Documentation in Psychiatric Mental

Health Nursing Practice

Prepared by: VILMA R. MIGUEL

Clinical Instructor
 Learning Objectives:

 Discuss the purposes of client records in the psychiatric mental health nursing practice
 Explain measures used to maintain confidentiality and security of computerized client
records.
 Compare different documentation methods: source-oriented and problem-
oriented medical records, PIE, focus charting, charting by exception, computerized
records, and the case management model.
 Explain how various forms in the client record (e.g., critical pathways care plans,
Kardexes, flow sheets, progress notes, discharge/transfer forms) are used to document
steps of the nursing process.
 Compare and contrast the documentation needed for clients in acute care, long-term care, and home health care settings.
 Identify prohibited abbreviations, acronyms, and symbols that cannot be used in any form
of clinical documentation. 8. Identify essential guidelines for reporting client data.
Definition of Terms

 Documentation is an extremely essential nursing

function to monitor and maintain the standard of
care given to the patient.
 Record, also called a chart or client record, is a
formal, legal document that provides evidence
of a client’s care and can be written or computer
based.
 Recording, also called charting or documenting, is
the process of making an entry on a client record.
 Definition of Terms

 Critical Pathway
Also known as care pathway, integrated care pathway, clinical pathway, or care
map, is one of the main tools used to manage the quality in healthcare concerning
the standardization of care processes. It has been shown that their
implementation reduces the variability in clinical practice and improves outcomes.
Clinical pathways aim to promote organized and efficient patient care
based on evidence-based medicine, and aim to optimize outcomes in settings
such as acute care
and home care.
Definition of Terms

 Case Management
It is a collaborative process of assessment, planning,
facilitation, care coordination, evaluation and advocacy
for options and services to meet an individual’s and
family’s comprehensive health needs through
communication and available resources to promote
patient safety, quality of care, and cost effective
outcomes.
Definition of Terms

 Handoff report
Nurse bedside shift report, or handoff, has been defined
in the literature as a process of exchanging vital patient
information, responsibility, and accountability between
the off-going and oncoming nurses in an effort to ensure
safe continuity of care and the delivery of best clinical
practices.
Purposes of Documentation in the Nursing Practice

 Communication
 Planning Client Care
 Auditing Health Agencies
 Research
 Education
 Reimbursement
 Legal Documentation
 Health Care Analysis
Purposes of Documentation in the Nursing Practice

Communication.
The record serves as the vehicle by which different health
professionals who interact with a client communicate with each
other.
Planning Client Care.
Each health professional uses data from the client’s record to
plan care for that client. A primary care provider, for example,
may order a specific antibiotic after establishing that the client’s
temperature is steadily rising and that laboratory tests reveal
the presence of a certain microorganism
Purposes of Documentation in the Nursing Practice

Auditing Health Agencies.

An audit is a review of client records for quality assurance
purposes
Accrediting agencies.
The accrediting body may review client records to determine if a
particular health agency is meeting its stated standards.
Research.
The information contained in a record can be a valuable source of data
for research. The treatment plans for a number of clients with the same
health problems can
yield information helpful in treating other clients.
 Purposes of Documentation in the Nursing Practice

Education
Students in health disciplines often use client records as educational tools. A
record can frequently provide a comprehensive view of the client, the illness,
effective treatment strategies, and factors that affect the outcome of the illness.
Reimbursement
Documentation also helps a facility receive reimbursement from the
government. For a facility to obtain payment through Medicare, the client’s
clinical record must contain the correct diagnosis- related group (DRG) codes
and reveal that the appropriate care has been given.
Purposes of Documentation in the Nursing Practice

Legal Documentation
The client’s record is a legal document and is usually admissible in
court as evidence. In some
jurisdictions, however, the record is considered inadmissible as
evidence when the client objects, because information the client gives
to the primary care provider is confidential.
Health Care Analysis
Information from records may assist health care planners to identify
agency needs, such as overutilized and underutilized hospital
services. Records can be used to establish the costs of various
services.
 DOCUMENTATION RECORDS / SYSTEMS

 Source-Oriented Record
The traditional client record is a source-oriented record. Each person or
department makes notations in a separate section or sections of the
client’s chart. For example, the admissions department has an
admission sheet; the primary care provider has a physician’s order form,
a physician’s history sheet, and progress notes; nurses use the nurses’
notes; and other departments or personnel have their own records. In
this type of record, information about a particular problem
is distributed throughout the record.
DOCUMENTATION RECORDS / SYSTEMS

 Problem-Oriented Medical Record

In the problem-oriented medical record (POMR), or
problem-oriented record (POR), established
by Lawrence Weed in the 1960s, the data are arranged
according to the problems the client has rather than the
source of the information. Members of the health care
team contribute to the problem list, plan of care, and
progress notes. Plans for each active or potential
problem are drawn up, and progress notes are recorded
for each problem.
DOCUMENTATION RECORDS / SYSTEMS

 PIE
The PIE documentation model groups information into three
categories. PIE is an acronym for problems, interventions, and
evaluation of nursing care. This system consists of a client care
assessment flow sheet and progress notes. The flow sheet uses
specific assessment criteria in a particular format, such as human
needs or functional health patterns. The time parameters for a
flow sheet can vary from minutes to months.
In a hospital intensive care unit, for example, a client’s blood
pressure may be monitored by the minute, whereas in an
ambulatory clinic a client’s blood glucose level may be recorded
once a month.
DOCUMENTATION RECORDS / SYSTEMS

 Focus Charting
Focus charting is intended to make the client and client concerns and strengths the
focus of care.
Three columns for recording are usually used: date and time, focus, and progress
notes. The focus may be a condition, a nursing diagnosis, a behavior, a sign or
symptom, an acute change in the
client’s condition, or a client strength.

The progress notes are organized into (D) data, (A) action, and (R) response,
referred to as DAR.
The data category reflects the assessment phase of the nursing process and
consists of observations of client status and behaviors, including data from flow
sheets (e.g., vital signs, pupil reactivity). The nurse records both subjective and
objective data in this section.
DOCUMENTATION RECORDS / SYSTEMS

 Charting by Exception
Charting by exception (CBE) is a documentation system in
which only abnormal or significant
findings or exceptions to norms are recorded. CBE
incorporates 3 key elements (Guido, 2010):
1. Flow sheets.
Examples of flow sheets include:
a. graphic records of a vital sign sheet;
b. head and face assessment in a daily nursing
assessments record;
c. Braden assessment of the skin
DOCUMENTATION RECORDS / SYSTEMS

Charting by Exception (ELEMENTS)

 2. Standards of nursing care. Documentation by reference to the
agency’s printed standards of nursing practice eliminates much of the
repetitive charting of routine care. An agency using CBE
must develop its own specific standards of nursing practice that identify
the minimum criteria for client care regardless of clinical area. Some
units may also have unit-specific standards unique to
their type of client.
DOCUMENTATION RECORDS / SYSTEMS

Charting by Exception (ELEMENTS)

3. Bedside access to chart forms. In the CBE system, all
flow sheets are kept at the client’s bedside to allow
immediate recording and to eliminate the need to transcribe
data from the nurse’s to the permanent record.
DOCUMENTATION RECORDS / SYSTEMS

 Computerized Documentation
Electronic health records (EHRs) are used to manage the
huge volume of information required in contemporary
health care. That is, the EHR can integrate all pertinent
client information into one record. Nurses use computers
to store the client’s database, add new data, create and
revise care plans, and document client progress. Some
institutions have a computer terminal at each client’s
bedside, or nurses carry a small handheld terminal,
enabling the nurse to document care immediately after it
is given.
DOCUMENTATION RECORDS / SYSTEMS

 Case Management
The case management model emphasizes quality, cost-
effective care delivered within an established length of
stay. This model uses a multidisciplinary approach to
planning and documenting client care, using critical
pathways. These forms 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.
GENERAL GUIDELINES FOR RECORDING

 Date and Time

Document the date and time of each recording. This is essential not only for legal
reasons but also
for client safety. Record the time in the conventional manner (e.g., 9:00 am or 3:15
pm) or according to the 24-hour clock (military clock), which avoids confusion about
whether a time was am or pm.
 Timing
Follow the agency’s policy about the frequency of documenting, and adjust the
frequency as a client’s condition indicates; for example, a client whose blood pressure
is changing requires more frequent documentation than a client whose blood pressure
is constant.
As a rule, documenting should be done as soon as possible after an assessment or
intervention.
No recording should be done before providing nursing care.
GENERAL GUIDELINES FOR RECORDING

Legibility
All entries must be legible and easy to read to prevent interpretation
errors. Hand printing or easily understood handwriting is usually
permissible. Follow the agency’s policies about handwritten
recording.

Permanence
All entries on the client’s record are made in dark ink so that the re- cord
is permanent and changes can be identified. Dark ink reproduces well on
microfilm and in duplication processes. Follow the agency’s policies about
the type of pen and ink used for recording.
In regards to EHRs, changes are made in accordance with the software
guidelines. It is important for the nurse to understand the policies and
procedures of the health care institution regarding documentation.
GENERAL GUIDELINES FOR RECORDING

 Accepted Terminology
Abbreviations are used because they are short, convenient, and easy
to use. Abbreviations are convenient; however, they are often
ambiguous. This ambiguity places the client at risk for medical errors
and significant harm, possibly even death (Galliers, Wilson, Randell, &
Woodward, 2011).
Ambiguity occurs when an abbreviation can stand for more than one
term, leading to misinterpretation.
GENERAL GUIDELINES FOR RECORDING

 Correct Spelling
Correct spelling is essential for accuracy in recording. If unsure how to spell a
word, look it up in a dictionary or other resource book. Two decidedly different
medications may have similar spellings;
for example, Fosamax and Flomax.

 Signature
Each recording on the nursing notes is signed by the nurse making it. The
signature includes the name and title; for example, “Susan J. Green, RN” or “SJ
Green, RN.” Some agencies have a
signature sheet and after signing this signature sheet, nurses can use their
initials.
With computerized charting, each nurse has his or her own code, which allows
the documentation to be identified.
GENERAL GUIDELINES FOR RECORDING

 Accuracy
The client’s name and identifying information should be stamped or written on each
page of the clinical record. Before making an entry, check that the chart is the
correct one. Do not identify charts by room number only; check the client’s name.
Special care is needed when caring for clients with the same last name.
Record only information that pertains to the client’s health problems and care. Any
other personal information that the client conveys is inappropriate for the record.
Recording irrelevant information
may be considered an invasion of the client’s privacy and/or libelous.
A client’s disclosure that she was addicted to heroin 15 years ago, for example,
would not be
recorded on the client’s medical record unless it had a direct bearing on the client’s
health problem.
GENERAL GUIDELINES FOR RECORDING

 Sequence
Document events in the order in which they occur; for
example, record assessments, then the nursing
interventions, and then the client’s responses. Update or
delete problems as needed.
 Conciseness
Recordings need to be brief as well as complete to save
time in communication. The client’s name and the word
client are omitted.
For example, write “Perspiring profusely. Respirations
shallow, 28/min.” End each thought or sentence with a
period.
GENERAL GUIDELINES FOR RECORDING

 Completeness
Not all data that a nurse obtains about a client can be
recorded. However, the information that is
recorded needs to be complete and helpful to the client
and health care professionals.
Nurses’ notes need to reflect the nursing process.
Record all assessments, dependent and
independent nursing interventions, client problems, client
comments and responses to interventions and tests,
progress toward goals, and communication with other
members of the health team.
GENERAL GUIDELINES FOR RECORDING

Legal Prudence
Accurate, complete documentation should give legal
protection to the nurse, the client’s other caregivers, the
health care facility, and the client. Admissible in court as a
legal document, the clinical record provides proof of the
quality of care given to a client. Documentation is usually
viewed by juries and attorneys as the best evidence of what
really happened to the client.
DOCUMENTATION PRINCIPLES:

 The only evidence available years later

 Used to reconstruct the care provided
 Considered to be an accurate reflection of
care provided to the patient
 Scrutinized by both plaintiff and defense
attorneys
 Should paint a factual picture of past events
 May reflect upon professional credibility
The Medical Record Should Contain The Following Types
Of Information:

 Thorough history
 Relevant information regarding diagnosis and treatment
 Assessment of suicide/violence
 Consultations regarding medications prescribed with
dosages and any observable side effects. If there are
observable side effects, documentation that the behavioral
health provider has contacted the prescribing provider.
 Informed consent
 Treatment compliance/non-compliance (describe objectively)
 Boundary issues
 Termination
What May Not Be Documented In Behavioral Health:

Detailed account of sexuality

• Interpersonal conflicts
• Issues that may be embarrassing to the patient if
disclosed
• Third party names
But In Some Cases:
• Sexual behavior
• Criminal behavior/history
When Documenting In An EMR System, It Is Important To
Remember The Following Additional Principles:

 Use only approved abbreviations, acronyms and

symbols
 Exercise caution when moving from one patient record
to another
 Do not cut and paste information from one EMR data
field to another
 Link each data field in the EMR to the patient by name
and health record number
 When referring to another patient, use that patient’s
health record number, not his/ her name
When Documenting In An EMR System, It Is Important To
Remember The Following Additional Principles:

 Each entry and signature must be associated with a

date/time stamp
 Avoid relying upon templates or diagnosis aids
 Ensure patient data is encrypted and avoid removing
portable devices from the office if they contain patient data
 Make sure your system indicates when modifications are
made to patient record
 Preserve all electronic data, emails, phone messages and
computer records
 Do not delete information
 Do not give out your “login password”
Correcting Medical Record Information:

 Draw a single line through entry errors (make sure

original entry is still legible) • Write “mistaken entry”
 Use first initial and last name
 Write the correct entry as close as possible, but not over
it.
 Sign and date the entry (including time)
 Document the correct entry
 DO NOT alter the original entry, or “black it out”
Correcting Medical Record Information:

When correcting an error in an EMR, keep in mind the

following:
Every entry should be date, time, author stamped
 A symbol identifying new/additional entries should be
viewable
The original entry should still be viewable, “strike through”
methods with author, date, time, commentary, linked to the
original entry are often used
Note the reason for the correction
If a hard copy is printed, the hard copy must also be
corrected
DO’S AND DON’TS FOR
WRITTEN DOCUMENTATION

 DO
• Write legibly in permanent ink
• Put patient ID # on each page
• Sign, initial and date (month, day, year, time), each entry
• Make entries as soon as possible (do not make entries in
advance and identify late entries as such)
• Incorporate prior records into documentation
• Include test results/consultations in record as well as notes
that you reviewed.
• Document informed consent/refusal
DO’S AND DON’TS FOR
WRITTEN DOCUMENTATION

• Use specific, factual, objective language, and not language

that speculates, opines, or is subjective in nature
• Document all facts relevant to an event, course of
treatment, patient condition, and response to treatment
• Document rationale for deviating from standard treatment,
when applicable
DO’S AND DON’TS FOR
WRITTEN DOCUMENTATION

 DON’T
• Don’t leave blank areas on a page
• Don’t squeeze in late entries
• Don’t use personal/non-standard abbreviations when
documenting
• Don’t include names of informal consults, nor should
informal consults document in the medical record
• Avoid using words like error, mistake, accident, inadvertent,
and malpractice
• Don’t erase/ block out entered information
DOCUMENTING NURSING ACTIVITIES

 The client record should describe the client’s ongoing

status and reflect the full range of the nursing process.
Regardless of the records system used in an agency,
nurses document evidence of the nursing process on a
variety of forms throughout the clinical record.
TYPES of DOCUMENTATION
SOAPIE and SOAPIER

Subjective Background or historical information that may be relevant to

understanding the patient’s current or future clinical state such as description of events
leading from the last encounter to the current visit, pertinent past and family histories,
social habits placing the patient at risk for disease, current medications used to manage
existing conditions and known allergies.

Objective Observable, measurable or quantifiable data obtained from past records,

physical examinations, tests, procedures, screenings and other diagnostic techniques.

Assessment Possible diagnosis including reported differentials and

impressions by the dictating physician or clinical staff treating the patient.

Plan Completed or follow-up care plans, treatment actions,

education.

Not applicable Irreconcilable statements that don’t apply to the previous classes
 Example of a SOAPI note:

 “S –Mr. Smith is an 88-year-old male with a diagnosis of congestive heart

failure. The patient is alert and oriented x 1 but pleasantly confused. He
complained of shortness of breath on this shift and stated the 2 liters of oxygen
made him feel better. He verbally denied pain and his nonverbal pain score
was 0. His daughter visited today and advised that he was trying to climb out
of bed to go to the bathroom because of his confusion. She stated he “forgot
he was in the hospital.”
 O –Today, the patient’s vital signs were as follows: BP 162/82, Pulse 64 and
regular, Respirations 20 per minute, and pulse ox 98% on 2L Oxygen via nasal
cannula. His lungs are diminished with scattered crackles. Bowel sounds are
active, and the patient had a bowel movement x 2 today, both soft. Incontinent
of urine and wearing a diaper. Skin intact at this time. Skin color is pale. 2+
non-pitting edema noted in bilateral calves and ankles.
Example of a SOAPI note:

 A –The patient’s status is improving, and he is less short of breath than in

previous days. He continues with edema. Currently, the patient is at risk for
falls due to confusion and will need fall precautions enforced.
 P –Initiate fall precautions with a bed alarm/body alarm. Continue with Lasix
for diuresis. Awaiting cardiology consult tomorrow. Pt had an echocardiogram
today, and the results are pending.
 I –Assessed patient and reconciled medications. Spoke with daughter, pt’s
power of attorney, to provide update and education on patient’s condition.
Laboratory obtained morning labs without a problem, and vascular therapy
placed a new 18g peripheral IV as the previous one was due for a change. Pt
took all morning meds without a problem. Reoriented patient and provided
opportunities for toileting and for making needs known every 1-2 hours today
to lessen the risk of fall.”
NARRATIVE SOAPIE and SOAPIER

 The acronyms SOAPIE and SOAPIER refer to formats that

add interventions, evaluation,
and revision:
I—Interventions refer to the specific interventions that have
actually been performed by
the caregiver.
E—Evaluation includes client responses to nursing
interventions and medical treatments.
This is primarily reassessment data.
R—Revision reflects care plan modifications suggested by
the evaluation. Changes may be made in desired outcomes,
interventions, or target dates. Newer versions of this format
eliminate the subjective and objective data and start with
assessment, which combines the subjective and objective.
Focus charting

 Focus Charting of F-DAR is intended to make the client and

client concerns and strengths the focus of care. It is a method
of organizing health information in an individual’s record.
 Focus Charting is a systematic approach to documentation.
 Focus Charting Parts
Three columns are usually used in Focus Charting for
documentation:
• Date and Hour
• Focus
• Progress Notes
Focus charting

 The progress notes are organized into (D) data, (A) action, and
(R) response, referred to as DAR (third column)

Date/Hour Focus Progress Notes

11/17/2021 Focus of care, this •Data
8:00pm may be:a  •Action
nursing diagnosi •Response
s

a sign or a
symptom
an acute change in
the condition
behavior
Focus charting

Progress Notes
Data (D)
The data category is like the assessment phase of the nursing process. It is in
this category that you would be writing your assessment cues like: vital signs,
behaviors, and other observations noticed from the patient. Both subjective and
objective data are recorded in the data category.
Action (A)
The action category reflects the planning and implementation phase of the
nursing process and includes immediate and future nursing actions. It may also
include any changes to the plan of care.
Response (R)
The response category reflects the evaluation phase of the nursing process and
describes the client’s response to any nursing and medical care.
F-DAR for Hyperthermia

Focus charting

Date/Hour Focus Progress Notes

11/20/2021 Hyperthermia D:
8:00am •Temperature of 38.9 OC via axilla
•Skin is flushed and warm to touch
A:
•Tepid Sponge Bath (TSB) done
7:30pm
•Administered 150mg IV Paracetamol as per doctor’s
order
•Encouraged adequate oral fluid intake
•Encouraged adequate rest
R:
10:00pm
•Temperature decreased from 38.9 to 37.1 OC
 SBAR

 SBAR stands for Situation, Background, Assessment and Recommendation. According to

Safer Healthcare, SBAR was originally developed by the U.S. Navy as a way to
communicate information on nuclear submarines. However, the healthcare system adopted
it in the 1990s, and now it’s used worldwide.
 According to the Institute for Healthcare Improvement, “SBAR is an easy-to-remember,
concrete mechanism useful for framing any conversation, especially critical ones, requiring
a clinician’s immediate attention and action.” It gives clinicians a specific, unambiguous
way to communicate critical information to one another, leaving little room for error and
minimizing the chance that a miscommunication will cause patient deterioration.
 The components of SBAR are as follows:
• Situation: Clearly and briefly describe the current situation.
• Background: Provide clear, relevant background information on the patient.
• Assessment: State your professional conclusion, based on the situation and background.
• Recommendation: Tell the person with whom you’re communicating what you need from
him or her, in a clear and relevant way.
SBAR

When calling the physician, follow the SBAR process:

 (S) Situation: What is the situation you are calling about?
Identify self, unit, patient, room number. Briefly state the
problem, what is it, when it happened or started, and how
severe.
(B) Background: Pertinent background information related
to the situation could include the following: The admitting
diagnosis and date of admission. List of current medications,
allergies, IV fluids, and labs Most recent vital signs. Lab
results: provide the date and time test was done and results
of previous tests for comparison. Other clinical information.
Code status
SBAR

 (A) Assessment: What is the nurse’s assessment of the

situation?
 (R) Recommendation: What is the nurse’s
recommendation or what does he/she want?
Examples: Notification that patient has been admitted
Patient needs to be seen now Order change. Document
the change in the patient’s condition and physician
notification
SBAR

Example; SBAR Report to Physician about a Critical Situation

S Situation. Dr. King, this is Shen Co calling from the ER
complex. I have Mr. Red in Room 311, a 53- year-old man who
looks pale and sweaty, feels confused and weak, and is
complaining of chest pain rated as 7/10.
B Background • He has a history of HTN. • He was admitted
for a GI bleed • His vital signs are BP 100/60, pulse 120, RR 21
A Assessment I think he’s got an active bleed and we can’t
rule out an MI, but we don’t have a troponin or a recent lab
results
 R Recommendation I’d like to get an EKG and labs, and I
need for you to evaluate him right away
ADPIE Method

 A – Assessment. Includes the subjective and objective data supporting the identified
problem.
D – Diagnosis. Provides direction to what interventions should be used for the client. This
part
of the charting is usually stated in a two-part format accepted by the North American
Nursing
Diagnosis Association (NANDA) – the diagnostic statement follow the problem, etiology
and
symptom (PES)
P – Planning. Include specific orders designed to manage the problem of the client, collect
additional data about the problem and the goals of care.
I – Interventions. These refers to the actions taken by the nurse relevant to the presented
problem. It includes independent, dependent and collaborative nursing actions
E – Evaluation. Evaluates the response of the c lient to the interventions performed.
Computerized Documentation Electronic health records (EHRs)

 are used to manage the huge volume of information

required in contemporary health care. That is, the EHR
can integrate all pertinent client information into one
record. Nurses use computers to store the client’s
database, add new data, create and revise care plans,
and document client progress.
Kardex

 A Kardex is a desktop file system that gives a brief overview

of each patient and is updated every shift. It is like having a
cheat sheet for nurses to reference that is separate from the
patient chart. It is usually kept in a central location, such as the
nursing station, for quick access.
 Principles in Nursing Documentation

 Accordingly, the American Nurses Association (ANA) presents these principles:

Principle 1. Documentation
Characteristics High quality documentation is:
• Accessible
• Accurate, relevant, and consistent
• Auditable
• Clear, concise, and complete
• Legible/readable (particularly in terms of the resolution and related qualities of
EHR content as it is displayed on the screens of various devices)
• Thoughtful
• Timely, contemporaneous, and sequential
• Reflective of the nursing process
 Principles in Nursing Documentation

 Principle 2. Education and Training

Nurses, in all settings and at all levels of service, must be provided
comprehensive education and training in the technical elements of
documentation and the organization’s policies and procedures that are
related to documentation. This education and training should include
staffing issues that take into account the time needed for documentation
work to ensure that each nurse is capable of the following:
• Functional and skillful use of the global documentation system
• Competence in the use of the computer and its supporting hardware
• Proficiency in the use of the software systems in which documentation or
other relevant patient, nursing and health care reports, documents, and
data are captured
Principles in Nursing Documentation

 Principle 3. Policies and Procedures

The nurse must be familiar with all organizational policies
and procedures related to documentation and apply
these as part of nursing practice. Of particular importance
are those policies or procedures on maintaining efficiency
in the use of the “downtime” system for documentation
when the available electronic systems do not function.
Principles in Nursing Documentation

 Principle 4. Protection Systems

Protection systems must be designed and built into
documentation systems, paper-based or
electronic, in order to provide the following as prescribed by
industry standards, governmental
mandates, accrediting agencies, and organizational policies
and procedures:
• Security of data
• Protection of patient identification,
• Confidentiality of patient information
• Confidentiality of clinical professionals’ information
• Confidentiality of organizational information
Principles in Nursing Documentation

 Principle 5. Documentation Entries

Entries into organization documents or the health record
(including but not limited to provider
orders) must be:
• Accurate, valid, and complete;
• Authenticated; that is, the information is truthful, the author
is identified, and nothing has been added or inserted;
• Dated and time-stamped by the persons who created the
entry;
• Legible/readable; and
• Made using standardized terminology, including acronyms
and symbols.
Principles in Nursing Documentation

 Principle 6. Standardized Terminologies

Because standardized terminologies permit data to be
aggregated and analyzed, these
terminologies should include the terms that are used to
describe the planning, delivery, and
evaluation of the nursing care of the patient or client in
diverse settings
Responsibilities of the Nurse in Documentation

 1. The nurse understands his/her accountability for documenting

on the clinical record the care
he/she personally provides to the clients.
2. The nurse documents the care process including information
or concerns communicated to
another health care provider.
3. The nurse documents all relevant information about clients in
chronological order with date
and time.
4. The nurse carries out comprehensive, in-depth and frequent
documentation when clients are acutely ill, high risk or have
complex health problems.
5. The nurse documents timely the care he/she provides.
Responsibilities of the Nurse in Documentation

 6. The nurse corrects any documentation error in a timely and

forthright manner.
7. The nurse remarks any late entry, if indicated, with both
date and time of the late entry and of the actual event.
8. The nurse indicates his/her accountability by adding his/her
signature and title as approved by his/her organization to each
entry and correction he/she makes on the clinical record.
9. The nurse safeguards the privacy, security and
confidentiality of clinical record by appropriate storage and
custody.
10. The nurse updates himself/herself with contemporary
documentation knowledge.

END
HIGHLIGHTS

 Client records are legal documents that provide evidence of a client’s care.
 The nurse has a legal and ethical duty to maintain confidentiality of the
client’s record; this includes special
measures to protect client information stored in computers.
 Client records are kept for a number of purposes, including
communication, planning client care, auditing health agencies, research,
education, reimbursement, legal documentation, and health care analysis.
 Examples of documentation systems include source oriented, problem
oriented, PIE, focus charting, charting by , computerized documentation,
and case management.
.
 HIGHLIGHTS

 In source-oriented clinical records, each health care professional group provides its
own record. Recording is oriented around the source of the information.
 In problem-oriented clinical records, recording is organized around client problems.
 Computers make care planning and documentation relatively easy. The use of
computer terminals at the bedside allows immediate documentation of nursing actions.
 The case management model emphasizes quality, cost-effective care delivered within
an established length of stay.
 The Kardex is used to organize client data, making information quick to access for
health professionals.
HIGHLIGHTS

 Nursing progress notes provide information about the progress the client
is making toward desired outcomes. The format for the progress note
depends on the documentation system at the facility.
 Long-term documentation varies depending on the level of care provided
and requirements set by Medicare and Medicaid.
 Home health agencies must standardize their documentation methods to
meet requirements for Medicare and other third-party disbursements.
 Legal guidelines for the process of recording in a client record include
documenting date and time, legible entries, using dark ink, using
accepted terminology and spelling, accuracy, sequence, appropriateness,
completeness, conciseness, and including an appropriate signature.
 References

American Nurses Association. (2001). Code of ethics for nurses with

interpretive statements.
Washington, DC: Author.

Association of Operating Room Nurses. (n.d.). Hand-off com- munication tools

overview. Retrieved
from http://www.aorn .org/search.aspx?searchtext=aorn%20hand%20off%
20toolkit

Berger, J. T., Sten, M. B., & Stockwell, D. C. (2012). Patient handoffs:

Delivering content efficiently
and effectively is not enough. International Journal of Risk & Safety in
Medicine, 24, 201–205.
doi:10.3233/JRS-2012-0573
 References

 The Joint Commission. (2010). Facts about the official “do not use” list. Retrieved from
http://www.jointcommission.org/ assets/1/18/Do_Not_Use_List.pdf

Paans, W., Sermeus, W., Nieweg, R., & van der Schans, C. P. (2010). Prevalence of
accurate
nursing documentation in patient records. Journal of Advanced Nursing, 66, 2481–2489.
doi:10.1111/j.1365-2648.2010.05433.x

Riesenberg, L. A., Leitzsch, J., & Cunningham, J. M. (2010). Nursing handoffs: A

systematic review
of the literature. American Journal of Nursing, 110(4), 24–34.
doi:10.1097/01.NAJ.0000370154.79857.09