Communication of the Nursing Process: Documentation

1. Communication of the Nursing Process: Documentation Pamela Fowler, MS, RNC Assistant Professor Rogers State University

2. Why Document? • Professional responsibility • Legal protection • Regulatory standards • Reimbursement

3. Societal Factors Affecting Nursing Documentation • Increased consumer awareness • Increased acuity of hospitalized patients • Increased emphasis on outcomes

4. Trends in Charting • Reduction in duplicate charting • Bedside charting • Multidisciplinary charting • Clinical paths • More uniformity in documentation • Computerized documentation • Fax machines

5. Desired outcomes for documentation • The chart is legally sound • The chart reflects the nursing process • The chart describes the patient’s ongoing status from shift to shift • The plan of care and the chart complement one another

6. The documentation system is designed to facilitate retrieval of information for quality improvement activities and research. • The documentation system supports the staffing mix and acuity levels in the current healthcare environment

7. Charting systems • Effective and efficient charting has been an issue to nursing throughout history. • Numerous methods of charting have evolved over time. • More are evolving every day.

8. Narrative • A diary or story like approach to the recording of patient care • Are more efficient if used in combination with flowsheets for recording some repetitive data

9. Narrative • Advantages • familiar to most nurses • can be easily combined with other methods • if done correctly contains the complete NP • especially useful in emergent situations

10. Narrative • Disadvantages • lack of structure • task oriented and time consuming • information may be difficult to retrieve • does not always reflect critical thinking, decision making and analysis

11. SOAP charting • A problem oriented charting method • Subjective data • Objective data • Assessment • Plan

12. SOAP charting • Has been expanded to include • SOAPIE • add Interventions • add Evaluation • SOAPIER • add Revision

13. SOAP, SOAPIE, SOAPIER • Advantages • well structured • reflects the nursing process • easier to track particular problems for QI • can be used effectively with standard careplans • frequently used in the integrated plans

14. SOAP, SOAPIE, SOAPIER • Disadvantages • requires rethinking documentation process • seldom in its original form • can be redundant • not the most efficient for nurses • has met some resistance

15. PIE charting • Also problem oriented • Problem • Intervention • Evaluation • Originally designed to eliminate the traditional care plan and to integrate an ongoing care plan into documentation

16. PIE • Advantages • simplifies charting by using flow sheets • eliminates the traditional separate care plan • encourages use of some of NP • each problem identified is evaluated q shift • lends itself well to primary nursing • enhances professional credibility

17. PIE • Disadvantages • outcomes may not be prominently addressed • assumes all nurses practice at same level of sophistication and knowledge • how to incorporate the LPN as documentor • not well-suited to LTC or terminally ill • can create lengthy documentation if the patient has numerous problems

18. Focus charting • A method for organizing the narrative documentation to include data, action and response for each identified concern.

19. Focus • Advantages • provides structure • promotes documentation of NP • increases ease of locating information • encourages identification of patient concerns, not just problems • promotes analytical thinking

20. Focus • Disadvantages • can become a narrative note • requires a change in thinking • can be difficult to construct accurately and logically

21. Computerized Charting • One of the strongest trends in nursing documentation throughout the US and Canada. • Very common in the larger facilities in this area. • Smaller facilities may have no computer charting or may have only a portion of charting computerized.

22. Computerized charting • Advantages • Legible records • Readily available records • Improved nursing productivity • Reduction in record tampering • Support of use of the NP • Reduction in redundant documentation • Clinical prompts, reminders, and warnings

23. Computerized charting • Advantages, cont • Categorized nursing notes • Automatically printed reports • Documentation according to standards of care • Improved recruitment and retention of nurses • Improved knowledge of outcomes • Availability of data • Prevention of medication errors

24. Computerized charting • Disadvantages • Unfamiliar to users • Lack of portability • Problems with security and confidentiality • Disruptive computer downtime • Size of the record • Erroneous acceptance of information • Limitation of format

25. Computerized charting • Disadvantages, cont • Resistance • Inadequate numbers of terminals • Computer lag during peak usage time • Nurse’s difficulty in giving up worksheets • Cost

26. Charting by exception • Includes flowsheets, documentation by reference to standards of practice, protocols, a nursing data base, nursing diagnosis based care plans and SOAP progress notes

27. Charting by exception • Advantages • most current data available at bedside • flowsheets eliminate need for worksheets • guidelines can be printed on back of forms • trends are easily discerned • normal findings are precisely defined • repetitive charting of routine care eliminated • charting time is decreased • easily adapted to documentation on clinical paths

28. Charting by exception • Disadvantages • can require duplication of charting • works best with all RN staff • requires a major change in systems • requires a major educational effort • may impact reimbursement • may have legal ramifications

29. Legal Aspects of Charting • Document the clinically significant details • Sign every entry • Write neatly and legibly • Use proper spelling, grammar, and appropriate medical phrases • Document in blue or black ink and use military time

30. Legal • Use authorized abbreviations • Use graphic records to record vital signs • Record the patient’s name on every page • Chart promptly • Avoid block charting • Chart after delivery of care • Fill in blanks on chart forms

31. Legal • Document exact quotes • Eliminate bias from written descriptions of patients • Chart only care you provide or supervise • Do not tamper with records • Correctly identify late entries • Record only accurate information

32. Legal • Do not omit significant information from the chart • Correct mistaken entries properly • Do not rewrite the record • Do not lose or destroy medical records • Do not add to the notes of others • Do not use the medical record to criticize others

33. The Incident/Variance Report • Should be completed when any unusual occurrence warrants documentation • Record the details in objective terms • Do not admit liability of blame • Chart only what is observed firsthand • Describe actions taken to provide care • Do not include names/addresses of witnesses

34. Incident/Variance reports • Document time of incident, names of physician, supervisor and family members notified • Send the report to the persons designated by policy to review them • If additional information is found after filling out the form, file an amendment properly dated and signed.

35. Incident/Variance reports • What to put in the chart • factual, honest and objective description of the incident • Do not mention the incident/variance report in the charting • Include any statements made by patients or family particularly if the statements indicate that their actions contributed to the incident/variance.