Chapter 7
Documentation of Nursing Care
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.
Chapter 7
Lesson 7.1
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.
Learning Objectives
Theory
1)Identify three purposes of documentation.
2)Correlate the nursing process with the process of
charting.
3)Discuss maintaining confidentiality and privacy of paper
or electronic medical records.
4)Compare and contrast the five main methods of written
documentation.
Clinical Practice
1)Correctly make entries on a daily care flow sheet
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved. Slide 3
Purposes of Documentation
Provides a written record of the history,
treatment, care, and response of the patient
while under the care of a health care provider
Is a guide for reimbursement of costs of care
May serve as evidence of care in a court of
law
Shows the use of the nursing process
Provides data for quality assurance studies
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved. Slide 4
Purposes of Documentation(cont’d)
Is a legal record that can be used as
evidence of events that occurred or
treatments given
Contains observations by the nurses about
the patient’s condition, care, and treatment
delivered
Shows progress toward expected outcomes
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved. Slide 5
Documentation and the Nursing Process
Written nursing care plan or interdisciplinary
care plan is framework for documentation
Charting organized by nursing diagnosis or
problem
Implementation of each intervention
documented on flow sheet or in nursing notes
Evaluation statements placed in nurse’s
notes and indicate progress toward the stated
expected outcomes and goals
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved. Slide 6
The Medical Record
Contains data about patient’s stay in a facility
Only health care professionals directly caring
for the patient, or those involved in research
or teaching, should have access to the chart
Patient information should not be discussed
with anyone not directly involved in the
patient’s care
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved. Slide 7
Methods of Documentation
(Charting)
Source-oriented (narrative) charting
Problem-oriented medical record (POMR)
charting
Focus charting
Charting by exception
Computer-assisted charting
Case management system charting
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved. Slide 8
Source-Oriented or Narrative
Charting
Organized according to source of information
Separate forms for nurses, physicians,
dietitians, and other health care professionals
to document assessment findings and plan
the patient’s care
Narrative charting requires documentation of
patient care in chronologic order
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved. Slide 9
Source-Oriented or Narrative
Charting (cont’d)
Advantages
Information in chronologic order
Documents patient’s baseline condition for each shift
Indicates aspects of all steps of the nursing process
Disadvantages
Documents all findings: makes it difficult to separate
pertinent from irrelevant information
Requires extensive charting time by the staff
Discourages physicians and other health team
members from reading all parts of the chart
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved. Slide 10
Example of Source-Oriented
(Narrative Charting)
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved. Slide 11
Problem-Oriented Medical Record
Charting (POMR)
Focuses on patient status rather than on
medical or nursing care
Five basic parts: database, problem list, plan,
progress notes, and discharge summary
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved. Slide 12
Problem-Oriented Medical Record
Charting (POMR) (cont’d)
Advantages
Documents care by focusing on patients’ problems
Promotes problem-solving approach to care
Improves continuity of care and communication by
keeping relevant data all in one place
Allows easy auditing of patient records in
evaluating staff performance or quality of patient
care
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved. Slide 13
Problem-Oriented Medical Record
Charting (POMR) (cont’d)
Disadvantages
Results in loss of chronologic charting
More difficult to track trends in patient status
Fragments data because more flow sheets
required
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved. Slide 14
PIE Charting
P—problem identification
I—interventions
E—evaluation
Follows the nursing process and uses nursing
diagnoses while placing the plan of care
within the nurses’ progress notes
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved. Slide 15
Example of PIE (Problem, Intervention,
Evaluation) Charting
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Question 1
Monica, a nurse in the operating room, knows
that charting must be all of the following except:
1)subjective.
2)accurate.
3)brief.
4)complete.
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved. Slide 17
Chapter 7
Lesson 7.2
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.
Lesson Objectives
Theory
4)Compare and contrast the five main methods
of written documentation. (continued)
5)List the legal guidelines for recording on
medical records.
6)Relate the approved way to correct entries in
medical records that were made in error.
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved. Slide 19
Lesson Objectives
Clinical Practice
2)Document the characterization of signs or
symptoms in a sample charting situation.
3)Use a systematic way of charting to ensure that all
pertinent information has been included.
4)Apply the general charting guidelines in the
clinical setting.
5)Navigate electronic medical records and
document care correctly.
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved. Slide 20
Focus Charting
Directed at nursing diagnosis, patient
problem, concern, sign, symptom, or event
Three components:
D: data, A: action, R: response (DAR)
OR
D: data, A: action, E: evaluation (DAE)
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved. Slide 21
Focus Charting (cont’d)
Advantages
Compatible with the use of the nursing process
Shortens charting time: many flow sheets,
checklists
Disadvantages
If database insufficient, patient problems missed
Doesn’t adhere to charting with the focus on
nursing diagnoses and expected outcomes
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved. Slide 22
Example of Focus Charting
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Charting by Exception
Based on the assumption that all standards of
practice are carried out and met with a normal
or expected response unless otherwise
documented
A longhand note is written only when the
standardized statement on the form is not met
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved. Slide 24
Charting by Exception (cont’d)
Advantages
Highlights abnormal data and patient trends
Decreases narrative charting time
Eliminates duplication of charting
Disadvantages
Requires detailed protocols and standards
Requires staff to use unfamiliar methods of
recordkeeping and recording
Nurses so used to not charting that important data
is sometimes omitted
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved. Slide 25
Computer-Assisted Charting
Electronic health record (EHR)
Computerized record of patient’s history and care
across all facilities and admissions
Computerized provider order entry (CPOE)
Provides efficient work flow
Automatically routes orders to appropriate clinical
areas
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved. Slide 26
Computer-Assisted Charting (cont’d)
Documentation done as interventions are
performed using bedside computers
Variations depending on the system
Some produce flow sheets with nursing
interventions and expected outcomes
Others use a POMR format to produce a
prioritized problem list
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved. Slide 27
Computer-Assisted Charting (cont’d)
Advantages
Date and time of the notation automatically recorded
Notes always legible and easy to read
Quick communication among departments about
patient needs
Many providers have access to patient’s information
at one time
Can reduce documentation time
Reimbursement for services rendered is faster and
complete
Can reduce errors
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved. Slide 28
Computer-Assisted Charting (cont’d)
Disadvantages
Sophisticated security system needed to prevent
unauthorized personnel from accessing records
Initial costs are considerable
Implementation can take a long time
Significant cost and time to train staff to use the
system
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved. Slide 29
Case Management System Charting
A method of organizing patient care through
an episode of illness so clinical outcomes are
achieved within an expected time frame and
at a predictable cost
A clinical pathway or interdisciplinary care
plan takes the place of the nursing care plan
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved. Slide 30
Accuracy in Charting
Be specific and definite in using words or
phrases that convey the meaning you wish
expressed
Words that have ambiguous meanings and
slang should not be used in charting
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved. Slide 31
Brevity in Charting
Sentences not necessary
Articles (a, an, the) may be omitted
The word “patient” omitted when subject of
sentence
Abbreviations, acronyms, symbols acceptable
to the agency used to save time and space
Choose which behaviors and observations
are noteworthy
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved. Slide 32
Legibility and Completeness in
Charting
If writing not legible, misperceptions can
occur
Be sure to include as much information as
needed
Completeness is more important than brevity
(see Boxes 7-1 through 7-3 for charting
guidelines)
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved. Slide 33
The Kardex
Not a part of the permanent medical record
A quick reference for current information
about the patient and ordered treatments
Usually consists of a folded card for each
patient in a holder that can be quickly flipped
from one patient to another
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved. Slide 34
Information on the Kardex
Room number, patient name, age, sex, admitting
diagnosis, physician’s name
Date of surgery
Type of diet ordered
Scheduled tests or procedures
Level of activity permitted
Notations on tubes, machines, other equipment in use
Nursing orders for assistive or comfort measures
List of medications prescribed by name
IV fluids ordered
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved. Slide 35
Question 2
John is reviewing the Kardex on his patient. Which
statement is not true regarding the Kardex?
1)A Kardex is a work tool rather than a required part
of the medical record.
2)A Kardex does need to be kept up to date.
3)A Kardex will have information such as room
number, date of surgery, diet, medications, etc.
4)A computerized patient care system will definitely
have a Kardex for each patient.
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved. Slide 36
Question 3
Madison, a pediatric nurse, prefers charting by exception.
She realizes all of the following are true except:
1)charting by exception was developed in 2005 by a group of
nurses at St. Luke’s Medical Center in Sarasota, Florida.
2)the goal is to decrease the lengthy narrative entries of
traditional systems.
3)charting by exception is based on the assumption that all
standards of practices are carried out.
4)a longhand note is written only when the standardized
statement on the form is not met.
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved. Slide 37
Question 4
Mrs. Smith, LPN, has just charted the following
assessment on her patient.
2/14/2008 3:00 PM VS stable. Voided 450 mL clear straw-
colored urine. Pt denies pain but appears tired. Amy Smith,
LPN
Which of the following entries is incorrect?
1)Time of entry
2)Nurse stating an opinion
3)No line before name
4)All of the above
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved. Slide 38
Question 5
Sally went into her patient’s room to administer an antibiotic.
Her patient states, “I am not going to take another pill
because they aren’t working.” What should Sally do?
1)Leave the pill on the bedside table and come back in a few
minutes.
2)Throw the pill in the trashcan.
3)Circle the medication on the medication record, give a
reason for the refusal in the progress notes, and notify the
physician.
4)Crush up the medication in the patient’s food and inform the
charge nurse.
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved. Slide 39
