Documentation Principles

documentation skills in healthcare institutions

1. Documentation
Musa Abu Sbeih
Head of Nursing Affairs Department

2. Documentation Principles
•Comprehensive and flexible
•Quality and continuity
•Track patient outcomes
•Reflect current standards
•Patient identification on every page of the
record
•Date, time and name/initials, title of the

3. Client Record
•Permanent legal document
•Provides an ongoing account of care

4. Purpose of Records
•Communicate information accurately, effectively
and in a timely fashion.
•Financial billing.
•Education.
•Assessment.
•Research.
•Auditing.
•Legal record.

5. JCAHO Requirements
•Assessment of needs
–Physical
–Psychosocial
–ENVIROMENTAL
–Self care
–Client education
–Discharge plan

6. JCAHO Requirements
•Evaluation of outcomes
–Response to treatment
–Teaching
–Preventive care
–Client status
–Degree of progress
–Family involvement

7. Guidelines For Documentation
•Factual
•Accurate
•Complete
•Current
•Organized

8. Inaccurate Example
•Pt c/o stomach ache. Returned from x-ray 2
hours ago. Dr. Smith called for change in
medication order. Ate small amount of
breakfast. No relief from pain medication.
Up walking in hall, tolerated well.
Discharge planner in to talk with family
prior to going to x-ray.

9. Accurate Example
•C/o abd. pain 4/10 RUQ for two hours
becoming increasingly worse despite food
and fluids. Position change and walking
have not helped. Similar to previously dx
gallbladder pain. Denies n/v/d or other
symptoms. Declines pain meds at this time.
VS WNL. I to call if became worse.

10. Record Keeping Forms
•Nursing history (HX)
•Graphic or flow sheet
•Medication administration record
•Nursing KARDEX
•Acuity recording systems
•Standardized care plans
•Discharge summary

11. Narrative Documentation
•Problem oriented medical records (PMOR)
–Database
–Problem list
–Nursing care plan
–Progress note
•Source records

12. Progress Notes
•Soap(IE)
–Subjective
–Objective
–Assessment
–Plan
–INTERVETNION
–Evaluation
•Pie
–Problem, intervention, evaluation
•Dar:
–Data, action, response

13. CHARTING BY EXCEPTION:
All Standards Are Met Unless
Otherwise Documented
•Reduces repetition and time
•Shorthand for normal findings and routine
care
•Based on clearly defined standards and
criteria
•Predefined findings
•Predetermined interventions

14. Consequences Of Inadequate
Documentation
•Fragmented care
•Repetition of tasks
•Delayed therapy
•Omitted therapy
•Delayed recovery

15. Other Forms of Communication
•Team meetings
-Multidisciplinary team members share
information
-Members identify problems and solutions
•Consultation
-One professional gives advice to another

16. Patient Report
•Nurse to nurse report when providers
change.
•Nurse to nurse report at change of shift.
•Nurse to provider report for change of
condition or for instruction.
•Diagnostic reports from diagnostic
departments (x-ray, lab, etc.).

17. Long Term Care Documentation
•OBRA act
•Documentation
–Often done on flow sheets
–Less frequently
•Caregiver qualifications
•Assessments
•Individualized care plans
–Nursing care must be justified by the documentation

18. Computerized Documentation
•Legal risk of breaches of confidentiality
•Charting errors so nothing is deleted