Documentation - Recording & Reporting

Documentation - recording & reporting

Definition:

Documentation is anything written or printed that is relied on as record or proof for authorized persons.

Or

It is a permanent written or computer based communication, that document the information relevant to client's health care management.

A medical record should furnish all health care providers with a concise, accurate, written picture of a client's medical and nursing problems, care planned and the care given, and the client's response to treatment.

The chart or healthcare record is a legal record.

The process of adding written information to the chart is called recording or documentation.

Documentation is a part of the implementation phase of the nursing process and is necessary for the evaluation of client.

Purposes:

1.       Communication: The primary purpose of documentation of clients care is communication among health personnel to promote continuity of care. The record should be the most current and accurate source of information about a clients health care status.

2.       Care planning: Each healthcare professional utilizes the data from the client record to plan care for the client. Nurses use baseline and ongoing data to evaluate the effectiveness of the nursing care plan. Client record also points out the health problems of the country and provides a baseline for local, state, national and international health service planning.

3.       Quality review & Auditing: Charts may be reviewed to evaluate the quality of care received and the competence of the nurse providing that care. A regular review of information in client record gives a basis for evaluation of the quality and appropriateness of care provided in the hospital. Nurses monitor or review records through the year to determine the degree to which quality improvement standards are met.

4.       Research: Statistical data relating to the frequency of clinical disorders, complications, use of specific medical and nursing measures, deaths and recovery from illness can be gathered from the client record. The record can be studied by researchers who are hoping to learn from study of similar cases.

5.       Education: Healthcare professionals and students reading a clients chart can learn a great deal about the clinical manifestations of particular health problems, effective treatment methods etc.

6.       Legal documentation: Client records are legal documents that may be entered in to court proceedings as evidence. The record can also be used in accident or injury claims made by the client.

7.       Financial billing & reimbursements: The medical record is the document that shows the extent to which hospital should be reimbursed for services , it is a client bill. Client records are also used to demonstrate to payers that client received the care for which reimbursement is being sought.

8.       Vital statistics: Client record, registers and reports provide the vital statistics and give information needed to evaluate the services rendered by the agency to the community.

Guidelines for quality documentation:

·         Factual: A record must contain descriptive, objective information about what a nurse sees, hears, feels and smells. The use of inferences without supporting data is not acceptable because it is misunderstood. The use of vague terms such as "appears seems" or "apparently" is not acceptable. A subjective description when recording subjective data document the client's words within quotation.

·         Accurate: Every entry in the records should be accurate. It is essential to avoid the use of unnecessary words and irrelevant detail.

·         Date and time: Document the date and time of each recording.

·         Correct spelling: E.g. Walk patient in hell.

             Fecal heart tones heard.

             Patient observed to be seeping quietly.

·         Appropriateness: Record only information that pertains to the client's health  problems and care. E.g.: Physician Note "If the nurses would learn to read medication orders, we would have a lot fewer emergencies around here"

"Patient in extreme pain because previous nurse too busy to give pain meds"

·         Completeness. E g: May shower with nurse

                   Skin-Somewhat pale but present

·         Conciseness or brevity

·         Legal aspect

·         Legibility

·         Organization

·         Sequence and timings

·         Corrections

·         Signature

·         Abbreviations

·         Confidentiality

Legal guidelines for recording

1.       Do not erase, apply correction fluid or scratch out errors made while recording

2.       Draw single line through error, write error above it and sign your name. Then record correctly

3.       Enter only objective description of client behavior. Client's comments should be quoted.

4.       Avoid rushing to complete charting be sure information is accurate.

5.       Do not leave blank spates in the nurse's notes.

6.       Chart only for yourself.

7.       If order is questioned then record that clarification was sought.

8.       Begin each entry with time and date of entry & end with your signature, title.

9.       Record immediately after the event.

10.   Do not share passwords.

11.   All records should be written with blue or black ink or typed for better

Types of records:

·         Outpatient and inpatient record:

Out-patient record is filled in the out-Patient department. This will contain the biodata of the patient, diagnosis, family history of past and present illness, signs and symptoms etc.

In-patient record is the record which is maintained when the patient gets admitted in the hospital.

·         Nursing records:

It is record of the treatment and nursing measures carried out by the nurse, their effects and observations made on the patient.

·         Medical records:

It is regarding the medication investigation and diet the patient should receive.

·         T. P.R records:

In this temperature, pulse and respiration are written in graphic form so that the slight deviation from the normal can be noted at a glance.

·         Lab records:

·         Intake output records:

·         Records of physiotherapy occupational therapy and other specific treatment.

·         Registers:

To maintain statistical measures every hospital maintains certain register such as birth, death, admission and discharge etc.

Methods of recording:

·         Source-oriented records:

·         One in which each healthcare group keeps data on its own separate forms

·         Each reader must consult various parts of the record to get a complete picture

·         Narrative charting:

Everything that went on that day and that time.

E.g 3.09.14 - 7:30Am patient awake, alert, sitting up in bed, vital signs taken, IV site right hand has redness. 8:30 Am 100% of full liquid breakfast taken. 9:00 Am partial bath at bedside, pt tolerated sitting in chair for 30 mins without fatigue.-Ms. B. ()SN.

E.g Patient stated "I am scared for surgery. Last time I had lot of pain when I got out of bed". Discussed measures for pain control and importance of postoperative activity. Pt stated "I feel better prepared now".

·         Problem oriented medical records (POMR): Originated by Dr. Lawrence Weed in the 1960s

·         It is organized around a patient's problems rather than around sources of information. All caregivers may contribute to problem list. Fosters collaboration an-long the health team members.

·         It has 4 major sections : database, problem list, care plan and progress notes

·         SOAP

S- subjective data

O- objective data

A- assessment

P- plan

I-     Intervention

E- evaluation

E.g: S- "I am scared for surgery. Last time I had lot of pain when I got out of bed".

O- asking frequent questions about surgery. Wife present and supportive

A- deficient knowledge regarding surgery

P- explain routine preoperative preparation. Demonstrate & explain rationale for turning, coughing and deep breathing exercises post operatively.

PIE

P- problem

I- intervention

E- evaluation

E.g P- deficient knowledge regarding surgery

I- explained routine preoperative preparation.

E- Pt demonstrated & explained rationale for turning, coughing and deep breathing exercises post operatively correctly.

·         Focus charting:

·         Here the patient and patient concerns are the only focus. The focus may be the condition, a behavior, or change in client's condition.

·         The progress notes are organized into- DAR

·         D- data

·         A- action or nursing intervention

·         R- response of the patient.

·         E.g D- "I am scared for surgery. Last time I had lot of pain when I got out of bed". Asking frequent questions about surgery. Wife present and supportive

·         A- explained routine preoperative preparation.

·         R- Pt demonstrates & explaines rationale for turning, coughing and deep breathing exercises post operatively correctly. States feeling better.

·         Charting by exception:

In which only abnormal or significant findings or exceptions are recorded Focuses on documenting deviations from established norms.

The nurse writes a progress note only when the standardized statement on the form is not met.

·         Case management model/Critical pathways.

Common record keeping forms:

·         Graphic sheets and flow charts: Certain routine observation of specific measurements made repeatedly is called flow sheets. It provides quick and easy reference for assessing the changes in client's status.

·         Kardex and client care summary:

o   Nursing information needed for the daily care of the client is accessible in nursing kardex.

o   It contains information concerning the client's current ongoing plan of care.

o   Information commonly found in the kardex card include:

·         Basic demographic data

·         Primary medical diagnosis

·         Physicians order

·         Nursing care plan

·         Nursing interventions

·         Scheduled tests and procedure

·         Safety precautions

·         Standardized care plans:

·         It is based on institutions standards of nursing practice.

·         It is preprinted established guidelines used to care client with similar health problems.

·         After assessment staff nurse identifies the standard care plans appropriate for the patient.

·         It is prepared by a group of expert clinicians.

·         Discharge summary form:

It provides important information pertaining to the clients continued health care after discharge, the reason for hospitalization, significant findings, client's status and specific health teaching plans. It makes the summary concise and instructive.