Learning Objectives
1. State the reasons for maintaining a written and continuous health record.
2. List the categories of information that are included in the health record.
3. Discuss the advantages and disadvantages of both manual and computerized documentation.
4. Discuss the goal, content, and procedure of writing progress notes.
5. Differentiate among the following types of charting in progress notes: narrative, SOAP, sOApIER, APIE, PIE, DAPE, DARP, DARE, and CBE.
6. State the advantages and disadvantages of the following types of documentation: narrative, problem-oriented, discipline area, charting by exception, case management, critical pathways, and medication administration records.
7. Identify the data that are commonly found on a How sheet.
8. State eight guidelines that are generally accepted for documentation.
9. Practice using descriptive terms, abbreviations, and acronyms commonly used in charting.
10. Identify and differentiate the regulations and method of documenting for the following: an error in charting, a late entry, and an error that occurred regarding care for a client.
11. Describe the process and content of reporting information to nurses. Discuss how this type of report differs from communicating to other members of the healthcare team.
|
IMPORTANT TERMINOLOGY |
||
|
case management |
graphic flow sheet |
problem-oriented |
|
change-of-shift reporting |
medication administration |
medical records |
|
charting by exception |
record |
progress notes |
|
electronic medical |
narrative charting |
walking rounds |
|
records |
nurses’ notes |
|
|
focus charting |
||
|
Acronyms |
|
|
APIE |
MIS |
|
CBE |
PIE |
|
DAPE |
POMR |
|
DARE |
RAP |
|
DARP |
RIE |
|
EMR |
SOAP |
|
MAR |
SOAPIER |
|
MDS |
|
DOCUMENTATION
The health record is a manual or electronic (computer) account of a client’s relationship with a healthcare facility. Healthcare providers chronologically and systematically record all information regarding the client’s health, past and current problems, diagnostic tests, treatments, responses to treatments, and discharge planning through handwritten or keyboard entries. Because you, the nurse, are usually the primary caregiver, the information that you put in the record is very important to inform other caregivers of the client’s appearance, behavior, and responses. You must record such information clearly, accurately, and frequently. The commonly used term for documentation is “charting.” The client’s health record is usually called the “chart.”
Purposes of the Health Record
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
Communication
Because the goal of the healthcare team is to work together to provide the best possible care for the client, the health record is a communication tool that all caregivers use to exchange information with one another. Each caregiver enters information about the client’s condition, treatments, responses to treatments, and plans. Instructions for treatment of the client (e.g., physician orders, care plans, or care paths) are also included in the health record. Together, these data, notes, and instructions provide a way for healthcare providers to remain in touch about the nature of the client’s health problems, possible treatments, treatments given, and client responses.
Think of the health record as a bank where information is deposited, stored, and made available to all who need it. This central resource for information ensures that a client’s care is consistent and effective.
Another aspect of communication that is important to the client is the documentation and verification of his or her own health status. A client may require this record of information for specific reasons, such as employment or for a disability application.
See Box 37-1 for some thoughts on how nurses help facilitate communication.
Key Concept When communicating with others, it is important to consider each person’s age, sex, ethnic and religious background, state of health, life experiences, body image, feelings about being in the healthcare facility language preference, and other personal factors.
BOX 37-1.
Facilitating Communication in Healthcare
Nurses facilitate communication between clients and members of the nursing team in various ways, including:
♦ Maintaining the confidentiality of all information about clients
♦ Skillfully interviewing clients to determine their healthcare needs
♦ Listening attentively to what the client is saying
♦ Teaching clients and their families certain aspects of care
♦ Documenting information on the nursing care plan and in the client’s record
♦ Reporting the condition of the client to other members of the healthcare team
♦ Participating in team conferences and client care conferences
♦ Treating each client as a unique individual
♦ Using both verbal and nonverbal means of communication and observing client’s verbal and nonverbal reactions
♦ Using touch as a therapeutic modality, while not invading the client’s personal space or threatening the client
Accountability
The health record is documented evidence that the healthcare agency and providers have acted responsibly and effectively. Such evidence of accountability is required for legal, regulatory, and financial reasons.
Legal Requirements and Protection. The healthcare record fulfills a legal requirement mandating all businesses and corporations that provide public services keep records of their interactions with clients. Thus, the health record is a legal document.
The health record is an important piece of evidence when questions of inadequate, incorrect, or poor healthcare arise. If a client, family member, or attorney questions the quality of care given, the well-written and comprehensive health record is the best source of information describing what actually occurred. Accurate, precise, and timely entries into the health record are your protection against accusations of inadequate or poor nursing care.
Nursing Alert If your health records are audited or if you go to court, the basic legal concept is: if it was not documented, it was not done. (The nurse who makes an error must document what was actually done and any new actions taken.)
Regulatory Requirements. All healthcare agencies must meet certain standards of care established by governmental or voluntary regulatory agencies. One standard is record keeping. Another standard is providing safe and effective healthcare and verifying it through quality assurance programs. Complete and accurate healthcare records help agencies prove that they have met both standards.
Financial Accountability. Just as payment for your groceries requires a receipt listing the items you selected, clients and third-party payers depend on a complete list of services and products provided before paying for healthcare. To facilitate this process, you must record all treatments given, examinations administered, and special equipment used (e.g., an air mattress). Third-party payers will not reimburse the healthcare facility unless billed-for services and supplies are recorded in the health record. Thus, you must enter every aspect of your care to tell the third-party payer what has been done. Failure to do so may result in a loss of payment to the employing agency, ultimately leading to higher costs for clients and consumers.
Research and Education
Healthcare planners examine health records of individuals and groups to determine patterns of illness, trends, or effective treatment strategies. This research is necessary to select the best treatment for an individual or to search for better treatments for specific health problems. Health records, particularly those kept in computer databases, provide excellent research opportunities in healthcare.
The health record is also an excellent educational tool. Students in healthcare vocations benefit from reading and comparing the data of various clients as they enlarge their knowledge of health, illnesses, treatments, and responses.
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. The MIS may contain only specific medical information. It is not uncommon for the health record to have a hard copy printout of data from the MIS attached to a manual record. Another documentation system is referred to as electronic medical records (EMRs). As MISs and EMRs become more user-friendly and cost-effective, healthcare facilities have commonly converted from manual to electronic formats because of the advantages of simplified and rapid data management (see Fig. 36-2).
Manual Records
The manual health record is a collection of various forms and documents. It tells the story of the client’s relationship with the healthcare facility. A notebook or binder kept in a central location (e.g., the nurses’ station or main administrative offices) in the healthcare facility secures these papers. You may keep some of the forms in a client’s record at his or her bedside for your convenience—for example, a fluid intake and output sheet or a Daily Nursing Assessment Flow Sheet.
NCLEX Alert Questions on any NCLEX examination might include the proper way to document information. Using your skills at definition of the stages of the nursing process including assessment/documentation gathering, implementation/interventions, appropriate goal setting, and evaluation will help you answer the question correctly
The manual health record documents assessment data, care plans, medications and treatments, vital signs, treatment outcomes, and the client’s daily progress. Care providers enter information by hand in ink at frequent intervals. Table 37-1 lists the purposes of the various forms included in the manual health record. The nurse is held legally responsible for the legibility, thoroughness, and timeliness of documentation.
Computer Records
For many years, healthcare facilities have used an MIS for diet, laboratory, and pharmacy orders, billing, and statistical data collection. The grander EMR systems store, process, and transmit client data, treatment strategies, and outcomes over a computer network, in other words, the entire medical chart. EMR systems use networks of terminals attached to a satellite of terminals that handle the actual storing and processing of information. Usually individual computer sites consist of a monitor and keyboard that are located in every client room, nursing care station or unit, as well as in other key places throughout the healthcare facility. The healthcare provider can enter information via a keyboard, a light pen, a mouse, or by touching the screen. EMR systems utilize various methods to record assessment data, care plans, nursing information, client responses, and changes in the client’s condition. Training for these systems is traditionally done during a new-hire’s orientation. Commonly the employer assumes that the new employee will have had basic knowledge of computers and keyboard systems.
Direct transfer of electronic information from one handheld machine (e.g., blood glucose monitor) to another machine (e.g., the client’s computerized record) has many advantages. Additionally, electronic data can simultaneously be transmitted to a physician’s office or be transmitted to a distant location for interpretation by an expert (e.g., the radiologist). As computers become standard equipment within each client’s unit, electronic charting at the bedside may replace most pen and paper documentation.
All the information included in the MIS or EMR is similar to that found in the manual record. Entering and retrieving information, however, is different. Once you have learned to use the computer system, you will understand the advantage of speed and convenience in both the entry and retrieval of information.
Usually the type of electronic documentation is designed for a healthcare agency’s specific needs. Although requirements for documentation are the basically the same for all healthcare facilities, each agency’s requirements and, thus, their system is unique (e.g., long-term care vs. acute care facilities).
Key Concept If the healthcare facility where you work uses an electronic system, you will need to take orientation classes to learn how to use the system correctly NEVER share your access code(s) to a facility’s electronic documentation system.
Contents of the Health Record
The health record contains four general categories of information: assessment documents, plans for care and treatment, progress records, and plans for continuity of care.
Key Concept Confidentiality is a major concern. It is imperative that a clients healthcare information be protected. Never share electronic information unless documentation protocols provide for the transmitting of data from one person or place to another person or place.
Assessment Documents
Assessment documents record all information about the client obtained through interview, examination, diagnostic procedures, or consultation. These documents include the physician’s history and physical examination, the nursing admission history, and other records that list or describe related aspects of information about the client. All caregivers contribute to this bank of information. (For specific forms, purposes, and responsible caregivers, see Table 37-1.) The actual formats of the various records and forms vary among agencies.
TABLE 37-1. Contents of the Health Record
|
GENERAL CATEGORY |
SPECIFIC FORM OR SCREEN |
PURPOSE |
RESPONSIBLE CAREGIVER |
|
Assessment documents: forms/screens |
Admission record Medical history and physical Nursing admission history Minimum data set (MDS) Laboratory record Consultation |
Lists client’s name, address, sex, age, physician, insurance company, reason for admission Records physician’s history and physical examination findings Records nurse’s history Records information that identifies the client’s ability to perform activities of daily living and functional losses that affect this ability Records results of blood, urine, stool, or other body substance analysis Records findings and opinions from consults requested by primary caregivers |
Admitting staff Physician Usually RN, but may be LPN in some facilities Admitting RN, but may be LPN in some facilities Laboratory personnel: physicians, technicians Consulting physician or other care provider |
|
Plans for care and treatment |
Problem list Physician’s orders Nursing care plan Teaching plan Clinical care path Consents for treatment |
Describes physician’s goals for treatment List instructions to nurses or technicians to implement client’s diagnostic tests, treatments, or medications Lists client’s expected outcomes of nursing care Lists nursing actions to achieve outcome Identifies client’s teaching needs Lists teaching strategies Lists diagnostic tests, treatments, and expected client outcomes on a timeline; usually designates responsible caregiver Explains expected and possible adverse outcomes for treatments; contains client’s signature |
Physician Physician Usually RN, but may be LPN in some facilities Nursing staff All caregivers Admitting personnel; physician; nursing staff |
|
Progress records: forms/screens |
Flow sheet Medication administration record Progress note |
Documents large amounts of information briefly and concisely by a timeline. Includes intake and output sheets, graphic sheets for vital signs, anesthesia sheets during surgery, routine nursing care sheets, intensive care unit records. Efficient records. Lists ordered medications, amount, route, and ordered time of administration for noting time of actual administration and response to medication Describes client’s treatment, responses to treatment, and unusual events; documents progress toward achieving outcomes. Can be a general form or format for all team members or individual formats used by specialty areas, such as nursing, physicians, respiratory, and physical therapy |
Depending on purpose of flow sheet, all care providers but particularly RN, LPN, and perhaps aides Usually prepared by pharmacy; medication administration documented by RN, LPN All care providers |
|
Plans for continuity of care form/screen |
Teaching record Transfer form/screen Discharge/transfer summary |
Lists times and teaching strategies used; client’s responses Summarizes client’s condition and responses to treatment to prepare for transfer to another unit, facility, or community health agency Summarizes client’s condition on discharge from the healthcare facility |
Usually RN, but may be LPN in some facilities Usually RN, but may be LPN in some facilities Physician and RN or LPN |
You will acquaint yourself with these forms as part of your orientation with any healthcare employer. Long-term care and some home care agencies use a standard form called a minimum data set (MDS) as part of the admitting nursing history. This form is sometimes called a resident assessment protocol (RAP). This form measures a client’s ability to perform the activities of daily living and identifies functional losses that affect this ability. Several other assessment forms are available to aid the nursing care team in developing an individualized plan of care for each client. Federal and state regulatory agencies require these forms. You must answer all the questions asked on the form to ensure that your employer is complying with regulatory requirements.
The MDS helps to ensure that all clients are assessed in the same way. Because these forms are the same in all agencies, you will find them easy to use if you move from one agency to another.
Plans for Care and Treatment
The purpose of the plans for care is to ensure that all caregivers provide the same care and treatments for the client. The physician’s plan of care contains goals for treating the client and specific instructions called orders to guide the nursing staff. Some Nurse Practice Acts require that the nursing care plan be developed by the registered nurse after a thorough assessment of the client’s health status. Commonly a team approach is used. The development of a plan of care uses both LPNs/LVNs and RNs. When discussing initiation and assessment of a care plan, the legal role of the LPN/ LVN differs from state to state. Additionally, each type of clinical facility will have in-house guidelines and regulations for the nursing plans of care. State regulating agencies for acute versus long-term care will also mandate specific approaches for the development of nursing care plans. Discussed later in this topic, another version, called the clinical care path, is a plan that specifies expected outcomes and treatments at specified times for all members of the healthcare team.
As stated previously, numerous formats and versions of plans of care are fundamentally based on the traditional nursing care plan. The needs of the client, the facility, and the nurse commonly dictate which format will be chosen. It is not uncommon to have several versions within one facility. For example, the care plan format in an emergency department will differ from that of a critical care unit, a maternal-child unit, or a medical-surgical unit. The graduate will be oriented to the appropriate version of documentation after he/she has been hired as an employee.
Formats of Written Documentation
Many formats for charting or documenting the client’s progress exist. These formats use various versions of the nursing process. Charting is based on the nursing process: assessment, nursing diagnosis, planning and goal setting, implementation/interventions, and evaluation. Reasons to use a progress note entry are to:
• Establish a baseline of data
• Enter data at regular intervals
• Summarize the client’s condition
• Document changes in the client’s condition
• Document a response to treatment
Several systems of data entry are used. To know what type of charting, record keeping, and documenting that you need to use, you should first consult your instructor and the institution’s policy and procedure manuals.As part of orientation to your student experiences and later, when you are employed as a nurse, you will be informed of the facility’s needs, forms, and formats. Each format has advantages and disadvantages. Typical documentation formats include:
• Narrative-chronological
• Problem-oriented (focus)
• Discipline area documentation
• Charting by exception
• System flow sheet
• Case management
• Critical pathway
• Collaborative pathway
• Care mapping
• Graphic flow sheet
• Medication administration record
Narrative-Chronological. Progress notes are written in several formats, often using specific forms, which usually are designed by each institution. A progress note essentially summarizes the progress of the client toward achieving his or her care plan goals. Typically written in a narrative, chronological format, a progress note can be a summary or narration of an event, conversation, assessment, or activity. This narrative format is kept chronologically. Charting can be done hourly, every 2 hours, per event, or more often.
When nurses chart on a progress note, the form is commonly called the nurses’ notes. Some facilities use a team approach where all documentation is continuous on one general progress note. Most hospitals use separate progress notes for physicians, nurses, physical therapy, respiratory therapy, and other healthcare specialties. Additional information about discipline area documentation is provided in this topic.
Narrative charting is a type of nurses’ notes that essentially documents what is occurring throughout the day in a chronological manner.The usual opening note on charts that use narrative style is the nurse’s first assessment after assuming responsibility for that client. The nurse may do a body system assessment starting with general observation, then assessments of the neurologic, integumentary, cardiovascular, gastrointestinal, and genitourinary systems and others. This is often referred to as “head-to-toe” charting. Subsequent entries add to the assessment, note changes in condition, or record facts. For example:
0830 C/o pain of 8 on a 0-10 pain scale.—M. Garcia, LVN 0845 Medicated with 50 mg Demerol IM as per order in
LUOQ.—M. Garcia, LVN 0930 States, “I feel so much better; the pain is only a 3 now.”
—M. Garcia, LVN 1015 Dr. E. Jones removed and replaced abdominal dressing.—M. Garcia, LVN
Narrative charting is very thorough and detailed. It is also time-consuming. Narrative, chronological charting is useful and popular with nurses who need to document complex descriptions with thorough assessments.
Area Charting. Some formats of charting focus on a specific problem rather than on general assessment data. When problem-oriented medical records (POMR) charting is used, the whole healthcare team works collaboratively to identify priority problems, and they work collectively to solve these problems. This type of charting focuses on specific problems and is sometimes called focus charting.
Several shorter versions of narrative charting have been devised and are used for POMR, which have the benefit of greater time efficiency, but may not include pertinent data that would be included in narrative formats. Acronyms provide memory aides on what to include in charting. Types of charting include SOAP, SOAPIER, APIE, PIE, DAPE, DARP, and DARE. These acronyms are identified in Table 37-2. In general, these acronyms delineate the following terms: subjective, objective, approach, analysis, plan, interventions, response, education, and evaluation.
Discipline Area Documentation. Documentation by discipline area would include separate notes for physicians,nurses, and other healthcare team members, such as dietary, respiratory therapy, physical therapy, occupational therapy, or home health providers. Each specialty may have specific formats or forms used to chart about that particular field. Forms and formats used include narrative or a version of SOAP.
TABLE 37-2. Commonly Used Nursing Note Formats
|
FORMAT OR ACRONYM |
CATEGORY |
CONTENT |
|
POMR (Specific problems SOAP or SOAPE |
are identified) S Subjective O Objective A Assessment or analysis |
Subjective client data; usually direct quotes from client Objective client data identified through observation, examination, or interview Conclusions drawn from data; often stated as a nursing diagnosis or client care problem |
|
or SOAPIE or SOAPIER |
P Plan I Intervention E Evaluation R Revision |
Expected outcome; if a SOAP note, this states nursing strategies to treat the nursing diagnosis or client care problem Nursing strategies to treat the nursing diagnosis or client care problem Outcomes of nursing care; reassessment of client New plans for treatment of care problem based on client outcomes or responses |
|
APIE or PIE |
A Assessment P Plan I Intervention E Evaluation |
Objective and subjective data about the client; may include a conclusion in the form of nursing diagnosis or client care problem. (If system is PIE, A is recorded on a flow sheet at regular intervals.) Expected outcome listed or Planned strategies to treat the nursing diagnosis or client care problem Nursing care given Outcomes of nursing care; responses of client; reassessment information |
|
Focus (Problem stated as nursing diagnosis or client care problem) |
||
|
DAPE |
D Data A Assessment P Plan E Evaluation |
Objective and subjective data about client obtained through observation, interview, and examination Conclusions drawn from data; may be nursing diagnosis or client care problem Expected outcomes listed or planned strategies to treat the nursing diagnosis or care problem Outcomes of nursing care; responses of the client; reassessment information |
|
DARE |
D Data A Action R Response E Education |
Objective and subjective assessment data that support the Focus Nursing interventions to treat the problem Outcomes of interventions; reassessment data Client education |
|
DARP |
D Data A Assessment or Action R Response P Plan |
Subjective data per client (e.g., pain) followed by assessment or action taken (pain medication needed or given). Response to assessment or action charted (pain relieved by pain medication). A plan is formed for further evaluation (provide medication per orders). |
|
Charting by exception (CBE) |
Uses a SOAPIER or a system flow sheet format for progress notes where abnormal signs or symptoms (the “exception” to normal status) are specifically identified, assessed, and interventions are documented. |
See above for SOAPIER content. A system flow sheet provides routine assessment/data collection at intervals. Normal or expected data are checked or initialed. Abnormalities or unexpected findings are referred to progress notes for further discussion. |
The main advantage of this type of record keeping is that providers in each subspecialty can find their own forms quickly and follow the progress of their therapies without having to read notes from other disciplines. However, it can be difficult to monitor data as a holistic view of the client. The data can appear separate and fragmented, which might not be seen as related to other subspecialties. For example, respiratory therapy may chart that the client did not tolerate the breathing treatment. The nurse may not read the individual entries of the healthcare team and may be unaware that the client is not benefiting from his respiratory treatment.
Charting by Exception. Charting by exception (CBE) is a type of narrative charting that usually uses a flow sheet listing body systems and their typical findings, such as lung sounds: clear, crackles, or rhonchi. The nurse checks off the correct assessment findings on the preprinted sheet. Flow sheets have the advantage of listing the most common normal and abnormal findings, so the chance of leaving out important documentation is decreased.
After charting or checking-off normal findings, the next step of CBE is making a notation about the abnormal findings on a separate nurses’ note. In other words, normal findings are given a check on a box on the flow sheet; abnormal findings and the care for these findings are more thoroughly documented in separate nurses’ notes. CBE could be considered a short-hand version of narrative charting and may be considered more efficient, especially for the client who is physically stable with an uncomplicated care plan. However, it may be a disadvantage when a legal defense claim, such as negligence, is necessary. When CBE is used, the nurse must be sure that all charting is thorough and complete.
Key Concept In some areas, “reporting by exception is practiced. In this case, not all recurring client information is repeated. The nurse only reports changes in the client’s condition, new orders, upcoming procedures, and unusual or changing behavior
Case Management. Case management is popular in situations in which the emphasis is on quality care that is delivered in the most cost-effective manner. The client is considered the focus of a case study, and the goal is to achieve specific outcomes that are identified in a multidisciplinary team approach. This type of record keeping is also known as case studies, care mapping, collaborative pathways, or critical pathways. The team shares information and priorities. It is often used in a “typical” stable client and may be seen in home care organizations, such as in the provision of postoperative wound care. Case management may not be suitable for a client with special or complex individual needs.
Graphic Flow Sheet. A graphic flow sheet is a graph, form, or picture that records large amounts of information collected at intervals over a specified period in brief, concise entries.
NCLEX Alert Because of the wide variety of specific documentation methods, NCLEX questions tend to relate specific clinical situations. From these situations, the graduate must choose the most appropriate, clear and effective response. More than one response may be correct, but there is only one, best correct answer to the given situation.
The medication administration record (MAR) lists all medications that the physician has ordered for the client, with spaces for the caregiver to mark when medications are given. Injection site locations are also documented. Often the facility separates the MARs from the bulk of the client’s health record for convenience so that the nurse has rapid access to a listing of all current medications, can document medications immediately after they are given, and can administer medications according to the healthcare provider’s orders.
In addition to the MAR, other examples of information that is kept on a graphic flow sheet include:
• 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
As stated, these forms often include some form of graphic representation that will help care providers see visual representations of trends or clusters of information. This type of form is commonly used by non-licensed personnel as well as licensed nurses.
Both manual and MIS records have flow sheets. The flow sheet in the manual records is a page in the client’s record or a separate sheet kept near the client’s bedside. A computerized flow sheet may be a screen that has a simple “yes” or “no” response that can be completed quickly and efficiently using a light pen or keyboard. The flow sheet may have highlighted blanks for data entry similar to recording intake and output on paper.
Sometimes the data on the flow sheet are summarized elsewhere in the health records so that not all data or forms are kept. An EMR system is particularly useful for data compilation and storage. If the record is a manual paper chart, the flow sheet itself may be discarded by the primary care nurse or team leader because the formal, summary entry is recorded elsewhere. For example, data from a bedside intake and output flow sheet may be discarded at the end of each shift because the data are summarized and placed in the MIS.
