DOCUMENTING AND REPORTING 2.

Problem-oriented medical record

3. PIE model
 Effective Communication 4. Focus charting
- Vital to the quality of client 5. Charting by exception (CBE)
care 6. Computerized documentation
 Discussion 7. Case management Model
- An informal oral
consideration of a subject by SOURCE-ORIENTED RECORD
2 or more health care
 Traditional Client Record
personnel to identify a
- Can easily locate forms on
problem or establish
which to record data & easy
strategies to resolve a
to trace information specific
problem.
to one’s discipline
 Report
 Narrative Charting
- Oral, written or computer-
- A traditional part of the
based communication
source-oriented record
intended to convey
- Consists of written notes that
information to others.
include routine care, normal
 Record
findings and client problems.
- A.K.A. chart or client
record PROBLEM-ORIENTED MEDICAL
- A formal, legal document that RECORD
provides evidence of a
client’s care & can be written - A.K.A problem-oriented record
or computer based. (POR)
- The data are arranged according to
 Documenting the problems the client has rather
- A.K.A. recording or than the source of the information
charting
- The process of making an  Advantages
entry on a client record  Encourages collaboration
 Problem list in the front of the
PURPOSE OF CLIENT RECORDS chart alerts caregivers to the
client’s needs & makes it
1. Communication
easier to track the status of
2. Planning client care
each problem
3. Auditing health agencies
 Disadvantages
4. Research
 Caregivers differ in their
5. Education
ability to use the required
6. Reimbursement
charting format
7. Legal documentation
 Takes constant vigilance to
8. Health care analysis
maintain an up to date
DOCUMENTATION SYSTEMS problem list

1. Source-oriented record
  Assessments & interventions - Eliminates the traditional care plan
must be repeated (inefficient) & incorporates an ongoing care
plan into the progress notes.
4 BASIC COMPONENTS OF POMR
FOCUS CHARTING
1. Database
- Consists of all information - Intended to make the client &
known about the client when client concerns & strengths the
the client first enters the focus of care
health care agency. - Provides a holistic perspective of
2. Problem list the client & the client’s needs
- Derived from database - 3 columns for recording:
- Usually kept at the front of  Date and time
the chart  Focus
- Serves as an index to the  Progress notes
numbered entries in the
progress notes  Focus
- Listed in the order in which -May be a condition, a nursing
they are identified diagnosis, a behavior, a sign
- List continually updated or symptom, an acute
3. Plan of care change in the client’s
- Is generated by the individual condition or a client strength
who lists the problems  Progress Notes
- Is made with reference to the - ARE organized into:
active problems  Data (D)
4. Progress notes o Reflects the
- A chart entry made by all assessment phase
health professionals involved of the nursing
in a client’s care process
- SOAPIER format is used:  Action (A)
 Subjective data o Reflects planning
 Objective data & implementation
 Assessment & includes
 Plan immediate & future
 Interventions nursing actions
 Evaluations  Response (R)
 Revisions o Reflects the
PIE MODEL evaluation phase
of the nursing
- Acronym of problems, process &
interventions & evaluation of describes the
nursing care client’s response to
- Consists of a client care any nursing &
assessment flow sheet & progress medical care
notes
CHARTING BY EXCEPTION (CBE) 5. Progress notes
6. Nursing discharge/referral
 ONLY abnormal or significant summaries
findings or exceptions to norms are
recorded ADMISSION NURSING ASSESSMENT

3 KEY ELEMENTS OF CBE - Also referred as initial database,

nursing history & nursing
1. Flow sheets assessment
2. Standards of nursing care - Completed when the client is
3. Bedside access to chart forms admitted to the nursing unit.
COMPUTERIZED DOCUMENTATION NURSING CARE PLANS
 Electronic Health Records (EHRs) 2 TYPES OF NURSING CARE PLANE
- Are used to manage the
huge volume of information  Traditional
required in contemporary - Written for each client
health care  Standardized
- Can integrate all pertinent - Developed to save
client information into one documentation time
record
KARDEXES
CASE MANAGEMENT MODEL
- Widely used, concise method
- Emphasizes quality, cost-effective of organizing & recording
care delivered within an established data about a client, making
length of stay information quickly
- Uses a MULTIDISCIPLINARY accessible to all healthcare
approach to planning & documenting professionals.
client care, using critical pathway - May or may not be part of the
client’s permanent record
 Variance
- A goal that is not met FLOW SHEETS
- A deviation from what was
- Enables nurses to record nursing
planned on the critical data quickly & concisely & provides
pathways – unexpected an easy-to-read record of the client’s
occurrences that affect the condition over time.
planned care or the client’s  Graphic record
responses to care.  Intake & output record
DOCUMENTING NURSING ACTIVITIES  Medication
administration record
1. Admission Nursing Assessment  Skin assessment
2. Nursing Care plans record
3. Kardexes
4. Flow sheets PROGRESS NOTES
 - Provide information about the - Allows for an easy & focused way to
progress of a client is making toward set expectations for what will be
achieving desired outcomes. communicated & how between
members of the team, which is
NURSING DISCHARGE/REFERRAL essential for developing teamwork &
SUMMARIES fostering a culture of patient safety.
 Introduction
- Completed when the client is being
 Situation
discharged & transferred to another
 Background
institution or to a home setting where
 Assessment
a visit by a community health nurse
 Recommendation
is required.
INTRODUCTION
GENERAL GUIDELINES FOR
RECORDING - State your name, unit, & client name
1. Date & time SITUATION
2. Timing
3. Legibility - Briefly state the problem or situation
4. Permanence
5. Accepted terminology BACKGROUND
6. Correct spelling
- State client admission diagnosis &
7. Signature
date of admission
8. Accuracy
- State pertinent medical history
9. Sequence
- Provide brief summary of treatment
10. Appropriateness
to date
11. Completeness
- Code status
12. Conciseness
13. Legal prudence ASSESSMENT

 Reporting - Vital signs

- To communicate specific information - Pain scale
to a person or group of people - Is there a change from prior
assessments
CHANGE-OF-SHIFT REPORTS
RECOMMENDATION
 Hand-off Communication
- A process in which information about - State what you would like to see
patient/client/resident care is done or specify that the care
communicated in a consistent provider needs to come & assess
manner including an opportunity to the client
ask & respond to questions - Ask if health care provider wants to
order any tests or medications
ISBAR HAND-OFF COMMUNICATION - Ask health care provider if she or he
TOOL wants to be notified for any reason
 - Ask, if no improvement, when you  Purpose
should call again 1. Obtain information that will
help plan nursing care
 Telephone reports 2. Provide clients the
- The person receiving should opportunity to discuss their
repeat it back to the sender care
to ensure accuracy 3. Evaluate the nursing care the
- ISBAR is often used client has received
- Usually include client’s name
& medical diagnosis,
changes in assessment, vital
signs, significant laboratory
data & related nursing
interventions

 Telephone orders
- Write the complete order
down on the physician’s
order form & read it back to
the primary care provider
- Question any ambiguous &
unusual order
- Have the doctor verbally
acknowledge the read-back
of the telephone order
- Must be countersigned by
the doctor within a time
period based on agency
policy (24 hours)

 Care Plan Conference

- A meeting of a group of
nurses to discuss possible
solutions to certain problems
of a client, such as inability to
cope with an event or lack of
progress toward goal
attainment

 Nursing Rounds
- Are procedures in which two
or more nurse visit selected
clients at each client’s
bedside.