors cannot overhear the conversation.
Key Points #1
• The primary purposes of the health record are to facilitate communication among
caregivers, provide evidence of accountability, and facilitate health research and
education.
• Healthcare records use sundry versions of medical information systems (MIS) to enter,
store, process, and retrieve client data.
• Assessment documents record all client information.
• Minimum data sets and resident assessment protocols guide nurses to develop
individualized care plans, especially in long-term facilities and home care.
• Plans for treatment of the client include the healthcare provider’s orders and the
nursing care plan.
• Progress records describe the treatment and responses of the client.
• Healthcare facilities use various formats to organize nursing progress notes in the
health record.
Key Points #2
• Plans for the continuity of care include teaching plans, transfer
notes, and discharge summaries.
• Accurate and complete documentation ensures effective
communication and accountability.
• Confidentiality means a client’s right to privacy that healthcare
personnel safeguard in both documentation and reporting.
• Reporting is an oral method of communicating that is timely,
precise, and accurate.
