8/7/2019 Documentation 123

1/17

Module 10Module 10--123123

DocumentingDocumenting

Recording OR ChartingRecording OR Charting

Prepared by:Mervat MohamedPrepared by:Mervat Mohamed

King Saud UniversityKing Saud University

College of NursingCollege of Nursing

Medical Surgical DepartmentMedical Surgical Department

8/7/2019 Documentation 123

2/17

DOCUMENTINGDOCUMENTING

A report:A report: is oral, written, oris oral, written, orcomputercomputer--based communicationbased communication

intended to convey information tointended to convey information to

others. For instance, nurses alwaysothers. For instance, nurses alwaysreport on clients at the end of areport on clients at the end of a

hospital work shift.hospital work shift.

8/7/2019 Documentation 123

3/17

DOCUMENTINGDOCUMENTING

A record:A record: is written or computeris written or computer--based. Allbased. Allpersonnel involved in a patients health carepersonnel involved in a patients health care

contribute to the medical record bycontribute to the medical record by chartingcharting,,

recordingrecording, or, ordocumentingdocumenting ((process of writing informationprocess of writing information))

on the health agencys forms.on the health agencys forms.

Medical recordMedical record, also called a chart or client record, is a, also called a chart or client record, is a

formal, legal document that provides informationformal, legal document that provides information

about a persons health problems, the care providedabout a persons health problems, the care provided

by health practitioners, and the progress of theby health practitioners, and the progress of the

patient. Although health care organizations usepatient. Although health care organizations usedifferent systems and forms for documentation, alldifferent systems and forms for documentation, all

client records have similar information.client records have similar information.

8/7/2019 Documentation 123

4/17

DocumentingDocumenting

A.A. Communication:Communication: patients record serves as thepatients record serves as thevehicle by which different members of the health teamvehicle by which different members of the health teamcommunicate and share information with each other.communicate and share information with each other.

B.B. Assessment:Assessment: nurses and other health team membersnurses and other health team membersgather assessment data from the patients record.gather assessment data from the patients record.

C.C. Planning patient care:Planning patient care: the entire health team usesthe entire health team usesdata from the patients record to plan care for thedata from the patients record to plan care for thepatient.patient.

D.D. Education & research:Education & research: nursing students, medicalnursing students, medicalstudents and other health team members often usestudents and other health team members often use

patient record as an educational tools. It provides apatient record as an educational tools. It provides acomprehensive view of the patients health status. Thecomprehensive view of the patients health status. Theinformation contained in a record can be a valuableinformation contained in a record can be a valuablesource of data for research.source of data for research.

Purposes of client recordsPurposes of client records

8/7/2019 Documentation 123

5/17

DocumentingDocumenting

E.E. Legal documentation:Legal documentation: the clients record is athe clients record is alegal document and is usually admissible in courtlegal document and is usually admissible in court

as evidence.as evidence.

F.F. Health care analysis:Health care analysis: records can be used torecords can be used toestablish the costs of various services and toestablish the costs of various services and to

identify those services that cost the agencyidentify those services that cost the agency

money and those that generate revenue.money and those that generate revenue.

G.G. Auditing health agencies:Auditing health agencies: patients record ispatients record isused to monitor the care received by the patientused to monitor the care received by the patient

and the competence of people giving that care.and the competence of people giving that care.

Purposes of client recordsPurposes of client records

8/7/2019 Documentation 123

6/17

DocumentingDocumenting

1.1. SourceSource--Orient Records:Orient Records: records organizedrecords organizedaccording to the source of documented information.according to the source of documented information.

This type of record contains separate forms on whichThis type of record contains separate forms on which

physicians, nurses, dietitians, physical therapists, andphysicians, nurses, dietitians, physical therapists, and

so on. One of the criticisms of sourceso on. One of the criticisms of source--oriented recordsoriented records

is that it is difficult to demonstrate that there is ais that it is difficult to demonstrate that there is a

unified, cooperative approach for resolving theunified, cooperative approach for resolving the

patients problems among caregivers.patients problems among caregivers.

2.2. ProblemProblem--Orient Records:Orient Records: records organizedrecords organizedaccording to the patients health problems. Problemaccording to the patients health problems. Problem--

oriented records contain four major components: theoriented records contain four major components: thedata base, the problem list, the plan of care, anddata base, the problem list, the plan of care, and

progress notes (progress notes (Table 1Table 1). The information is arranged). The information is arranged

to emphasize goalto emphasize goal--directed care, and to facilitatedirected care, and to facilitate

communication among health care professionals.communication among health care professionals.

Types of Patient RecordsTypes of Patient Records

8/7/2019 Documentation 123

7/17

DocumentingDocumenting

Purposes of client recordsPurposes of client records

ComponentComponent DescriptionDescription

DatabaseDatabase Contains initial health informationContains initial health information

Problem listProblem list Consists of a numeric of the patientsConsists of a numeric of the patientshealth problemshealth problems

Plan of carePlan of care Identifies methods for solving eachIdentifies methods for solving eachidentified health problemidentified health problem

Progress notesProgress notes describes the patients response to whatdescribes the patients response to what

has been done & revisions to the initialhas been done & revisions to the initialplanplan

Table 1Table 1 common components of a problemcommon components of a problem--oriented recordoriented record

8/7/2019 Documentation 123

8/17

DocumentingDocumenting

1.1. Narrative charting:Narrative charting: Narrative charting (Narrative charting (style ofstyle ofdocumentation generally used in sourcedocumentation generally used in source--oriented recordsoriented records))

involves writing information about the patient andinvolves writing information about the patient and

patient care in chronologic order. (patient care in chronologic order. (Figure 1Figure 1))

Methods of ChartingMethods of Charting

Nursing NotesNursing Notes

Date/timeDate/time Nurses RemarksNurses Remarks

13.30 pm13.30 pmStates I am having chest pain. Its like anStates I am having chest pain. Its like an

elephant is sitting on me B. Zook, RNelephant is sitting on me B. Zook, RN

13.40 pm13.40 pm Skin is pale & moist. O2 started at 5L/minSkin is pale & moist. O2 started at 5L/minNitroglycerin tablet administered sublingualNitroglycerin tablet administered sublingual

Figure 1Figure 1 Sample of narrative chartingSample of narrative charting

8/7/2019 Documentation 123

9/17

DocumentingDocumenting

2.2. SOAP chartingSOAP charting:: SOAP charting (SOAP charting (documentation styledocumentation stylemore likely to be used in a problemmore likely to be used in a problem--oriented recordoriented record))

acquired its name from the four essential componentsacquired its name from the four essential components

included in a progress note:included in a progress note:

* S : subjective data* S : subjective data

* O : objective data* O : objective data

* A : analysis of the data* A : analysis of the data

* P : plan for care* P : plan for care

SOAP charting helps to demonstrate interdisciplinarySOAP charting helps to demonstrate interdisciplinary

cooperation, because everyone involved in the care ofcooperation, because everyone involved in the care of

a patient makes entries in the same location in thea patient makes entries in the same location in thechart. (chart. (Table 2Table 2))

Types of Patient RecordsTypes of Patient Records

8/7/2019 Documentation 123

10/17

DocumentingDocumenting

Types of Patient RecordsTypes of Patient Records

LetterLetter ExplanationExplanation Nurses RemarksNurses Remarks

SubjectiveSubjective Information reported by the patientInformation reported by the patient SS -- Dont feel wellDont feel well

ObjectiveObjective Information reported by the nurseInformation reported by the nurse OO -- Temperature 38CTemperature 38C

AnalysisAnalysis Problem identificationProblem identification AA FeverFever

PlanPlan Proposed treatmentProposed treatment PP Increased fluid intake & MonitorIncreased fluid intake & Monitorbody temperaturebody temperature

TableTable 2 SOAP Charting format2 SOAP Charting format

8/7/2019 Documentation 123

11/17

DocumentingDocumenting

Focus charting:Focus charting: Focus charting (Focus charting (modified form of SOAPmodified form of SOAPChartingCharting) uses the word focus rather than problem,) uses the word focus rather than problem,

because some believe that the word problem carriesbecause some believe that the word problem carries

negative connotations.negative connotations.

Focus charting used DAR model:Focus charting used DAR model:D = data category reflects the assessment phase ofD = data category reflects the assessment phase of

the nursing processthe nursing process

A = action category reflects planning & implementationA = action category reflects planning & implementation

phase of the nursing process.phase of the nursing process.

R = response category reflect the evaluation of theR = response category reflect the evaluation of the

nursing process (nursing process (Figure 2Figure 2).).

DAR notation tends to reflect the steps in the nursingDAR notation tends to reflect the steps in the nursing

process.process.

Types of Patient RecordsTypes of Patient Records

8/7/2019 Documentation 123

12/17

DocumentingDocumenting

Types of Patient RecordsTypes of Patient Records

6/6/20066/6/2006 DD ((datadata)) -- Bladder distended 2 fingers above pubisBladder distended 2 fingers above pubis

10.15 am10.15 am Has not urinated since catheter was removedHas not urinated since catheter was removed

AA ((actionaction)) Assisted to toilet. Water turned on at faucetAssisted to toilet. Water turned on at faucet

RR ((responseresponse))-- voided 525ml of clear urine L. Cass, SNvoided 525ml of clear urine L. Cass, SN

Figure 2Figure 2 Example of DAR chartingExample of DAR charting

8/7/2019 Documentation 123

13/17

DocumentingDocumenting

4.4. PIE charting:PIE charting:

PIE charting is method of recording the patients progressPIE charting is method of recording the patients progress

under the headings of problem, intervention, and evaluation.under the headings of problem, intervention, and evaluation.

When the PIE method is used, assessments are documentedWhen the PIE method is used, assessments are documented

on separate form and the patients problems are given aon separate form and the patients problems are given acorresponding number (corresponding number (Figure 3Figure 3).).

Types of Patient RecordsTypes of Patient Records

Date/timeDate/time Nurses RemarksNurses Remarks

6/66/6

8.30 am8.30 am

P# 1 crackles heard on inspiration in the basesP# 1 crackles heard on inspiration in the bases

of R and L lungs.of R and L lungs.

I# 1 splinted with pillow.I# 1 splinted with pillow.

Instructed to breathe deeply, open mouth, and

cough at the end of expiration.

E# 1 Lungs clear with coughing. L Cass, HN

Figure 3Figure 3 Sample of PIE chartingSample of PIE charting

8/7/2019 Documentation 123

14/17

DocumentingDocumenting

5.5. Computerized Charting:Computerized Charting:

Computerized charting (Computerized charting (documentingdocumenting

patient information electronicallypatient information electronically) is most) is most

useful for nurses when a terminal isuseful for nurses when a terminal isavailable at the point of care or besideavailable at the point of care or beside

Types of Patient RecordsTypes of Patient Records

8/7/2019 Documentation 123

15/17

DocumentingDocumenting

Because the clients record is a legal document and may beBecause the clients record is a legal document and may be

used to provide evidence in court, many factors areused to provide evidence in court, many factors are

considered in recording.considered in recording.

1.1. Data & Time:Data & Time: Documenting the date and time of eachDocumenting the date and time of eachrecording. This is essential not only for legal reasons but alsorecording. This is essential not only for legal reasons but also

for client safety. Record the time in the conventional mannerfor client safety. Record the time in the conventional manner(e.g.(e.g. 9:009:00 am oram or3:203:20 pm) or according to the 24pm) or according to the 24--hours clockhours clock

(military clock).(military clock).

2.2. Timing:Timing: follow the agencys policy about the frequency offollow the agencys policy about the frequency ofdocumenting, and adjust the frequency as a clients conditiondocumenting, and adjust the frequency as a clients condition

indicates; for example, a client whose blood pressure isindicates; for example, a client whose blood pressure is

changing requires more frequent documentation than a clientchanging requires more frequent documentation than a clientwhose blood pressure is constant.whose blood pressure is constant.

3.3. Legibility:Legibility: all entries must be legible and easy to readall entries must be legible and easy to readto prevent interpretation errors.to prevent interpretation errors.

General Guidelines for RecordingGeneral Guidelines for Recording

8/7/2019 Documentation 123

16/17

DocumentingDocumenting

4.4. Performance:Performance: all entries on the clients record are made inall entries on the clients record are made indark ink so that the record is permanent and changes can bedark ink so that the record is permanent and changes can be

identified.identified.

5.5. Accepted Terminology:Accepted Terminology: use only commonly accepteduse only commonly acceptedabbreviations, symbols, and terms that are specified by theabbreviations, symbols, and terms that are specified by the

agency.agency.

6.6. Correct Spelling:Correct Spelling: correct spelling is essential for accuracycorrect spelling is essential for accuracyin recording. If unsure how to spell a word, look it up in ain recording. If unsure how to spell a word, look it up in a

dictionary.dictionary.

7.7. Signature:Signature: each recording on the nursing notes is signed byeach recording on the nursing notes is signed bythe nurse making it. The signature includes the name andthe nurse making it. The signature includes the name and

title; for example, title; for example, Susan j. Green, RNSusan j. Green, RN or or SJ Green, RNSJ Green, RN8.8. Sequence:Sequence: documenting events in the order in which theydocumenting events in the order in which they

occur; for example, record assessments, then the nursingoccur; for example, record assessments, then the nursing

interventions, and then the clients responses.interventions, and then the clients responses.

General Guidelines for RecordingGeneral Guidelines for Recording

8/7/2019 Documentation 123

17/17

DocumentingDocumenting

9.9. Accuracy:Accuracy: the clients name and identifying informationthe clients name and identifying informationshould be written on each page of the clinical record.should be written on each page of the clinical record.

Accurate notations consist of facts or observations ratherAccurate notations consist of facts or observations rather

than opinions or interpretations. It is more accurate, forthan opinions or interpretations. It is more accurate, for

example, to write that the client example, to write that the client refused medicationrefused medication ( (factfact))

than to write that the client than to write that the client was uncooperativewas uncooperative ( (opinionopinion))

General Guidelines for RecordingGeneral Guidelines for Recording

GGoooodd LLucuckk