GUIDELINES,

PROTOCOLS,
TOOLS IN
DOCUMENTATION
RELATED TO
CLIENT CARE
Mrs. Arsenia M. Garrido
Documentation & Reporting
Report – oral, written or computerized intended to convey
information to others.
Record – is a chart or a client record – a formal & legal
documents that provides evidence of client care.
Recording/charting/documenting – process of making entry
on the client record.
I. Purposes of Client Records:
1. Communication – served as communication for all
discipline.
2. Planning of client care – evaluate plan of care.
3. Auditing health agencies – record review if it conforms with
the standards.
4. Research – source of data for research.
5. Education – students used clinical record for plan of care.
6. Reimbursement – obtained payment from the govt.
7. Legal documents – used as evidence in court.
8. Health care analysis – overutilization or underutilization
of health service.
II. General Guidelines for Recording:
9. Client record is a legal document – it can be used as
evidence in court, nurse’s must maintain confidentiality
of the record.
10.Meet legal standards in the process of recording.
11.Document date & time for every recording.
12.Timing – recording should be done after an assessment or
intervention.
13.It must be legible & easy to record.
6. All entries must be made in dark permanent ink.
7. Use only commonly used, acceptable abbreviations,
symbols, terms that are specified by the agency &
internationally accepted.
8. Correct spelling for accuracy.
9. Every entry must have a signature & title.
10. Correct sequence or order.
11. Recording must be concise and complete.
12. Admissible in court (legal prudence).

III. General Guidelines for Recording:

13. Client record is a legal document – it can be used as
evidence in court, nurse’s must maintain confidentiality
of the record.
14. Meet legal standards in the process
IV. Documentation/Recording and Reporting
– Client record describe the on-going status of the
client.
– Reflect the full-range of the nursing process.

Different forms used:

I. Admission assessment
 Initial data-base
 Nursing history/assessment
II. Nursing care plan
– Assessment
– Nursing diagnosis
– Nursing intervention
– Outcomes
 (2) Types of nursing care plan
1. Traditional care plan – it has (3) columns.
1.1. nursing diagnosis
1.2. expected outcome
1.3. nursing intervention
2. Standardized care plan – addresses individual client
needs.
III. Kardex
– Concise method of recording & organizing data.
– Information quickly accessible to all health provider.
– Information such as:
1. Information of client – name, room, age, date admission
2. Allergies
3. Medication date and time of administration
 4. IV fluids date ordered administration
5. Daily tx and procedure
6. Diagnostic procedures – X-ray, cal
7. Specific data – diet, safety precaution
8. Problem list goals, intervention, evaluation

IV. Progress Notes

– Assessment, reassessment data.
– Information about client’s problems &
nursing intervention
V. Nursing Discharge/Summaries
– Includes discharge plan/instructions
given directly to the client & family.
(medications, activities, diet, tx, follow-
up visit)
– Referral of client
1. Within the facility – from one ward to
another for continuing of care (from ICU
to ward)
2. Transferred to other institution –
discharge note & referral slip (tx &
medication)
 “DOCUMENTATION SYSTEM”
I. Problem-Oriented Medical Record
(POMR)
– or Problem-Oriented Record (POR)
– Established by Lawrence Weed 1960’s
– Data are arranged according to the
problems of the client
– Member of the health team contribute
– To the problem
– Plan of care
– Progress note
Advantages of POMR:
1. Encourages collaboration
2. Problem list in the front of the chart alerts
caregivers to the clients needs.
Disadvantages:
3. Caregivers differ in their ability to use the
required charting format.
4. Take constant vigilance to maintain an up-to-
date list.
5. Inefficient because assessment & intervention
that apply to more than one problem.
4 Components of POMR:
1. Data Base
 Consist all information known about the client at first
visit to the health facility. It includes the:
1.1. nursing assessment
1.2. history
1.3. social & family data
1.4. result of physical examination
1.5. diagnostic test
2. Problem List
 Derived from the data base
 Kept at the front of the chart
 Problems are listed in the order in which they are
identified and resolved.
 Primary care providers write problems as medical
diagnosis, surgical procedure or symptoms.
  Nurses write problems as nursing diagnosis.
 As client’s changes, more data are obtained
 So it may be necessary to redefine problem.
3. Plan of Care
 It is made with reference to active problem
 Care plan are generated by the one who lists the problems
 Primary care providers – write physician’s orders
 Nurses – nursing care plans
 Written plan in the record is listed under each problem in
the progress note.
4. Progress Note
 A chart entry made by all health professionals involved in
client’s care
 They use the same sheet for notes
 They are numbered to correspond to the problems on the
problem list
II. SOAP format is usually used
S - ubjective data – information obtained from
what the client say. It possible quotes the
clients words. It is included only when it is
important & relevant to the problem.
O - bjective data – information that is measured
or observed by the uses of senses (vital signs,
laboratory, & other examination results).
A - ssessment – interpretation or conclusion
drawn about the subjective & objective data.
 During initial assessment, the problem list is
created from the data base so
 A – is the statement of the problem

 P - lan to solve a problem
I - ntervention - Specific care performed by the care
giver.
E - valuation - Client’s responses to nursing
interventions &
medical treatment
- Primarily reassessment data
Five components of the Evaluation Phase:
1. Collecting data related to the desired outcomes
(NOC indication)
2. Comparing data with the desired outcome
3. Relating nursing activities to outcome
4. Drawing conclusion about problem status
5. Continuing, modifying a terminating nursing care
plans
III. Charting by Exception
– A documentation system in which only
abnormal and significant findings or
exceptions to norms are recorded.
3 Key Elements:
1. Flow sheets – includes vital sign sheet – 1 & 0
– Graphic records (medication record, skin
assessment)
2. Standards of nursing care – documentation
that eliminates repetitive charting of routine.
3. Bedside access to chart form – flows kept at
bedside for immediate recording.
IV. Case Management
– Model emphasizes quality, cost-effective care delivered within
an established length of stay.
– A multidisciplinary approach to planning & documenting client
care using “CRITICAL PATHWAYS”
Critical Pathways
 A forms identify the outcomes that certain group of clients are
expected to achieve or each day of care along with the
interventions necessary for each day.
 If goals is met, no further charting is required.
Variance
 If goal is not met.
 Deviation from what was planned on the critical pathways –
unexpected occurrences that affect the plan.
 The nurse document the unexpected event, the cause & actions
taken to correct the situation.
 Complicated case are difficult to document on critical pathway.
V. Electronic Health Record (EHR)
– Computerized documentation.
– Are used to manage the huge volume of
information.
– It can integrate all pertinent client information
into one record.
– Store client’s data base, add new data, create
& revise care plans & document client’s
progress.
– Multiple flow sheets are not needed because
information can easily be retrieved.
– It makes care planning & documentation easy
Informatics – refers to the science of computer information
systems.
Health informatics – “health information technology”
- management of health information technology using
computers.
Nursing informatics – the science of using computer information
systems in the practice of nursing.
2006 - Technology Informatics Guiding Education Reforms (TIGER)
- designed plans to:
1. Enhance the nurses ability to use electronic health record to
improve health delivery.
2. Nurses to engaged in influencing the national health care
information system infrastructure.
3. Speed adoption of technology that can enhance the health
care safety & effectiveness.
Selected Pros and Cons of Computer Documentation
PROS
1. Computer records can facilitate a focus on client outcomes.
2. Bedside terminals can synthesize information from
monitoring equipment.
3. Such systems allow nurses to use their time more efficiently.
4. The system links various sources of client information.
5. Client information, requests, and results are sent and
received quickly.
6. Links to monitors improve accuracy of documentation.
7. Bedside terminals eliminate the need to take notes on a
worksheet before recording.
8. Bedside terminals permit the nurse to check an order
immediately before administering a treatment or medication.
9. Information is legible.
10.The system incorporates and reinforces
standards of care.
11.Standard terminology improves communication.

CONS
12.Client’s privacy may be infringed on if security
measures are not used.
13.Breakdowns make information temporarily
unavailable.
14.The system is expensive.
15.Extended training periods may be required when
a new or updated system is installed.
Examples of Common Computer-Related Acronyms:
1. CAI – Computer-assisted instruction
2. CPOE – Computerized provider (or physician) order
entry
3. CPR – Computer-based patient record
4. EDI – Electronic data interchange

2 most common types of computer systems used by a

nurse:
5. Management Information System (MIS)
 Designed to facilitate the structure & application of
data used to manage an organization or department.
 Provide analyses used for strategic planning, decision
making & evaluation of management activities.
2. Hospital Information System (HIS)
 Is a MIS that focuses on the types of data needed to
manage client care activities & health care organization.
 Provide people with the data needed to determine
appropriate actions.
I. Technology in Nursing Education
– Computers enhance academics for both students &
faculty by:
1. Access to literature
 Updated indexes of related materials can be searched.
 Users can select all or certain citations either print them
or store them in their computer.
 Complete publication & materials are available in
computerized format.
 Access statistics from Centers for Disease Control.

2. Computer – Assisted instructions

 Programs covered from CAI
Drug dosage calculations.
 Ethical decision making (Legal-aspects of nursing)
 ECG interpretation
3. Classroom Technology
 Access to internet.
 Mannequins used to stimulate realistic health care.
4. Distance-learning
 Educational opportunities in which the teacher &
student or learner are not physically present in the
same place at the same time.
Asynchronous – person involved not interacting at
the same time.
Synchronous – teacher & learner are communicating
simultaneously.
5. Computers can be used for learning evaluation.
1. Test banks
2. Data and record management of students
II. Technology in Nursing Practice
– Computers will assist the nurse in collecting & using
data through:
1. Documentation of Client Status & Record Keeping
1.1 Bedside Data Entry
 Client assessment
 Medication recording
 Progress notes
 Care plan updating
 Changes

2. Computer Based Client’s Records

4 Ways HER can improve health care:
1. Constant availability of client health information across
the life span.
2. Monitor quality
 3. Access to warehoused (stored) data.
4. Ability for clients to share in knowledge & activities
influencing their own health.
4. Data Standardization & Classifications
 Nurses benefits from the use of standard classification &
terms to describe & measure clinical disease procedures
& outcome data. (e.g. laboratory test results)
5. Tracking Client Status
 Other health provider can examined progress toward &
variance from the expected plan directly from the
computer.
6. Clinical Decision Support System
 Electronic forms/tools which incorporate evidence from
the literature into particular situation to guide care
planning.
  Characteristics of individual clients are used to generate client
specific assessments & recommendation.

Electronic Access to Client Data

 Data collected can be stored & transmitted to consulting
specialist.
1. Client monitoring & computerized diagnostic examination.
 Used of digital scales, pulse oximeter, thermometer, ECG
telemetry, fetal heart monitor, blood glucose analysis,
ventilator, IV infusion pumps.
 In specialty areas, MRI – computerized axial tomography (CT
scan), blood gas analyzes, pulmonary function test.
2. Telemedicine/telehealth
 Uses technology to transmit electronic data about clients to
persons at distal locations. (e.g. 2 way audio-visual communication
allows an international expert to examine & consult on a client.
Technology in Nursing Administration
– Computers are used in administration to manage the
following:
1. Human Resources
 A database of all employees.

2. Medical Records Management

 client’s records are easily search & relate to other
discipline.
3. Facilities Management
 Air-condition, ventilation, and alarm are computer
controlled.
4. Budget & Finance
 Billing & claims are transmitted quickly and complete
& accurate.
 5. Quality Assurance & Review
 External & internal stakeholder able to know that the
organization has a positive results & can examine
trends & uses of resources.
(e.g. length of stay, occupancy rate)
6. Accreditation
 Facilities must maintain database of policies and
procedures, standards of care & employees
accomplishment for accreditation process.

Technology in Nursing Research

 Computers are valuable assistance in conducting nursing
research.
 Computers facilitate, generate, refinements, analysis and
output of data in the whole nursing research process.
Evaluating the quality of nursing care:
1. Quality Assessment (QA) Program
 on-going systematic process designed to evaluate
and promote excellence in the health care
provided to client.
 quality assurance evaluate (3) components of
care.
a. Structure evaluation – focuses on the setting in
which care given (facilities, manpower, budget)
(organization, environment)
b. Process evaluation – focuses on how care was
given “Is the care relevant to the needs,
appropriate, complete, timely”
c. Outcome evaluation – focuses on demonstrable
changes in the client’s health status (how many)
QUALITY IMPROVEMENT
 “Continuous Quality Improvement”
 Total quality management, performance improvement
2000 – Committee on Quality of Health Care in America
of the Institute of Medicine”. The care should be safe,
effective, client centered, timely, efficient, and
equitable.
 Center for quality improvement & patient’s safety-
within the agency for Health Care Research & Quality
mission “To improve the quality & safety of all”
 Quality & safety education for nurses (QSEN)
QSEN Competencies:
- knowledge, skills, and attitude.
- safety (risk of harm to patients and providers)
 Nursing audit – examination or review of record
1. Retrospective audit
– evaluation of clients discharge record.
2. Concurrent audit
 evaluation of clients while client is still in the
hospital / receiving care.
 Observation, interviewing.
3. Peer review
 A nurse functioning in the same level, review and
appraise the quality of care.
 It is based on the pre-established standard.
R - evision - reflects care plan
modifications/changes made
by the evaluation. It is in desired outcomes
intervention or target dates.
New versions of the format eliminate:
1. Subjective data
2. Objective data

Start with assessment (APIE or APIER)

VI. FOCUS CHARTING
Is a method of organizing the narrative
documentation to include DAR to each
identified concern or focus.
Is a method for organizing health information
of the individuals record.
It is a systematic approach to documentation,
using nursing terminology to describe
individuals status and nursing action.
FOCUS
A current individual concern or
behavior, ex. Nausea, chest pain
A sign or symptoms of importance to
the nursing , medical diagnosis, or
treatment plan, ex. Fever,
constipation
An acute change in an individuals
condition ex. Respiratory distress,
seizure
A significant event in an individuals care
ex. Change in diet, catheterization, blood
transfusion
A key word or phrase indicating
compliance with standard care or policy.
Ex teaching plan
 PURPOSE

brings the focus of care back to the patient and

the patients’ concerns. Instead of a problem list
or list of nursing and medical diagnosis, a focus
column is used that incorporates many aspects
of patient and patient care.
The principal advantage of focus charting is in
the holistic emphasis on the patient and his/her
priorities including ease in charting.
 Objectives

To easily identify critical patient

issues/concerns in the progress notes.
To facilitate communication among all
disciplines.
Encourages the nurse to use the nursing
process and to evaluate the patients
response.
Encourages nurse to identify a broaden scope
of patient concerns, not just a problem.
General Guidelines
 Focus charting must be evident at least once
every shift.
 Focus charting must be patient-oriented not
nursing task-oriented.
 Separate the topic words from the body of
notes:
 Focus note written on the second column.
 Data, Action and Response on the third
column.
Separate the topic words from the
body of notes:
Focus note written on the second
column.
Data, Action and Response on the
third column.
Sign name for every time entry.
Document patient’s status on
admission, for every transfer to/from
another unit or discharge.
Follow the do’s of documentation.
For eight hours shift, use blue or black
ink for morning and afternoon shift, red
ink for night shift.
Specific Guidelines;

Begin with comprehensive

assessment of the patient using
inspection, palpation, percussion
and auscultation (IPPA).
Include in the assessment, collection
of information from the patient,
family, existing health records (such
as checklist/floor sheets, laboratory
results and other health care
providers.
 Establish a focus of care, to be
addressed in the Progress Notes.
Focus
identifies the content or purpose of
the narrative entry and is separated
from the body of the notes in order
to promote easy data retrieval and
communication.
DATA
 is the subjective and/or objective
information supporting the stated
focus or describing the observation
at the time of a significant event.
 This category reflects the
assessment phase of the nursing
process.
 ACTION
 describes the nursing interventions
(independent, basic and perspective)
past, present or future., such as
medication, treatments, calls to physician
& patient teaching.

 Thiscategory reflects the planning and

implementation phase of the nursing
process.
RESPONSE
describes the patient
outcome/response to
interventions or describes how
the care plan goals have been
attained. This entry always
includes a new time.
DATA AND ACTION ARE RESPONDED AT ONE HOUR
AND RESPONSE IS NOT ADDED UNTIL LATER, WHEN
THE PATIENT OUTCOME IS EVIDENT.
DATE / TIME FOCUS DATA, ACTION, RESPONSE

09/ 15/ 08 Chest D= “Sumasakit ang dibdib

10 AM Pain ko”
Midclavicular line, pain
of 4 on scale of 5
A= Medicated with Isordil
5mg, SL Carol Sy, RN
12 PM Chest R= resting in bed,”
Pain nabawasan na ng sakit ang
dibdib ko. Rating of 2.
Carol Sy, RN
DATA IS USED WHEN THE PURPOSE OF THE NOTE IS TO DOCUMENT ASSESSMENT
FINDING AND THERE IS NO FLOW SHEET/CHECKLIST FOR THAT PURPOSE.

DATE/ TIME FOCUS DATA, ACTION,

RESPONSE
19/15/08 Post transfer
10am assessment D: Received from RR via
stretcher, awake and
alert, vital signs stable,
IV right forearm patent,
foley catheter in place
with clear yellow urine,
dressing on RLQ is clean
and dry, moving all
extremities voluntarily,
"Minimal incisional pain
at this time rating 3.
_________
Carol Sy, RN.
OTHER EXAMPLE:
DATE / HOUR FOCUS PROGRESS NOTES
09/ 15/ 08 Pain D= Guarding abdominal incision.
10 AM Facial grimacing.
Rates pain at “8” on scale
of 0-10.
A= Administered morphine
sulfate 4
mg IV
12 PM Pain R= Rates pain at “1”. States
willing to
ambulate.
Carol Sy, RN
Poor Wording
 Eats poorly
 Patient confused
 Uncooperative
 Patient complains of pain
Better Wording
 Ate ½ meal and drank 80
ml fluid
 Does not recognize family
 Refuses to brush his own
teeth or wash own face
 Acute abdominal pain
described as sharp,
constant, RLQ, no relief from
tylenol
SUMMARY

Focus charting can help you monitor

patient problems and avoid repetitious
documentation, a focus which may be
written as a nursing diagnosis can be
change in an acute condition, a potential
problem, a treatment procedure or a
patient behavior
Reference:
• Kozier and Erb’s Fundamentals of
Nursing
Concepts, Process, and Practice (10th
edition)
Audrey Berman • Shirlee Snyder• Geralyn
Frandsen
• DOH Manual (Nursing Service
Department)
Exercises:
1. Rosa, 17 yrs. old, a student, accompanied by her friend in a teen
parent clinic because of amenorrhea & claimed that her last
menstrual period (LMP 1-20-19). She is experiencing nausea &
vomiting, dizziness, and fatigue. On assessment, Rosa, has a
positive pregnancy test, at 8 weeks AOG. BP – 110/70, PR – 70 bmp.
She cried loudly and stated, “I am afraid to go home, my parent will
kill me.”
a. Sort the following data of Rosa into a SOAPIE note & FDAR.
2. A 10 yr. old boy, admitted at the ER in stooped position complaining
of severe vomiting, fever, & right lower iliac pain. On assessment,
temp. 38.5˚C, PR – 70 bpm, RR – 25 bpm & elevated WBC count
25,000 /mm. On palpation, intense pain at Mc Burney’s point. He is
crying loudly, “Aray! Masakit ang aking tiyan, tulungan ninyo po
ako.”
a. Sort the following data of the client into a SOAPIE note & FDAR.
 Nursing Service Department
NURSE’S NOTE – (SOAPIE)
Last Name: First Name: Date Room No.: Bed No.: Hosp. No.:
Admitted:
Attending Physician Age: Sex: Civil
Status:
Nursing
S Needs & Problem: Evaluation and to
Date/Time Interventio
O Potential or Actual Endorse
n
PATIENT NAME: AGE/SEX: CIVIL STATUS: RELIGION:

Attending Physician Date admitted Room No. Bed No. Hosp. No.

NURSE’S PROGRESS NOTES (FOCUS CHARTING – FDAR)

Date/Time Focus Data, Action, Response

Reporting – to communicate specific information to a group of
people.
TYPES OF REPORTING:
1. Change-of-shifts reports “Endorsements”
Hand-off communication – a process in which information about
patient/client data is communicated in a consistent manner.
2. Telephone reports – changes in client condition results of
examination (Radiologic, lab)
3. Telephone orders – write the complete orders on the doctor’s
order form & read it back. Indicate the time & date & it must be
countersigned by the physician who ordered within 24 hours.
4. Case conference – done to discuss problems & possible
solutions, it is usually attended by multidisciplinary team.
5. Nursing round – summary of the client’s need & intervention
implemented.
THANK YOU