NCM 103 (Week 2)

Documentation &
Reporting
Client care

Presentation By: GCastillo

 Objectives
• Discuss purposes for client records.
• Compare and contrast different documentation methods: source-oriented and
problem-oriented medical records, PIE, focus charting, charting by exception,
computerized records, and the case management model.
• Discuss guidelines for effective recording that meet legal and ethical standards.
• Identify essential guidelines for reporting client data.
Key Terms

• Client record
• Documentation • SOAPIE/SOAPIER
• Focus charting • Source-oriented record
• Narrative notes • End-shift report
• PIE charting • Incident report
• Problem-oriented record • Referral
• Progress notes
 Recording , Charting, Documenting
• The process of making an • A record, a chart or client record -
entry on a client record. is a formal, legal document that
provides evidence of a client’s
care and can be written or
computer based.
✓Nursing assessments and
interventions can be recorded by
RNs and which can be charted by
unlicensed personnel.
PURPOSES OF CLIENT RECORDS

• Communication
• Planning Client Care
• Auditing Health Agencies • Reimbursement
• Research • Legal Documentation
• Education • Health Care Analysis
DOCUMENTATION SYSTEMS

1. Source-Oriented Record or 2. Problem-Oriented Medical

a traditional client record. Record
 DOCUMENTATION SYSTEMS
Source-Oriented Record or a traditional client
record
▪ Information about a
particular problem is
distributed throughout the • admission sheet;
record. • physician’s order form, a
physician’s history sheet, an
progress notes;
▪Narrative charting • nurses’ notes; and
is a traditional part • Other departments or personnel
of SOR. have their own records.
Narrative charting
Example:
Documentation System:
Problem-Oriented Medical Record or
Problem Oriented Record (POR)

•Established by Lawrence Weed (1960)

•Data are arranged according to the problems
the client has rather than the source of the
information.
•Members of the health care team contribute to
the problem list, plan of care, and progress
notes
 POMR
Disadvantages:
Advantage :
✓encourages ✓caregivers differ in their ability to
use the required charting format,
collaboration and
✓ it takes constant vigilance to
✓the problem list in the maintain an up-to-date problem list,
front of the chart alerts and
caregivers to the client’s ✓ it is somewhat inefficient because
needs and makes it assessments and interventions that
easier to track the apply to more than one problem
status of each problem must be repeated.
Four basic components of POMR:
 DATABASE
Includes:
• nursing assessment,
• history, social and family data,
• the results of the physical examination and baseline
diagnostic tests.

✓Data are constantly updated as the client’s health

status changes
PLAN OF CARE

• The written plan in the record is listed under each

problem in the progress notes and is not isolated as
a separate list of orders;
Includes:
✓Physician’s orders or medical care plans;
✓Nurses write nursing orders or nursing care plans.
PROGRESS NOTES

• Are numbered to correspond to

the problems on the problem
list and may be lettered for the
type of data;
• SOAP format is frequently used
(subjective, objective,
assessment, planning)
 Formats of Data in the Progress Notes
• Focus charting
• SOAP format
• SOAPIE
• SOAPIER
I—Interventions refer to the specific interventions
that have actually been performed by the
caregiver.
E—Evaluation includes client responses to nursing
interventions and medical treatments. This is
primarily reassessment data.
R—Revision reflects care plan modifications
suggested by the evaluation. Changes may be
made in desired outcomes, interventions, or target
dates
Example:
Formats of documentation
F- focus may be a condition,
• Focus Charting - make the a nursing diagnosis, a
client and client concerns and behavior, a sign or
strengths the focus of care. symptom, an acute change
• Provides a holistic perspective in the client’s condition, or a
of the client and the client’s
needs client strength.
D- data
(subjective/objective)
A- action
R- response
Computerized Documentation
Electronic Health Records (EHRs) or
COMPUTER-BASED CLIENT RECORDS

• To store the client’s database, add new data, create and revise care
plans, and document client progress.
• To record nursing actions and client responses, the nurse either
chooses from standardized lists of terms or types narrative
information into the computer.
✓Multiple flow sheets are not needed in computerized record
systems because information can be easily retrieved in a variety of
formats.
 4 ways to improve health care using EHR
(1) constant availability of client
health information across the life • BEDSIDE DATA ENTRY
span,
(2) ability to monitor quality Allow recording of:
(3) access to warehoused (stored) ✓medication administration
data
✓Assessments, progress notes,
(4) ability for clients to share in
knowledge and activities care plan updating, client
influencing their own health acuity, and accrued charges.
• The nurse is using a laptop
computer to record data at the
client’s bedside.
GENERAL GUIDELINES FOR RECORDING

Rule #1: Date and Time

• Record the time in the conventional manner (e.g.,
9:00 am or 3:15 pm) or according to the 24-hour
clock (military clock).
Rule #2: Timing
• As a rule, documenting should be done as soon as
possible after an assessment or intervention.
Rule #3: Legibility
• All entries must be legible and easy to read to
prevent interpretation errors.
 GENERAL GUIDELINES FOR RECORDING
Rule #4: Permanence
• All entries on the client’s record are made in dark ink so
that the record is permanent and changes can be
identified.
Rule #5: Accepted Terminology
• Use only commonly accepted abbreviations, symbols,
and terms that are specified by the agency.
• Abbreviations are convenient; however, they are often
ambiguous.
 GENERAL GUIDELINES FOR RECORDING
Rule #6: Correct Spelling
• Is essential for accuracy in recording.
Rule #7: Signature
• Each recording on the nursing notes is signed by the nurse
making it. Includes the name and title; for example,
“Susan J. Santos, RN” or “SJ Santos, RN.”
• Some agencies have a signature sheet and after signing
this signature sheet, nurses can use their initials.
• With computerized charting, each nurse has his or her
own code.
 GENERAL GUIDELINES FOR RECORDING
Rule #8: Accuracy
• The client’s name and identifying information should be
stamped or written on each page of the clinical record.
Rule #9: Sequence
• Record assessments, then the nursing interventions, and
then the client’s responses.
Rule #10: Appropriateness
• Record only information that pertains to the client’s
health problems and care
 GENERAL GUIDELINES FOR RECORDING
Rule #11: Completeness
• The information helpful to the client and health care
professionals.
Rule #12: Conciseness
• Be brief as well as complete to save time in
communication.
Rule #13: Legal Prudence
• Admissible in court as a legal document, the clinical
record provides proof of the quality of care given to a
client.
• Best evidence of what really happened to the client
Legal & Ethical Implications of Documentation

✓You protect your patient’s interests- as well

as your own.
✓The failure to document appropriately has
been a pivotal issue in malpractice cases.
✓Although the actual medical record & other
records belong to the facility, the information
contained in them belongs to the patient,
who has the right to obtain a copy of the
materials
Tools in Reporting
client care
Guidelines / Protocols
Definition: REPORTING

• Oral or written or computer-based communication

intended to convey information to others
• Should be concise, including pertinent information but no
extraneous detail.
•ISBARR
•Change of shift report
•Incident Report
•Referral system
 Tools in Reporting
ISBARR • Ensures accurate handover of
information between shifts.
•SBAR originally
developed by the U.S. • It gives clinicians a specific,
Navy as a way to unambiguous way to
communicate critical
communicate information to one another,
information on leaving little room for error
and minimizing the chance
nuclear submarines. that a miscommunication will
cause patient deterioration.
ISBARR for Nurses

I-Introduce Yourself: Introduce yourself and your role in the patient’s

care
State the unit you are calling from when speaking with a physician over
the phone.
(S) Situation: What is the situation you are calling about? Identify self,
unit, patient, room number. Briefly state the problem, what is it, when
it happened or started, and how severe.
ISBARR for Nurses

(B) Background: Pertinent background information related to the

situation could include the following:
✓The admitting diagnosis and date of admission.
✓List of current medications, allergies, IV fluids, and labs.
✓Most recent vital signs.
✓Laboratory results: provide the date and time test was done and results of
previous tests for comparison.
✓Other clinical information.
✓Code status
ISBARR for Nurses

(A) Assessment: What is the nurse's assessment of the situation?

• Give a summary of the patient’s condition. Explain what you think the
problem is.
ISBARR for Nurses

(R) Recommendation: What is the nurse's recommendation or what

does he/she want?
Examples:
✓Notification that patient has been admitted
✓Patient needs to be seen now or Order change
ISBARR for Nurses

(R) Read Back: Document the change in the patient's condition and
health care provided.

ISBARR

Identify

Situation

Background

Assessment

Recommendation

Read Back

Name of nurse:
Name of nurse:
Date contacted:
Signature:
 Example: Obstetric unit
Identify Patient’s MRN and
Staff nurse Gee, OB unit
Situation ➢ Reason for admission (eg Excessive vomiting @12 weeks)
➢ Diagnosis if known (eg Active stage of labor)
➢ Mode of delivery and date (eg Cesarian Section for CTG changes)
➢ Operation and date (eg Vag hysterectomy + A/P repair)
Background Relevant previous history eg Elective CS for breech, allergic to penicillin,
any social issues of note
Assessment Latest clinical assessment, clinical & investigations eg IE: 4 cm ROT -1 @
7.30
Urine output, Labs, Hb B/P, pulse, temperature and respirations, pain score,
patient anxiety
Recommendation Actions required after handover (eg Call surgeon for urgent consult –
specify level of urgency with timeframe; “Dr Samuel to discuss situation
with patient and partner at 10:00am”)
Risks - eg eclampsia
Assign individual responsibility for conducting any task
Read Back
 Tools in Reporting
Change of Shift Report
• The “handoff” communication - a process in which
information about patient/client/resident care is
communicated in a consistent manner including an
opportunity to ask and respond to questions.
Three important features:
1. “two way, face-to-face communication
2. written support tools
3. content in handover which captures intention
 Key Elements for Effective Handoff
Communication
• The communication • Method for verifying the
should include the information (e.g., repeat-back,
following: read-back techniques)
• Up-to-date information • Minimal interruptions
• Opportunity for receiver of
• Interactive information to review relevant
communication allowing client data (e.g., previous care and
for questions between treatment)
the giver and receiver of
client information
Tools in Reporting
Incident Report
• “An unusual occurrence About:
report” • accidents or incidents,
• Used to make all facts • occurrence of client
available to agency infection or
personnel, to contribute
to statistical data. • the loss of personal
effects

• To help health personnel

prevent future incidents or
accidents.
Guidelines to avoid unusual occurrence of I.R
Tools in Reporting
Referral System
Referral Guidelines
Thank you!