CHART

DOCUMENTATION
& REPORTING
 REPORT

• An oral, written, or computer-based

communication intended to convey
information to others
RECORD / CHART / CLIENT RECORD

• Written entry into the patient’s medical record

of all pertinent information about him or her.
These entries validate the patient’s problem
and care and exist as a legal record
• A formal, legal document that provides
evidence of a client’s care and can be written
or computer-based.
 •
PURPOSES OF THE CHART Serves as vehicle
• Uses which
datadifferent
from the health
chartcare
to professionals
plan
• COMMUNICATION •• Audit
Chart isassists
a review of
health
communicate with
• PLANNING CLIENT CARE • client
Information
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eachplanners
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• chart
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• AUDITING HEALTH AGENCIES
• Prevents repetition
valuable
• purposes
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Helps
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students
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• RESEARCH and delays
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educational
retrieve
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of
• EDUCATION • Charts are usually
reimbursement
hospital servicesfrom
• REIMBURSEMENT admissible in
the governmentcourt
• LEGAL DOCUMENTATION
• HEALTH CARE ANALYSIS
KARDEX / PATIENT CARE SUMMARY

• Trade name for card-filing system that allows

quick reference to particular need of the
patient for certain aspects of nursing care.
 KARDEX Contain the Following:

• Basic demographic data

• Health provider’s name (physician)
• Primary medical diagnosis
• Medical & surgical history
• Current order from the physician
• Nursing care plan
• Nursing orders
KARDEX Contain the Following: (cont..)
• Scheduled tests and procedures
• Safety precaution used in patient care
• Factors related to ADL
• Nearest relative / guardian / emergency
contact
• Emergency code status (e.g., do not
resuscitate)
• Allergies
DOCUMENTATION
SYSTEM
METHODS OF DOCUMENTATION
 METHODS

1. SOURCE-ORIENTED MEDICAL RERCORD

2. PROBLEM-ORIENTED MEDICAL RECORD
3. PIE DOCUMENTATION
4. FOCUS CHARTING
5. CHARTING BY EXCEPTION
6. COMPUTERIZED DOCUMENTATION
7. CASE MANAGEMENT
1. SOURCE-ORIENTED MEDICAL RERCORD

• Traditional client record

• Organization of patient’s chart so each
discipline (e.g., Nursing, Medicine, RT, PT)
has a separate section in which to record
data.
SOURCE-ORIENTED MEDICAL RERCORD

a) NARRATIVE CHARTING
• Consist of written notes that include routine
care, normal findings, and client problems
• A story-like format to document information
specific to patient conditions and nursing care
• Tendency to be repetitious and time
consuming
SOURCE-ORIENTED MEDICAL RERCORD

a) NARRATIVE CHARTING
• Stated “I’m dreading surgery. Last time I had a lot of pain
when I got out of bed.” Discussed alternatives for pain
control and importance of postoperative activity.
Encouraged to ask for pain medication before pain
becomes severe. Stated, “I feel better prepared now.”
Verbalized positive effect of activity on healing and
circulation.
2. PROBLEM-ORIENTED MEDICAL RECORD

• POMR is a method of documentation that

emphasizes patients’ problems.
• Data are organized by problem or diagnosis.
SOAP (Subjective—Objective—Assessment—Plan)
S—Subjective data (verbalizations of the patient)
O—Objective data (that which is measured and
observed)
A—Assessment (diagnosis based on the data)
P—Plan (what the caregiver plans to do).
SOAP (Subjective—Objective—Assessment—Plan)
S—“I’m worried about what it will be like after surgery.”
O—Asking frequent questions about surgery. Has had no
previous experience with surgery. Wife present and
supportive.
A—Deficient knowledge regarding surgery related to
inexperience. Patient also expressing anxiety.
P—Explain routine preoperative preparation. Demonstrate
and explain rationale for turning, coughing, and deep
breathing (TCDB) exercises. Provide explanation and
teaching booklet on postoperative nursing care.
 3. PIE DOCUMENTATION

• Similar to SOAP charting in its problem-

oriented nature
• simplifies documentation by unifying the care
plan and progress notes.
• no assessment information
• notes are numbered or labeled according
to the patient’s problems.
 3. PIE DOCUMENTATION

• P—Problem, I—Intervention, and E- Evaluation

PIE (Problem—Intervention—Evaluation)
P—Deficient knowledge regarding surgery related to
inexperience.
I—Explained normal preoperative preparations for surgery.
Demonstrated TCDB exercises. Provided booklet on
postoperative nursing care.
E—Demonstrated TCDB exercises correctly. Needs review of
postoperative nursing care.
 4. FOCUS CHARTING

• Involves the use of DAR notes

– Data, SUBJECTIVE & OBJECTIVE
– Action, NURSING INTERVENTION
– Response EVALUATION OF EFFECTIVENESS
 4. FOCUS CHARTING

D – Stated, “I’m worried about what it will be like after

surgery.” Asking frequent questions about surgery. Has
had no previous experience with surgery.
TURN, COUGH Wife present
DEEP BREATHING
and is supportive.
A – Explained normal preoperative preparations for surgery.
Demonstrated TCDB exercises. Provided booklet on
postoperative nursing care.
R – Demonstrates TCDB exercises correctly. Needs review
of postoperative nursing care. States, “I feel better
knowing a little bit of what to expect.”
 5. CHARTING BY EXCEPTION

• Focuses on documenting deviations from

established forms
§ Saves time & highlights changes in patient’s condition
• Standards are integrated into documentation
forms (normal findings) or predetermined
interventions
• Nurse only writes progress note only if goals
from the form is not met
 5. CHARTING BY EXCEPTION

• Flow sheets, standards of nursing care…

 6. COMPUTERIZED DOCUMENTATION

• Facilitate focus on patient outcomes

• Can sync info from monitoring equipment
• Links various sources of client
information
• Bedside terminal eliminates the need to
take noted before recording
• Check an order before administering
medication
 7. CASE MANAGEMENT

• Incorporates interdisciplinary approach to

documenting patient care
• Standardized plan of care into CRITICAL
PATHWAYS for a specific disease or condition

care plan that include patient problems, key interventio

ns and expected outcomes within a time frame