Documenting and Reporting in Nursing Practice  Health institution or the agency is the rightful owner of the client’s record –

“ Effective communication among health professionals is vital to the quality of this does not, however, exclude the client’s rights to the same records
client care.”  For the purpose of education and research – student or graduate is bound by
a strict ethical code and legal responsibility to hold all information in
Definition of Terms confidence by not using a name or any statements in the notations that
 Discussion would identify the client
- Informal oral consideration of a subject by two or more health care
personnel Ensuring confidentiality of computer records
 Report Because of the increased use of Electronic Health Records, health care agencies
- Oral, written, or computer-based communication intended to convey have developed policies and procedures to ensure the privacy and confidentiality
information to others of client information stored in computers.
 Record  Personal password that is not to be shared
- Also called chart or client record  Never leave a computer terminal unattended after logging on
- Formal, legal document that provides evidence of a client's care  Do not leave client information displayed on the monitor where others may
- Can be written or computer-based see it
Recording, charting, or documenting  Shred all unneeded computer-generated worksheets
- Process of making an entry on a client record is called  Know facility's policy and procedure for correcting an entry error
 Follow agency procedures for documenting sensitive material
Documentation and Reporting  IT personnel must install a firewall to protect server from unauthorized access
 Reporting and recording
- are the major communication techniques used by health care providers. Purposes of Client Records
 DOCUMENTATION - Patient / Clients record provide the documented basis for planning
- serves as a permanent record of client information and care. patient care and treatment.
- is anything written or printed that is relied on as a record of proof for - Communication—Patient records are an important means by which
authorized persons. Documentation and reporting in nursing are needed physicians, nurses, and others communicate with one another about
for continuity of care. patient needs
- It is also a legal requirement showing the nursing care performed or not 1. Communication
performed by a nurse. 2. Planning client care
 REPORTING 3. Auditing health agencies
- takes place when two or more people share information about a client 4. Research
care, either face to face or by telephone. 5. Education
6. Reimbursement
Ethical and Legal Considerations 7. Legal documentation
The American Nurses Association Code of Ethics (2001) states that: - Admissible in court as evidence unless client objects because information
 Nurse is duty-bound to maintain confidentiality in all patient information client gives to primary care provider is confidential
 Client's record is protected legally as a private record of client's care 8. Health care analysis
 Access to the record is restricted to health professionals involved in providing - Identify agency needs such as overutilized and underutilized hospital
care to the client services
DOCUMENTATION SYSTEMS o assessments and interventions that apply to more than one
1. Source-Oriented Record problem must be repeated
- Traditional client record Components
- Each discipline makes notations in a separate section in the clients chart. The four basic components
- Information about a particular problem distributed throughout the  Database
record. - All information known about the client when the client first enters
- It is convenient because care providers can easily locate the forms on the health care agency
which to record data and it is easy to trace the information.  Problem list
- Narrative Charting is a traditionalpart of the source-oriented record. - Listed in order in which they are identified and others resolved
- EX, Emergency dept has an admission sheet; the physician has a
 Plan of care
physician’s order sheet and progress notes.
- Made with reference to active problems
Components of SOR
- Generated by individual who lists the problems
 Admission (face) sheet
 Progress notes
 Initial nursing assessment
- Made by all health professionals involved in a client's care
 Graphic record
- Numbered to correspond to the problems on the problem list and
 Daily care record
may be lettered for the type of data.
 Specific flow sheets
 Medication record - Uses SOAP, SOAPIE, SOAPIER documentation
 Nurses’ notes o S – subjective data
 Medical history and physical examination o O – objective data
 Physician’s order form o A – assessment – is the interpretation or conclusion drawn from
 Consultation records the SD and OD
 Client discharge plan and referral summary - initial assessment, this should be the statement of the problem
 Narrative charting - subsequent SOAP notes, this should describe the client’s condition and
o Written notes that include routine care, normal findings, and level of progress rather than restating the diagnosis or problem
client problems o P – plan
o Often chronologic o I – interventions
o E – evaluation
2. Problem-Oriented Medical Record o R – revision
- Data arranged according to client problem rather than the source of Example
information
 S – “My skin is always itchy on my back and arms, and it’s been like this
- Health team contributes to the problem list, plan of care, and progress
for a week.”
notes.
- Encourages collaboration and easy tracking of the status of each problem  O – skin appears clean, no rash nor irritations noted, scratch marks on
- D/A: both forearms, allergic to Leukoplast. No previous history of pruritus
o no charting format being followed  A – Alteration in comfort (pruritus): etiology unknown
o needs to be checked/updated every now and then  P – to promote comfort
 I – assess skin condition, apply lotion to prevent dryness, use mild soap,  Bedside chart forms – I & O, IVF flow sheet, TPR & BP monitoring
trim fingernails, apply calamine lotion as prescribed, refer for unusualities sheet
 E – client reported a reduction of itchiness, skin is moist and intact,
6. Computerized Documentation
absence of scratch marks
- Developed to manage volume
3. PIE of information
 Groups information into three categories - Used by nurses to:
o Problems  Store client's database, new
o Interventions data
o Evaluation  Create and revise care plans
 P - Consists of ongoing client assessment:  Document client's progress
o flow sheet - uses specific assessment criteria such as human - Information easily retrieved
needs and functional patterns - Speech-recognition technology
o progress notes - uses NANDA to word the problem  Nurse must be alert and
 D/A: nurse needs to review all the nurses notes to update herself which aware of others who might
ones were already performed and effective hear the dictation.
- Possible to transmit information
4. Focus Charting from one care setting to
- Focus on client concerns and strengths another
- Progress notes organized into DAR format
 Data 7. Case Management Model
- Assessment phase - Emphasizes quality, cost-
 Action effective care delivered within
- Planning and implementing phase established length of stay
- Uses multidisciplinary
 Response
approach, critical pathways,
- Evaluation phase
CBE
- Holistic perspective of client needs - Variance
- Nursing process framework for progress notes  A goal that is not met
- Documentation of variances
5. Charting by Exception (CBE) includes:
- Only abnormal or significant findings or exceptions to norms are recorded  Actions taken to correct the situation
- Incorporation of:  Justification of actions taken
 Flow sheets – graphic records such V/S sheet, I & O, IVF flow sheet, H
to T assessment etc. Documenting the Nursing Process
 Standards of nursing care - Describe client's ongoing status in record
- Reflect the full range of the nursing process
 Admission Nursing Assessment - Body temperature, pulse, respiratory
- Comprehensive admission assessment when client first admitted to rate, blood pressure, weight, other
nursing unit significant clinical data
- Ongoing assessments and reassessments recorded on flow sheets or  Intake and output
nursing progress notes - All routes measured and recorded
 Medication administration record
Nursing Care Plans
- Joint Commission requires clinical record to include: - Date of order, expiration date, name
o Evidence of client assessment and dose, frequency and route of
o Nursing diagnosis administration, nurse's signature
o Nursing interventions  Skin assessment record
o Client outcomes - Such as the Braden Assessment
o Current nursing care plans
 Traditional care plans
- Written for each client
 Standardized care plans
- Based on institutions standards of
practice

Kardexes
- Concise method of organizing and
recording data
- Series of cards kept in a portable
index file or on computer-generated
form
- Information quickly accessible
- Pertinent information about the client
arranged in sections
 Allergies
 List of medications including IV fluids
 List of daily treatments and procedures
 List of diagnostic procedures
 Physical needs to be met
 Stated goals

Flow Sheets
 Graphic record
Progress Notes Practice Guidelines for Long-Term Care Documentation
- Provide information about progress - Complete assessments, screening forms, and plan of care within the time
client is making toward achieving period
desired outcomes - Keep record of visits and phone calls
- Include information about client - Write nursing summaries and progress notes according to specified time
problems and nursing interventions periods
- Review and revise plan of care every 3 months or when status changes
Nursing Discharge/Referral Summaries - Document and report any change
- Completed when client discharged - Document all measures implemented in response to a change
 Terms that can be readily - Make sure progress notes address client's progress in relation to goals
understood
- Completed when client transferred to Home Care Documentation
another institution - Influenced by:
- Include some or all of the following:  Health Care Financing Administration (1985)
 Description of client's physical,  Medicare and Medicaid
mental, and emotional status  Other third-party payers
 Resolved health problems - Two records are required.
 Treatments to be continued  Home health certification and plan-of-treatment form
 Current medications  Medical update and patient information form
 Include restrictions that relate to Practice Guidelines for Home Health Care Documentation
activity, diet, and bathing  Complete a comprehensive nursing assessment and plan of care
 Functional/self-care abilities  Write a progress note at each visit
 Comfort level  Provide a monthly progress nursing summary
 Support networks  Keep a copy of the care plan in the client's home
 Client education  Practice Guidelines for Home Health Care Documentation
 Discharge destination  Report and document changes in plan of care
 Referral services  Encourage client or home caregiver to record data
Long-Term Care Documentation  Write a discharge summary
- Based on professional standards, federal and state regulations, policies of
health care agency General Guidelines for Recording
- Laws and requirements  Date and time
 Health Care Financing Administration - Conventional a.m./p.m. or 24-hour
 Omnibus Budget Reconciliation Act (OBRA) of 1987  Timing
 Medicare and Medicaid - No recording before providing care
- Recording must be done ASAP
  Legibility
- Must prevent interpretation errors
 Permanence
- Entries made in dark ink
 Accepted terminology
- When in doubt, write the term out fully
- May be different between agencies
 Correct spelling
- Look up in dictionary or resource book if unsure
 Signature
- Includes name and title  Accuracy
- Client’s name and identifying information should be stamped or written
on each page f the clinical record
- Before making an entry, check that the chart is the correct one
- Chart facts and observations, not opinions or interpretations
- Specific – use pain scale, measurements etc.
- When a recording mistake is made, draw a single line through it with your
initials; do not write the word “error”
- Do not erase, blot out, or use correction fluid; original entry must remain
visible
- Write on every line not in between lines, if a blank appears in a notation,
draw a line through the blank space so that no additional information can
be recorded
- Don’t chart for someone else
 Sequence
- Document events in the order they occur: assessment, intervention,
responses/evaluation
 Appropriateness
- Record only information that pertains to the client's health and care
- Recording irrelevant information may be considered invasion of privacy
 Completeness
- Information recorded must be complete and helpful
- Include care that is omitted because of client's condition, refusal
(document what was omitted, why it was omitted, and who was notified)
 Conciseness
 - No extra details - Clearly state what
- Client's name and "client" omitted you’re requesting. Be
 Legal prudence specific about
- Usually viewed by juries and attorneys in court as a legal document suggested action and
- Documentation - best evidence of what really happened to the client time frame. In verbal
communication, repeat
Reporting
back any order for
- To communicate specific information to a person or group of people
greatest accuracy.
 Change-of-shift reports
Making a
- "Handoff" communication
recommendation can
- Information communicated in a consistent manner including an
be as simple as saying,
opportunity to ask and respond to questions
“I’d like you to check
- Provide basic identifying information
on this patient.”
 Features
- Two way, face-to-face communication
- Written support tools
- Content in handover which captures intention
 SBAR tool and verbal report

SBAR
S – situation; B – background; A – assessment; R – recommendation
- easy-to-use standardized tool to improve communication that lets nurses
send a complete message to doctors concerning a patient’s condition
- less room for human error because of its accuracy
 Situation
- Create a brief statement of the problem. The word “brief” here is key. A
big part of SBAR is removing irrelevant information. Make sure to identify
yourself, your unit, and give the patient’s name.
 Background  Telephone reports
- Give a concise overview of the situation. This may include diagnoses, - Be concise and accurate; use SBAR tool
medical history, dates, medication info, or names of physicians involved. - Have chart ready to give any further information needed
Basically, anything that’s relevant. - The nurse receiving a telephone report should document date, time,
 Assessment name of the person giving the information, subject of the information
- Sum up what you think is going on. Consider results of any lab tests. If received, name and signature of the person who received the report
you can’t create a clear assessment, just say that. - The receiver should repeat the information to the sender to ensure
 Recommendations accuracy
 Telephone orders
- Many agencies only allow registered nurses to take telephone orders.
- Nurse writes down the order on the physician’s order form/sheet and
read it back to the physician to ensure accuracy
- Ask question or clarify if in doubt or orders are ambiguous/unusual
- Have physician verbally acknowledge the read back of the
verbal/telephone order
- Indicate on the physician’s order form/sheet that it is a verbal order (VO)
or telephone order
- Have the physician countersign within a time per agency policy; usually
within 24 hours

 Care plan conference

- A meeting of a group of nurses to discuss possible solutions to certain
problems of a client
- Allows each nurse the opportunity to offer an opinion about possible
solutions
- Other health care providers invited to offer expertise
 Nursing rounds
- Two or more nurses visit selected clients at bedside.
- Obtain information that will help plan nursing care and evaluate care
given
- Provides clients opportunity to discuss their care
- Need to use terms client can understand
 Vital Signs (Cardinal Signs) o Equipment should be functional and appropriate for the size and age
 Vital signs reflect the body’s physiologic status and provide information of the client
critical to evaluating homeostatic balance o Know the client’s usual range of VS
 Includes: o Know the complete history of client
o Temperature o Control and minimize environmental factors which affect patient’s VS
o Pulse rate o Use an organized, systematic approach
o Respiratory rate o Approach client in calm, caring manner while demonstrating
o Blood pressure proficiency in handling equipment
 VS may reveal sudden changes in client’s condition in addition to changes o Record all the data accurately and analyze it
that occur progressively overtime. A baseline set of VS are important to o Know the VS from the previous shift, to evaluate patient’s condition
identify changes in the patient’s condition o Verify and communicate significant changes
 VS are part of a routine physical assessment and are not assist in isolation,
other factors such as physical signs and symptoms are also considered Temperature
 Purpose - Hotness or coldness of the body
o To obtain base line data about the patient condition - Balance bet. heat and production & heat loss of the body
o For diagnostic purpose - Normal using oral: 37 d C/98.6 d F
o For therapeutic purpose - Two kinds:
o To plan and implement the nursing care 1. Core T
o To understand the effectiveness of the treatment - Temperature of internal organs and it remains constant most of the
o To modify or change the mode of treatment time (37 d C); range of 36.5-37.5 d C
o To understand the present problem or health condition of the patient - Temperature of the deep tissues of the body
 Times to Assess VS - Relatively constant
o On admission – to obtain baseline data - Measure with thermometer
o When a client has a change in health status or reports symptoms such 2. Surface T
as chest pain or fainting - Temperature of skin, subcutaneous tissue, fat cells and it rises and
o According to a nursing or medical order falls in response to the environment (ranges bet. 20-40 d C)
o Before and after the administration of certain medications that could - It doesn’t include internal physiology
affect RR or BP and CVS - Body continuously produces heat as by product of metabolism. when the
o Before and after surgery or an invasive diagnostic procedure amount of heat produced by the body equal to the heal lost, the person is
o Before and after any nursing intervention that could affect the vital in heat balance
signs/ E/g/ ambulation Factors affect the body’s heat production:
o According to hospital or other health institution policy 1. Basal metabolic rate (BMR) – decrease with age. In general, the younger
 Basic guidelines for measuring VS the person, the higher the BMR
o The nurse caring for the client is responsible for VS assessment 2. Muscle activity (exercise) – voluntary movement can increase metabolic
rate up to 2000 times, and heat production can increase up to50 times
than normal
 3. Thyroxine output – increase thyroxine output increases the rate of 5. Hormones – women usually experience more hormone fluctuations than
cellular metabolism throughout the body men. In women, progesterone secretion at the time of ovulation raise
4. Strong emotions body temp, by about 0.3-0.6 d C above basal temp.
5. Fever/disease condition – increases cellula metabolic rate, thus incrwses Sites to measure temp.
the body’s temp. Thermometer: an instrument to measure body temperature
Alterations in Body temp. 1. Oral – by putting thermometer under the tongue
 Normal: 37 d C/98.6 d F; range: 36-38 d C/96.8-100 d F  0.65 less than rectal T and 0.65 greater than axillary T
 Fever (high temperature) or Hypothermia (low temperature) – abnormal  Leave 3-5 minutes
 Pyrexia, fever: 38-41 d C/100.4-105.8 d F  Most common site fro temp measurement
 Hyper pyrexia, very high fever: 41 d C > 42 d C – leads to death  Inconvenient for:
 Hypothermia: 34-35 d C < 34 d C – death o Unconscious patients
Common types of Fevers o Infants and children
1. Intermittent fever – body temp. alternates at regular intervals bet. o Patients with ulcer or sore of the mouth
periods of fever and periods of normal or subnormal temp. o Pts with persistent cough
2. Remittent fever – wide range of temp. fluctuation (more than 2 d C)  Adv: easy access, pt comfort
occurs over the 24 hr period, all of which are above normal  Disadv: lead to false reading if a person has taken hot/cold food/drink
3. Relapsing fever – short febrile periods of a few days are interspersed with by mouth, has smoked (wait 10-15 min after meal/smoke)
periods of 1 or 2 days of normal temp.  Contraindication:
4. Constant fever: body temp. fluctuates minimally but always remains o Pts who cannot follow instruction to keep their mouth closed
above normal o Child below 7 yrs
Factors affecting body temp. o Epileptic or mentally ill patients
1. Age – infant is greatly influenced by the temp in the environment, and o Unconscious
must be protected from extreme changes. older people are also o Clients receiving O2
particularly sensitive to extremes in the environmental temp. due to o Clients with persistent cough
decrease thermoregulatory controls o Uncooperatice or in severe pain
2. Diurnal variations – body temp. normally change throughout theday, o Surgery of the mouth
varying between the early morning and late afternoon. The point of o Nasal obstruction
highest temp. is usually reached between 8pm and midnight, and lowest o If pt has nasal or gastric tubs in place
point is reached during sleep between 4:00 and 6:00 AM 2. Rectal – inserting the thermometer into the rectum or anus
3. Exercise – hard work and strenuous exercise can increase body temp. to  Gives reliable measurement & reflects the core body temp.
as high as 38.3 – 40 d C  3-5 minutes
4. Stress – stimulation of sympathetic nervous system can increase the  More accurate, most reliable, is >0.65 d C/ 1 d F higher than the oral
production of epinephrine and norepinephrine therby increasing temp, bcos few factors can influence the reading
metabolic activity and heat production  DIsadv: injure the rectum, need privacy, inappropriate for pts with
diarrhea & anal fissure
  Contraindications:
o Rectal or perennial surgery
o Fecal impaction
o Rectal infection
o Newborn infants
3. Axillary – safe and non-invasive
 Recommended for infants and children
 Disadv: long time (5-10 min)
 Less accurate as it is not close to major vessels
 Considered the least accurate & least reliable of all the sites bcos the
temp obtained can be influenced by a number of factors e.g. bathing,
friction during cleaning
 Route of choice in pt’s that cannot have their temp measured by
other routes
4. Tympanic – core body temp.
 Imprecise
5. Temporal artery – inconsistent reliability
ROUTE NORMAL RANGE D F/D C SITES
Oral 98.6 d F/37.0 d C Mouth
Tympanic 99.6 d F/37.6 d C Ear
Rectal 99.6 d F/37.6 d C Rectum
Axillary 97.6 d F/36.6 d C Axilla

Types of thermometer
 Electronic
 Chemical disposable
 Infrared (tympanic)
 Scanning infrared (temporal artery)
 Temperature-sensitive tape
 Glass thermometer