Documentation

Documentation

  • The term “documentation” refers to“any writtenor electronically generated information abouta client that describes client status, or thecare or services provided to that client. (Registered Nurses Association of British Columbia)
  • Documentation is written evidence of nursingpractice. (Sorenson & Luckmann 1994)
  • Documentation is the written legal record of all pertinent interactions with the client assessing, diagnosing, planning, implementing and evaluating.

Purposes

  • Communication
  • Planning Client Care
  • Auditing Health Agencies
  • Research
  • Education
  • Reimbursement
  • Statistics
  • Legal Documentation
  • Health Care Analysis(Quality  Assurance)

Methods of Documentation

Methods of Documentation there are-

  1. Source-oriented Records
  2. Problem oriented medical record (POME)
  3. PIE Documentation model
  4. Focus charting
  5. Charting by Exception
  6. Computerized Documention
  7. Case management system charting

1. Source-oriented Records - It is a narrative recording by each member of the health care teamon separate document from admission to discharge.

  • Admission data
  • Physician orders
  • Laboratory data
  • Graphic sheets
  • Discharge Planning
  • History and physical examination
  • Diagnostic reports
  • Nurses Notes
  • Rehabilitation and therapy notes

Advantages -

  • Information in chronologic order
  • Documents patient's baseline
  • Condition for each shift

Disadvantages

  • Difficult to separate inforformation
  • Discourages physicians
  • Requires extensive charting time by the staff

2. Problem Oriented Medical Record (POMR) - Problem oriented records are organized around the clients problem. POMR employs a structured, logical format focuses on the clients problem.

There are 4 components in POMR

Data base
Problem list
Plan of care
Progress notes
Example- SOAP Format or SOAPIE and SOAPIER

S -Subjective data
O -Objective data
A - Assessment
P - Plan
I -Intervention
E - Evaluation
R- Revision

Advantages 

  • Focusing on client's problem
  • Promotes problem solving approach to care
  • Improve continuity of care
  • Allows easy auditing of client records
  • Quality of patient care

Disadvantages -

  • Results in loss of chrologic charting
  • More difficult to track trends in client status

3. PIE Documentation Model - The main parts of this system are an integrated plane of care. assessment flow sheets and nursing progress notes. 

This system consists of a client care assessment flow sheet & progress notes.

PIE stands for-P-Problem, I - Intervention, E - Evaluation

4. Focus Charting

Focus charting highlights the concerns, problems or strengths.three components are DAR.

  • D- Data( Subjective and Objective)
  • A-Action( Nursing Intervention)
  • R-Response( Evaluation of Nursing care)

5. Charting by Exception

It is the documention of only abnormal or significant finding or exceptions to norms are recorded.

6. Computerized Documentation - Computerized clinical record system are being developed as a way to manage the huge volume of information required an health care delivery. Documentation done as interventions are performed using bedside computers.

7. Case management system charting - A methodology for organizing client care through an illness, using a critical pathway. A critical pathway is a multidisciplinary plan or tool that specifies assessments, interventions, treatments and outcome of health related problems a cross a time line.

Tools/Forms of Documention - There are many forms/tools used for client documentation and could be written or electronic in format and they include -

  • Kardexes - Kardexes are a communication tool used to convey the client's current orders as well as upcoming tests or surgery, diet etc, quickly and briefly.
  • Flow Sheet
  • Progress Notes
  • Discharge Summary 

DO'S & DON'TS OF DOCUMENTATION -

Do's-

  • Check that you have the correct file before begin writing.
  • Do use correct spelling, correct grammer and concise phrases.
  • Do make entries in consecutive order.
  • Do write the complete date and time of each entry, using am/pm or military time.
  • Do sign each eantry using your professional signature.
  • Write often enough to tell the whole story.
  • Do use accepted hospital abbreviations.
  • Correct charting errors.
  • Do write neatly and legible.
  • Chart the clients response to interactions
  • Do document nursing action taken following indication of a need for action.
  • Do continue documentation of problems until resolution.
  • Do indicate patient non compliance and do use direct patient quotes when appropriate.
  • Do document all physician contacts.
  • Do documents patient teaching.
  • Do use only hospital approved forms for charting.
  • Make sure your documentation reflects the nursing process.
  • Encourages others to document relevant information that they share with you.

Don'ts-

  • Leave blank space for a colleague to chart later.
  • Don't backdate, tamper with or add to notes previously written.
  • Don't write in margins.
  • Don't alter a patients record.
  • Don't use shorthand or abbreviations that aren't widely accepted.
  • After a record even if requested by a superior or a physician.
  • Don't use medical terms unless you are sure of their exact meaning.
  • Don't wait until the end of the shift to chart.
  • Don't chart for anyone, specially for nursing action performed by another nurse.
  • Do not erase or obliterate errors.
  • Don't skip lines between entries or leave space for others to chart.
  • Don't leave space for your signature.

Guidelines For Documentation 

  • Ensure that you have the correct client record or chart.
  • Ensure accurate recall of data.
  • Date and time of each entry.
  • Do not leave space in between entries.
  • Sign each entry with your full legal name and with your professional credentials.
  • Never change another person's entry even if it is incorrect.
  • Document all telephone calls that you received that are related to client's case.
  • Use permanent ink.
  • Document in chronological order.
  • Use correct spelling while documenting.
  • Accurate, complete documentation should give legal protection to the nurse, the client's other caregivers, the health care family and the client.
  • Clients have a right to protection of their privacy with respect to the access, storage, retrieval and transmitted their records.
  • A confidential communication is information given by one person to another with trust and confidence that such information will not be disclosed.

Legal Guidelines For Documentation -

  • Do not write comments about client.
  • Do not erase.
  • Record all facts and enter only factual data.
  • Correct all errors promptly.
  • All hospital personal are legally and ethically obligated to keep in confidence all the information provided in the records.
  • Be filed according to hospital norms, systematically so that they can be traced easily.
  • Records should be arranged alphabetically, numerically, index cards and geographically.
  • Use complete, concise descriptions of care.
  • Do not leave blank spaces in nurse's notes.
  • Record all entries legibly and in blank ink.
  • Start each entry with date, time and end with your signature.
  • Chart only for your self, never chart for someone else.
  • For computer documentation keep your password to yourself.
  • No stranger is ever permitted to read the records.
  • It should kept in a place, not accessible to the patient's and visitor's.
  • Use only standard abbreviations.
  • It are never sent out of the hospital without doctors permission.
  • No individual sheet is separated from the complete record.

 


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