Chapter 37 Documenting and Reporting

1. Chapter 37Documenting and Reporting

2. The Health Record • The health record is a manual or electronic account of a client’s relationship with a healthcare facility. • The nurse, being the primary caregiver, must record client information clearly, accurately, and frequently. • The commonly used term for documentation is “charting.” • The client’s health record is usually called the “chart.”

3. The Health Record (cont’d) • Accurate and complete documentation in the client’s health record is an essential communication tool. • It is used: • To maintain effective communication among all caregivers • To provide written evidence of accountability • To meet legal, regulatory, and financial requirements • To provide data for research and educational purposes • To document health status*

4. Communication • The health record is a communication tool: • Helps caregivers to exchange information with one another • Offers the client documentation and verification of his or her own health status • It includes information about the client’s condition, treatments, responses to treatments, and plans and instructions for treatment of the client.

5. Accountability • The health record is documented evidence that the healthcare agency and providers have acted responsibly and effectively. • Legal requirements and protection • It is a legal record. • Regulatory requirements • To prove the agency has met standards of care • *Financial accountability • Enables third-party payers to reimburse the facility • Record all treatments given, examinations administered, and special equipment used

6. Research and Education • Healthcare planners examine health records of individuals and groups to determine patterns of illness, trends, or effective treatment strategies. • Health records, particularly those kept in computer databases, provide excellent research opportunities in healthcare. • It is also an excellent educational tool.

7. Documentation Systems • The health record is either a manual (paper) document, an electronic document, or a combination of both. • Electronic documents are located in a medical information system (MIS), which is housed in a computer network. • Another documentation system is referred to as electronic medical records (EMRs).

8. Manual and Computerized Documentation • Manualrecords • Can be kept at the client’s bedside for convenience; documents all important data • *Documents assessment data, care plans, medications, treatments, vital signs • Computer records • Can simultaneously be transmitted to a physician’s office or to a distant location for interpretation • All information included in the MIS or EMR is similar to that found in the manual record. • Requires knowledge of use of the computer system • Speed and convenience in data entry *

9. Contents of the Health Record • The health record contains four general categories of information. • Assessment documents • RAP’s, MDS* • Plans for care and treatment • Progress records • Describes clients treatments, responses to treatments and unusual events • Plans for continuity of care • Review health record • Document appearance, behavior and response • A client’s healthcare information should be confidential.

10. Contents of the Health Record (cont’d) • Formats of written documentation are based on assessment, nursing diagnosis, planning and goal setting, implementation/interventions, and evaluation. • Flow sheet • Medication administration record

11. Contents of the Health Record (cont’d) • Plans for continuity of care forms are used to ensure that the client’s care is consistent and effective. • Teaching record • Transfer form/screen • Summarizes clients condition and responses to treatment to prepare for transfer to another unit, facility or community agency • Discharge/transfer summary

12. Documentation Formats • Narrative–chronological • Progress notes, nurses’ notes, narrative charting • Usually done every 2 hours or more • Problem-oriented (focus) • Focuses on specific problems* • SOAP, SOAPIER, APIE, PIE, DAPE, DARP, and DARE • Discipline area documentation • Charting by exception (CBE) • Ex. Lung sounds

13. Documentation Formats (cont’d) • System flow sheet • *list most common normal and abnormal findings, less chance of leaving out info • Case management • Critical pathway • Collaborative pathway • Care mapping • Graphic flow sheet • Medication administration record (MAR)

14. Advantages and Disadvantages • Narrative charting • Very thorough and detailed • Time-consuming • Documentation by discipline • Helps providers in each subspecialty find their own forms quickly and follow the progress of their therapies without having to read notes from other disciplines • Can be difficult to monitor data as a holistic view of the client

15. Advantages and Disadvantages (cont’d) • Charting by exception • Efficient, especially for the client who is physically stable with an uncomplicated care plan • May be a disadvantage when a legal defense claim, such as negligence, is necessary • Case management or critical pathways • Client is the focus of case study, achieves specific outcomes identified in a multidisciplinary team approach, may not be suitable for a client with special or complex individual needs.

16. Advantages and Disadvantages (cont’d) • *Medication administration record (MAR) • Lists all medications that the physician has ordered for the client, as well as other information • Used by nonlicensed personnel as well as licensed nurses

17. Data Commonly Found on a Flow Sheet • Vital signs, intake and output • Activities of daily living (ADLs) • Dietary or eating patterns • Neurologic checks (“neuro checks”) • Restraint observation and documentation • Frequent blood sugar monitoring • Postoperative records • Wound care and monitoring

18. Guidelines for Documentation** • Document what you see. • Be specific. • Use direct quotes. • Be prompt. • Be clear and consistent. • Record all relevant information. • Respect confidentiality. • Record documentation errors. • SEE Table 37-4, 37-5

19. Recording Documentation Errors • In case of an error in documenting, the nurse should cross out the incorrect statement with a single line, enclose it in parentheses, and write ERROR and initials next to it. • Some agencies recommend using recorded in error (RIE) instead. Other agencies use the term “mistaken entry.” • After filling in the term that the agency uses, record the correct statement. • The EMR has a mechanism for “late entries,” in which the nurse may identify an earlier error.

20. Reporting of Information • “Report-off”—the nurse summarizes the activities and conditions of assigned clients because he or she is leaving the unit for a break or at the end of a shift. • May be very brief or quite detailed • *Change-of-shift reporting is a means of exchanging information between the outgoing and incoming staff on each shift. • In walking rounds, caregivers move from client to client, discussing pertinent information.