MODULE 10

GUIDELINES AND PROTOCOL IN DOCUMENTATION

AND HEALTH CARE RECORS

LEARNING OBJECTIVES:
At the end of the lesson, the students will be able to:

a Compare and contrast different documentation methods use in recording

patient care.
b. Identify and discuss guidelines for effective recording that meets legal and
ethical standards.
c. Identify essential guidelines for reporting client data.

INTRODUCTION

Effective communication among health care professional is vital to

quality of care, generally health care professional communication through
discussion, reports and records. A discussion is an informal oral consideration
of a subject by two or more health care personnel to identify the problems
or establish the strategies to resolve the problems. A report is an oral,
written computer- based communication intended to convey information
two other. A record is written or computer-based, the process of making an
entry on the client record is recording, charting and documenting.

Time allotment/ duration:

3hrs per session

Core-Related values and Biblical Reflection:

Service
Psalms 9: 2-3 The Lord will judge the word with justice

LEARNING CONTENT
Topic Content:
Unit 1 - Purpose of Documentation
Unit 2 - Characteristic of Good Documentation
Unit 3 Common Record-Keeping Form
Unit 4 Methods of Documentation
 Documentation is defined as written evidence of:
*Interaction between and among health professional, clients and
families and health care organization.
*The administration of tests, procedures, treatments and client education.
*The results of client’s response to these diagnostic tests an intervention.
- a referred as charting, involves entering patient data in the client’s
record requires the use a clear and complete words.

PURPOSES OF DOCUMENTATION
COMMUNICATION
Documentation in medical records serves as the foundation for communication
among health care providers, as a continuous and contemporaneous records,
it forms of the care delivered, the treatment and care planned, and the result
of the care. Documentation allows health care professionals and other care
providers to use up-to-date, consistent date and care goals to ensure
continuity of care. Documentation that is clear, full accurate, and factual offers
a trustworthy, permanent record of patient treatment and accurate record of
the patient’s health care history.
* Documentation - as communication
Reporting and recording are the major communication technique
used by health care providers.
-serves as a permanent record of client information and care.
Reporting takes place when two or more people share information
about client care, either face to face or by telephone.

ACCOUNTABILITY
Documentation demonstrate responsibility and chronicles the clinical
professional practice. It can be used to establish who is responsible for
providing care and to address issues or concerns about the care that is
necessary. The clinician’s paperwork, may be used in performance
evaluation, internal organizational investigations and \or legal processes
(such as civil lawsuits).

LEGISTALTIVE REQUIRMENTS
Nurses and midwives are obligated to create and maintain records of their
professional practice in compliance with their profession’s standards of
Practice as well as organizational policy and procedure. Keep and maintain
documentation records are required, falsifying documentation, providing
incomplete or inaccurate documentation, and signing or issuing a document
that the person knows or suspects to be false or misleading may all be deemed
unprofessional by a regulatory authority.
QUALITY IMPROVEMENT
Documentation can be used to assess professional practice as part of quality
assurance procedures including performance evaluation, audits and
accreditation processes, mandated inspections and critical incident reviews.
Clinical professionals can also utilize this information to reflect on their practice
and make evidence-based improvements. Documentation provides proof of
the high quality of care and services provided to the public.

RESEARCH
Medical record documentation is a major source of data for health researcher.
It contains information about medical interventions, analyzes patient outcomes
and is a compact record that is required for reliable research data and
evidence-based practice.

FUNDING AND RESOURCE MANAGEMENT

Date extracted and classified from medical record may be utilized as a useful
tool for determining the sort of treatment that patients require, the services
given, and the efficiency and efficacy of care. Any of these issues might have
an effect on financing and resource distribution. Documentation of interventions
that is accurate and complete is a significant source of evidence and reasoning
for financing and resource management.

MAINTAINING QUALITY DOCUMENTATIONPRACTICE

Clinical staff, medical record staff, and hospital maintenance have a shared
responsibility and legal accountability to create and maintain environments
that support competent clinicians in providing quality, evidence-based
outcomes for patients as partners in efforts to achieve a quality practice
setting. These documentation recommendations urge employee, medical
record and clinical personnel, and others to implement strategies, policies,
procedures that promote successful documentation practices in the work
place.

Education- enhance students learning thru review of client’s record, serves

as an educational tool for students in health discipline
Research- provides valuable health- related data for research.
Legal Documentation- serves to provide proof what exactly happened to
the patient.
Audit and Quality Assurance- monitors the quality of care received by the
client and the competence of health care givers.
Statistics- provides statistical information that can be utilized for planning
people’s future needs.
Planning Client Care- provides data which the entire health care team uses
to plan care for the client.
 Reimbursement- provides the basis for decisions regarding care to be
provided and subsequent reimbursement to the agency,
to cover health related expenses.

CHARACTERISTICS OF GOOD DOCUMENTATION

Factual – contains descriptive, objective information
Accurate- uses clear and exact measurements
Complete- includes updated chart entries based on the facility’s standard
Current – entries of data are all up to dates
Organized – contains data categorized or organized in a hospital standard.
Properly Signed- includes nurses with full named and credentials
Properly Corrected Error- corrected data entries are properly labeled
“ERROR”

COMMON RECORD-KEEPING FORM

Admission Nursing History Form- guides the nurses to facilitate assessment and
identification of nursing diagnosis.

Flow Sheets – enable health team members to assess client’s status and
treatment

Kardex- contains routine information on the client’s activity and treatment

Acuity Records – guide for determining the duration of care and the number of
staff needed to provide care to groups of clients

Standardized Care Plans- facilitates the establishment of guidelines which are

used for clients with similar health problems

Discharged Summary Form- provides the summary of instructions for the clients
and family on various aspects of the clients’ health status.

METHODS OF DOCUMENTATION
Narrative Charting- descriptive account written chronologically in paragraphs
and contains details of client’s heath condition, interventions and
treatment and client’s response to treatment.

Source Oriented Charting- narrative recording of each member of the health

team using separate sheets

Problem-Oriented Charting – logical method of documentation composed of:

database, problem list, plan of care, progress notes
can be recorded or written in SOAP\ SOAPIER.
Pie Charting- a direct form of charting composed of flow sheets, progress notes,
plan of care (problem, intervention, evaluation)

Focus Charting- utilizes a column format for data subjective \objective, action –
intervention, response to the client.

Charting y Exception- narrative form of charting in which only the significant

findings are documented.

Computerized Charting- utilizing nursing information system that facilitates

documentation using computers.

Point- of-Care-Charting- a portable bedside computer facilitates immediate

input and retrieval of client’s data.
FDAR- F-focus (one of the sign and symptoms)
D- data (subjective \ objective data)
A-action - implementation
R-result or result

SOAPIE – Subjective
Objective
Assessment (nursing diagnosis)
P- Planning
I-Implementation
E- Evaluation

Elements of Effective Documentation

*Abbreviation and symbols

* Organization – start every entry with data and time
chart in chronological order
chart medication immediately after administration
sign your name after each entry
*Accuracy- use descriptive terms to chart exactly what was observed
or done, correct spelling and grammar
*Documenting a medication error
*name and dosage of the medication
*name of the practitioner who was notified of the error
*time of notification
*nursing intervention and medication treatment
client’s response to treatment
 *Confidentiality – nurse is responsible for protecting the privacy and
confidentiality of client interactions assessment, and care
*Factual- it contains descriptive, objective information about what
a nurse sees, hears and smells
*Complete- the information within the record must be complete
containing appropriate and essential information
*Current- timely entries are essential in patients ongoing care.
Delay in documentation leads to unsafe patient care.
*Organizes- communication information in a logic order.

IMPORTANCE OF MEDICAL RECORDS

a.past medical history and present condition
b. communication tools for a health care team
c. legal documentation
d. patient and staff education
e.quality control and research
f. documentation for billing and coding

APPROPRIATE DOCUMENTATION PROMOTES

Hight standard of clinical care.
Continuity of care.
Improved communication and dissemination of information between
And across services providers.
An accurate account of treatments, interventions and care plan.
Improve goal setting and evaluation of care outcomes.
Improved early detection of problems and changes in health status.
Evidence of patient care.