Basic Concepts of Nursing Notes by Lei Talabis
Documentation
Record- AKA chart or client record
- Formal, legal document that provides
evidence of a client’s care
- Can be written or computer based
Recording, charting, or documentation
- Making entry on a client’s clinical
record.
- Nurse’s notes
Report
- orally, written, computer based
- e.g. end of shift report/ hands off
report
Discussion
- informal oral consideration of a
subject.
- What to be done in patient care
Ethical and Legal Considerations
- Maintain confidentiality of patient
information.
- Client’s record
 Protected also legally as a
private record of the client’s
care.
- Access to the record
 Restricted to health
professionals.
- Institution or agency
 Rightful owner of client’s
record
- April 14, 2003 -changes in the laws
regarding client privacy became
effective.
- HIPAA of 1996
- PHI- Protected Health Information
 Data pertaining patient’s
record.
- HIPAA security rule- mandatory in
2005
- For research purposes and education
 Allow students to access
clients record.
 With consent
 Anonymity and privacy
 Applicable even if the patient is
already dead
Clinical (Client) Record
1
- Formal, legal document that provides
evidence of client’s care.
- It needs to be accurate, lahat ng
narecieve na care and response to
care of the patient.
- Paans, Sermeus, Nieweg, and van
der Schans (2010)- identified the
PES structure as a guideline for
nursing care
 P- client’s problem or
diagnosis
 E- Etiology or cause of the
problem
 S- signs and symptoms the
nurse should be assessing.
Purposes of Client Record
- Communication
 Vehicle for interaction of health
professionals.
- Planning Client Care
 To plan care for the client.
- Auditing Health Agencies
 For quality assurance
purposes.
- Research
 For research in treating other
clients with same case.
- Education
 Provide comprehensive view of
the client.
- Reimbursement
 To demonstrate to payers
(insurance companies) that
patients received the care for
w/c reimbursement is being
sought.
 Philhealth, medicare, health
insurances
- Legal documentation
 Admissible in court.
- Health care (decision) analysis
 It may assist HCP to identify
agency needs.
- Historical documentation
 Info concerning a patient’s past
healthcare might be pertinent
and can be used in the future.
Documentation Guidelines
- Aim:
Basic Concepts of Nursing Notes by Lei Talabis
 Complete
 Accurate
 Factual
 Current
 Organized data
 Concise
 Timely and confidential
manner
 To serve as a legal document.
- Content:
 Info must reflect nursing
process and professional
responsibilities.
 Record patient findings.
 NOT your own interpretation.
 Avoid words like good,
average, normal or sufficient.
 Avoid generalizations (e.g.
seems comfortable today)
 Note the problems as they
occur in an orderly and
sequential manner
(chronological)
 Record nursing interventions
 Chart precautions or
preventive measures
 Document all medical visits
and consultations
 Document in a legally prudent
manner.
 Document nursing response to
questionable medical orders
 Avoid the use of stereotypes or
derogatory terms when
charting.
- Timing:
 Chart in a timely manner
 Indicate in each entry the date
and time the entry was written
and time of pertinent
observations and interventions.
 Most agencies use military
time one 24-hour time cycle
 To avoid confusions
between am and pm
time
 6am-2pm (blue ink)
 2pm-10pm (black ink)
 10pm-6pm (red ink)
 Document nursing
interventions as closely as
possible at the time of
execution
2
 Never document interventions
before carrying them out.
 Write progress note for the
client.
 Upon admission
 When a procedure is
performed.
 Upon receiving post
procedure
 Upon communicating
with physicians.
 For any change in the
health status.
- Format:
 Correct chart before writing.
 Chart on the proper form as
designated by agency policy.
 Print or write legibly in dark ink
 Use correct grammar
and spelling
 Use standard
terminology
 Follow comp
documentation
guidelines.
 Date and time each entry.
 Chart chronologically on
consecutive lines.
 Never skip lines
 Draw a single line
through blank spaces.
- Accountability:
 Sign your first initial, last name,
and title to each entry.
 Do not use dittos, erasures, or
correcting fluids.
 Single line should be
drawn through an
incorrect entry and
words “mistaken entry”
or “error in charting”
should be printed above
or beside the entry and
signed.
 di na raw pala to
masyado ginagamit kasi
magiging questionable
sa court. Breakthrough
nalang.
 Ex. ganda ni love jonks
 Identify each page of the
record w/ patient’s name and
ID number.
Basic Concepts of Nursing Notes by Lei Talabis
 Recognize that the patient
record is permanent.
 Follow agency policy
(color of ink and type of
pen to be used)
 Ensure that the record in
complete.
- Confidentiality:
 Patients have moral and legal
right to expect that their info is
private.
 Most agencies allow students
to access patient records for
educational reasons.
 Actual patient names
and other identifiers
should not be used in
written or oral reports.
Documentation Systems (Methods of
Documentation)
1. PPR: Paper Based Patient Record
a. Source-oriented
i. Traditional client record.
ii. Info about a particular
problem is distributed
throughout the record.
b. Problem-oriented
2. EMR: Electronic Medical Record
Source-Oriented Medical Record
- Components:
 Admission (face) sheet
 Initial nursing assessment
 Special flow sheets
 Medication record
 Nurses notes
 Medical history and physical
examination
 Physician’s order form
 Physician’s progress notes
 Consultation records
 Diagnostic reports
 Consultation reports
 Client discharge plan and
referral summary.
Advantage:
 Most traditional
 Sometimes called conventional
method
3
 Each discipline can be easily
found
Disadvantage:
 Data are fragmented.
 Needs constant updating
 Sometimes inefficient because
there are chances wherein
assessment is being repeated
Progress notes
 Notes written to inform
caregivers of the progress a
patient is making
- Narrative notes:
 Written by nurses
 Routine care, findings
- Narrative documentation
 Story-like format
 Traditional
Advantages:
 Info is in chronologic
order
 Documents patient’s
baseline condition for
each shift.
 Indicates all aspects of
all steps of the nursing
process.
Disadvantages
 Makes difficult to
separate pertinent from
irrelevant info
 Requires extensive
charting time by the staff
 Discourages physicians
from reading all parts of
the chart.
Problem-Oriented Medical Record
- POMR or POR
- Organized around a patient’s
problems
- Data is arranged according to
problem list.
Advantages:
 Focuses only on client
problems
 Easier to track the status of
health problem
 Contributes collaboratively to
the plan of care
Disadvantages:
 Difficult to agree on what to put
in the chart
Basic Concepts of Nursing Notes by Lei Talabis
 Needs constant updating on
the problem list
 Somewhat inefficient.
Components of POMR:
 Database
 Compilation of all initial
information about the
patient and includes the
following
 Health state profile
(assessment) prepared
by the nurse
 medical history and the
physical examination
prepared by the
physician
 social and family history
 Initial diagnostic test
results
 Data are constantly
updated as the client’s
health status changes
 Problem list
 Derived from the
database.
 Kept at the front of the
chart.
 Primary care providers
write problems (medical
diagnosis, surgical
procedures or symptoms)
 Nurses write problems
(nursing diagnosis)
 Each problem is
categorized as active or
inactive. (existing or not)
 Plan of Care
 Initial list of orders or CP
is made with reference
to the active problems.
 CPs are generated by
the individual who lists
the problems.
 Primary care
providers
 Nurses
 Formulated for each
specifically numbered
problem on the problem
list.
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 Nursing plan is
expressed through
nursing order.
 Progress notes
 Consist of narrative
progress notes,
flowsheets, and
discharge notes.
 Follows SOAP format:
 S- Subjective
 O- Objective
 A- Assessments
 P- Plans or goals
 SOAP/SOAPIE/SOAPIE
R format
 I interventions
 E Evaluation
 R Revisions
 Flow sheets
 Used for recording
infos that is
monitored over
time.
 Discharge notes
 Time of the
episode of the
patient’s care is
terminated.
Pie Documentation Model
- P problems
- I Interventions
- E Evaluation
- This system consists of a client care
assessment flow sheet and progress
notes.
- Advantages:
 Saves time
 Eliminates traditional care plan
 Promotes continuity of care
 Incorporates ongoing care plan.
- Disadvantages:
 Not having a formal care plan.
 Nurses must review all the
nurses’ notes before giving
care.
Focus Charting
- Client’s concerns and strengths are
the focus of care.
- Three columns for recording:
 Date and time
Basic Concepts of Nursing Notes by Lei Talabis
 Focus
 Progress notes (data, action,
and response-DAR)
- Focus column
 Incorporates many aspects of
a patient and patient care.
- Focus
 and standards.
- Data
 Assessment phase
- Action
 Planning and intervention
- Response
 Evaluation phase
- Advantages
 Holistic emphasis on the
patient.
 Ease of charting.
- Disadvantages:
 If database is insufficient,
problems may be missed.
 Some nurses report the DAR
categories are artificial and not
helpful when documenting care.
Charting by Exception (CBE)
- All abnormalities or significant
findings.
- Three key elements:
 Flow sheets
 Graphic records
 Standards of nursing care
 Documentation by
reference to the
agency’s printed
standards of nursing
practice
 Bedside access to chart forms
 In CBE, all flow sheets
are kept in the client’s
bedside.
 To allow immediate
recording
 Eliminate the need to
transcribe data from the
nurse’s worksheet to the
permanent record.
- Shorthand documentation method
that makes use of well-defined
standards of practice.
- Only significant findings or
“exceptions” are documented in
narrative notes.
5
- Advantages:
 Eliminates lengthy, repetitive
notes.
 Highlights abnormal data and
patient trends.
- Disadvantages:
 Requires detailed protocols
 Limited usefulness
 “not charted, not done”- others
may feel uncomfortable in CBE
Documentation system.
 Write N/A to avoid
misinterpretations.
Computerized Documentation
Electronic Health Records (EHRs)
- Can integrate all pertinent client
information into one record.
- developed to manage the huge
volume of information required in
heath care
- Easiest but expensive way.
- Minimum data sets
 Key component to facilitate
data and outcome
comparisons.
- Nursing minimum data set (NMDS)
 Effort to establish uniform
definitions and categories for
collecting essential nursing
data for inclusion in computer
databases.
 Three categories:
 Nursing care elements
 NURSING
DIAGNOSES
 Patient demographic
elements
 SEX, DATE OF
BIRTH
 Service elements
 ADMISSION AND
DISCHARGE
DATES
- Never share password
- Legible
- Date and time are automatically
recorded.
- Terminals are usually easily
accessible.
- Pros:
Basic Concepts of Nursing Notes by Lei Talabis
 Nurses can use time more
efficiently.
 Focuses on client’s outcome.
 Info’s are received quickly.
 Can synthesize info from
monitoring equipment.
 Permits the nurse to check an
order immediately before
administering a treatment.
 Info is legible.
 Reinforces standards of care.
 Standard terminology improves
Case Management Model
communication.
- Cons:
 Client’s privacy may be
infringed.
 Breakdowns of comp make
info temporarily unavailable.
 System is expensive.
- Health informatics- management of
HC info.
- Nursing informatics- science of using
comp info systems in the practice of
nursing.
Computer Systems
- Management Information System
(HIS)
 Focuses in the types of data
needed to manage client care
activities.
- Guidelines and strategies for safe
computer charting
 Never give your password or
computer signature to anyone
 Don’t leave a computer
Formats for Nursing Documentation
terminal unattended after you
have logged in
 Follow correct protocol for
correcting errors.
= mark “mistaken entry” and
correct the information and
date the initial entry
= if the information is in wrong
chart, write “mistaken entry-
wring chart” and sign.
 Never create , change or
delete records unless you have
specific authority to do so
 Make sure that stored records
have back-up files an
important safety check
6
 Don’t leave information about a
patient displayed on a monitor
where others may see it
 Never use email to send
protected health information
unless it has been encrypted to
protect it from unauthorized
access
 Follow agency’s confidentiality
procedures for documenting
sensitive material
- Emphasizes quality, cost-effective
care delivered within an established
length of stay.
- Critical pathway
 Forms that identify the
outcomes that certain groups
of clients are expected to
achieve on each day of care,
along with the interventions
necessary for each day
- Variance
 goal that is not met.
 Unexpected event/occurrences.
- Advantages:
 Promotes collaboration
 Helps decrease length of stay
 Makes efficient use of time.
- Disadvantages:
 Critical Pathways work best for
clients with one or two
diagnoses & few individualized
needs.
- Admission Nursing Assessment
 AKA initial database, nursing
history, nursing assessment.
 Completed when the client is
admitted.
 Nurses generally records
ongoing assessments on
flowsheets or on nursing
progress notes.
 Can be organized:
 Health patterns
 Body systems
 Functional abilities
 Health problems
 Nursing model
Basic Concepts of Nursing Notes by Lei Talabis 7

 Type of healthcare  Sections:

setting.  Pertinent info of the
- Nursing Care Plans patient
 Client assessments  Allergies
 Nursing diagnoses  List of medications
 Nursing interventions  List of IV fluids
 Client outcomes  Daily treatments
 Evidence of a current nursing  Diagnostic procedures
care plan. ordered.
 It may be:  Specific data on how the
 Separated from client’s client’s physical needs
chart are to be met.
 Recorded in progress  Problem list, stated
notes goals, and a list of
 Incorporated into nursing approaches to
multidisciplinary plan of meet the goals.
care. - Flow sheets
 Types of Nursing Care Plan  Enables nurses to record data
 Traditional Care plan quickly.
 Written for each  Easy to read record of the
client client’s condition over time.
 Nursing diagnoses  Graphic record
 Expected  Indicates temp, pulse, rr,
outcomes bp, weight
 Interventions  Intake and Output Record
 Standardized Care Plan  Fluid intake
 To save  Medication Administration
documentation Record
time.  Designated areas for the
 Based on date of the medication
institution’s order, expiration date,
standards of medication name, and
practice. dose
 Must be  Skin Assessment Record
individualized by - Risk Factor Assessment Form
the nurse.  Screening checklist for
identification of at-risk
- Kardexes individuals.
 Widely used  Modifiable Factors
 Summary of the nursing  Non-Modifiable Factors
process being undergone by a - Progress Notes
client.  Includes info about client
 Accessible to all health care problems and nursing
professionals. interventions.
 Consists of series of cards  Format used depends on the
kept in a portable index file or documentation system in place
on comp-generated forms. in the institution.
 May or may not become a part - Nursing Discharge/referral
of the client’s permanent Summaries
record.  When the client is being
 Temporary worksheet (pencil discharged or transferred.
is used)
Basic Concepts of Nursing Notes by Lei Talabis
 Layman’s term in discharge
plan. (to make the family
understood)
- Change-of-shift Reports
 3 important features:
 Two-way, face to face
communication
 Written support tools
 Content in handover
which captures intention.
 Given to next shift for the
continuity of the client’s care.
 Key elements
 Up to date info
 Interactive
communication allowing
for questions
 Method for verifying the
info (ex. Repeat-back)
 Minimal interruptions
 Opportunity for receiver
of info to review relevant
client data.
 SBAR tool- can be used when
you’re reporting to the doctor.
 S- situation
 B- background
 A- assessment
 R- recommendation
- Telephone Reports
 MD may order a tx for a client
by telephone
 Received only by RNs
 Frequently done at night or in
emergencies.
 Clearly determine name, room
number, dx
 Write down the complete order
& read it back to the person.
 Order is transcribed to the
order sheet and countersigned
by the MD in 24hrs
- Incident reports
 Written to document any event
that is not consistent with the
routine care of client.
 Helps in analysis of trends and
systems in operations
 Provides for justification for
changes of policy
 Protection of the RNs, MDs
 Guidelines:
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 Filed by the RN who
witnessed the incident
 Describe what happened
in objective terms
 Concisely written
 Do not interpret or
explain the cause of the
incident nor blame
anyone.
 Submitted as soon as
possible to the
appropriate person.
 Do not photocopy.
 Keep a duplicate for
personal files.
 Objective
 Do not include names of
witnesses
 Document time/name of doctor
 Do not file in chart
 Do not write “incident report
made”
Documentation Guidelines
- Accuracy
- Date and time of each recording
- Legibility
- Correct spelling
- Permanence
- Universal terminology
- Signature
- Sequence
- Appropriateness
- Completeness
- Conciseness
- Legal prudence
Nursing students
- You are liable if your actions cause
harm to clients.
- You are expected to perform as a
professional when rendering care.
- You must separate your nursing
student role from student nurse in the
clinical area role.
“CARE THAT IS NOT DOCUMENTED IS
CARE NOT RENDERED”