Documenting, Reporting, Conferring, and Using

Characteristics of Effective Documentation
Consistent with professional and agency standards, Complete, Accurate, Concise, Factual, Organized and timely, Legally prudent, Confidential

What Is Confidential?
All information about
patients written on
paper, spoken aloud,
saved on computer “Name, address, phone, fax, social security
Reason the person is sick
Treatments patient receives”
Information about past health conditions

A nurse who fails to log off a computer after documenting patient care has breached patient confidentiality. T/F

A nurse who fails to log off a computer after documenting patient care has breached patient confidentiality.

Potential Breaches in Patient Confidentiality
Displaying information on a public screen,
Sending confidential e-mail messages via public networks,
Sharing printers among units with differing functions,
Discarding copies of patient information in trash cans,
Holding conversations that can be overheard,
Faxing confidential information to unauthorized persons,
Sending confidential messages overheard on pagers

A patient has the right to obtain, review, and revise the patient information in his or her health record.

A. True
B. False

B. False

A patient has the right to obtain and review, but not revise the patient information in his or her health record.

Patient can update but not revise certain aspects of their health record.

Patient Rights
See and copy their health record

Update their health record

Get a list of disclosures

Request a restriction on certain uses or disclosures

Choose how to receive health information

Policy for Receiving Verbal Orders in an Emergency
Record the orders in patient’s medical record.

Read back the order to verify accuracy.

Date and note the time orders were issued in emergency.

Record VO, the name of the physician followed by nurse’s name and initials.

Policy for Physician Review of Verbal Orders
Review orders for accuracy.

Sign orders with name, title, and pager number.

Date and note time orders signed.

Duties of RN Receiving a Telephone Order
Record the orders in patient’s medical record.

Read orders back to practitioner to verify accuracy.

Date and note the time orders were issued.

Record TO, full name and title of physician or nurse practitioner who issued orders.

Sign the orders with name and title.

One of the purposes of creating a patient record is to evaluate the quality of care patients have received and the competence of the nurses providing that care.

A. True

B. False

A. True

One of the purposes of creating a patient record is to evaluate the quality of care patients have received and the competence of the nurses providing that care.

Purposes of Patient Records
Communication with other healthcare professionals

Record of diagnostic and therapeutic orders

Care planning

Quality of care reviewing

Decision analysis


Legal and historical documentation


Purposes of Recording Data
Facilitate patient care.

Serve as a financial and legal record.

Help in clinical research.

Support decision analysis.






Zero after decimal point (i.e. 1.0)
Trailing zero (X.0mg)

Lack of leading zero (.X mg)

Methods of Documentation
Source-oriented records

Problem-oriented medical records

PIE charting

Focus charting

Charting by exception

Case management model

Computerized documentation

Electronic medical records (EMRs)

Which of the following methods of documentation is unique in that it does not develop a separate plan of care but instead incorporates the plan of care into the progress notes?

A. Source-oriented records
B. Problem-oriented records
C. PIE (problem, intervention, evaluation)
D. Focus charting

Answer: C. PIE (problem, intervention, evaluation)
PIE charting incorporates the plan of care into progress notes in which problems are identified by number.
In source-oriented records, each healthcare group keeps data on its own separate form.
Problem-oriented records are organized around patient problems rather than around sources of information.
Focus charting brings the focus of care back to the patient and the patient’s concerns.

Case Management Models
Collaborative pathways

Variance charting

Major Components of POMR
Defined database
Problem list
Care plans
Progress notes

Formats for Nursing Documentation
Initial nursing assessment

Kardex and patient care summary

Plan of nursing care

Critical collaborative pathways

Progress notes

Flow sheets

Discharge and transfer summary

Home healthcare documentation

Long-term care documentation

Types of Flow Sheet
Graphic record
24-hour fluid balance record
Medication record
24-hour patient care records and acuity charting form

PIE notes, SOAP notes, focus charting, and charting by exception are examples of which of the following formats for nursing documentation?

A. Critical/collaborative pathways
B. Progress notes
C. Flow sheets
D. Discharge summary

Answer: B. Progress notes
Progress notes inform caregivers of the progress a patient is making using the specified formats.
Critical/collaborative pathways are standardized plans of care developed for a patient with designated diagnoses.
Flow sheets are documentation tools included in the progress notes that record routine aspects of care.
Discharge summaries are clinical reports written to summarize the patient record.

Medicare Requirements for Home Healthcare
Patient is homebound and still needs skilled nursing care.

Rehabilitation potential is good (or patient is dying).

The patient’s status is not stabilized.

The patient is making progress in expected outcomes of care.

RAI = Resident Assessment Instrument (Long-term care)
Minimum data set


Resident assessment protocols

Utilization guidelines

Taylor – pgs. 347-348

Minimum Data Set
core set of screening, clinical and functional status elements that forms foundation of comprehensive assessment of all residents – Standardize communication about resident problems and condition. (Medicare requirement for certified facilities)

specific resident responses for one or a combination of minimum data set elements that identify residents who either have or are at risk for developing specific functional problems and who require further eval using Resident Assessment Protocols.

Resident Assessment Protocols
wanna RAP?) – structured, problem-oriented frameworks for organizing minimum data set info and examining additional clinically relevant info about a resident. Helps ID social, medical, nursing, and psychological problems and for the basis for individualized care planning

Utilization guidelines
specified in state operation manuals that instruct when and how to use the RAI.

Residents residing for longer than 14 days.

Residents residing for longer than 14 days.
Residents respond to individualized care.

Staff communication becomes more effective.

Resident and family involvement increases.

Documentation becomes clearer.

Change of Shift Report
Basic identifying information about each patient

Current appraisal of each patient’s health status
(Changes in medical conditions and patient response to therapy
Where patient stands in relation to identified diagnoses and goals)
Current orders (nurse and physician) and unfilled orders

Summary of each newly admitted patient

Report on patient transferred or discharged

Methods of Reporting
Face-to-face meetings
Telephone conversations
Written messages
Audio-taped messages
Computer messages

Conferring About Care
Consultations and referrals
Nursing and interdisciplinary team care conferences
Nursing care rounds

Benefits of Nursing Informatics
Increases in the accuracy and completeness of nursing documentation

Improvement in the nurse’s workflow and an elimination of redundant documentation

Automation of the collection and reuse of nursing data

Facilitation of the analysis of clinical data

Healthcare Technologies Developed by Nurses
Smart phones for perioperative nurses
Bedside medication system on PDA device
Vocere B2000 communications Badge

Page 352 Table 17-7 Taylor

Incident Reports A.K.A. Variance or occurrence report
When documenting in the chart, only state what happened. Do not use words, incident report, variance or occurrence report.

Be honest and factual.

Also complete facility form and submit to quality control and supervisor.

As a nursing student and or new nurse ask someone experienced to assist you.

Tool used to document occurrence of anything out of the ordinary hat results in or has the potential to result in harm to a patient, employee, or visitor.

Helps PREVENT future problems page 127-128 Taylor for example

What is the difference between incident reports and sentinel events
serious injury or death)

Situation, background (clinical background), Assessment (what is the problem), Request/Recommendation (What do I recommend/request to be done?)

many variations for different situations such as Nurse to Nurse, Nurse to Provider, Nurse to Radiology,

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