NCM 104/107 - DOCUMENTATION

“IF YOU DIDN’T DOCUMENT IT, YOU SOURCE ORIENTED CHARTING

DIDN’T DO IT” (NARRATIVE CHARTING)
 The “traditional” client record.
NURSING DOCUMENTATION  A source-oriented medical record
 Refers to the record of nursing care (SOMR) is a conventional method of
that is planned and delivered to preserving patient data in which
individual clients by qualified nurses or observations, actions, and results are
other caregivers under the direction of recorded by departments or
a qualified nurse. healthcare providers in specific
 It contains information in accordance parts of the patient’s file.
with the steps of the nursing process.
POMR (PROBLEM ORIENTED MEDICAL
PURPOSES OF DOCUMENTATION RECC
 Provides a written record of the  The Problem-Oriented Medical Record
history, treatment, care, and response (POMR), established by Dr. Lawrence
of the patient while under the care of a Weed in the 1960s, represents a
care provider. significant shift in medical
 Guide for reimbursement of costs of documentation by organizing patient
care. data around specific problems rather
 May serve as evidence of care in a than by the source of the information.
court of law. This method is structured to enhance
 Shows the use if the nursing process. clarity, continuity, and
 Provides data for quality assurance comprehensiveness in patient care.
study.
Basic Components:
PURPOSES OF DOCUMENTATION IN  Database
LEGAL PROCEEDINGS:  Problem
 To prove or disprove evidence of  Plan of Care
breach.  Progress Notes
 To draw conclusions or make
inferences. The Four (4) Basic Components
 To prepare a statement claim and 1. Database. A complete history and
counterclaim. physical examination, along with initial
 To use as evidence at trial. lab results and diagnostic tests,
 To provide to the experts for review provide a baseline of patient
and analysis. information.
2. Problem List. Derived from the
TYPES OF DOCUMENTATION database. Usually kept at the front of
 SOURCE ORIENTED CHARTING the chart & serves as an index to the
(NARRATIVE CHARTING) numbered entries in the progress
 POMR (PROBLEM MEDICAL notes. Problems are listed in the order
RECORD ORIENTED) in which they are identified & the list is
 PIE (PROBLEMS, INTERVENTIONS, continually updated as new problems
AND EVALUATION) are identified & others resolved.
 FOCUS CHARTING (FOCUS, DATA, 3. Plan of Care. For each identified
ACTION, AND RESPONSE) problem, initial plans are developed
 CPE (CHARTING BY EXCEPTION) and documented. These plans are
 COMPUTERIZED DOCUMENTATION divided into three categories:
(ELECTRONIC HEALTH RECORDS) diagnostic (further tests needed),
 CASE MANAGEMENT therapeutic (treatment plans), and
NCM 104/107 - DOCUMENTATION
patient education (information factual and can be verified by the healthcare
provided to the patient). provider.
4. Progress Notes. Using the SOAP Example: Blood pressure is 150/90 mmHg,
(Subjective, Objective, Assessment, heart rate is 95 bpm, and an ECG shows ST-
Plan) format, progress notes detail segment elevation.
ongoing care and updates for each
problem. This format ensures Assessment:
consistency and thoroughness in Description: The assessment section provides
documenting patient care. the healthcare provider’s interpretation and
analysis of the subjective and objective
SOAP Format or SOAPIE and SOAPIER data. It includes a diagnosis or a list of
The SOAP, SOAPIE, and SOAPIER formats potential diagnoses (differential diagnosis).
provide structured and systematic Example: The patient is experiencing
approaches to documenting patient care. symptoms indicative of acute myocardial
By following these formats, healthcare infarction (heart attack).
providers can ensure thorough and consistent
documentation, facilitating effective Plan:
communication, continuity of care, and Description: This section outlines the
informed decision-making. Each additional proposed plan of action to address the
component (Intervention, Evaluation, and patient’s problems. It includes diagnostic
Revision) enhances the depth and tests, treatments, interventions, patient
adaptability of the documentation, allowing for education, and follow-up plans.
a dynamic and responsive approach to patient Example: “Administer aspirin and
management. nitroglycerin, perform a cardiac
catheterization, and admit the patient to the
S - SUBJECTIVE DATA ICU for monitoring and further treatment.
0 - OBJECTIVE DATA
A - ASSESSMENT Intervention:
P - PLAN Description: This section details the specific
I- INTERVENTION actions and treatments carried out to
E - EVALUATION address the patient’s problems. It includes
R - REVISION medications administered, procedures
performed, and other therapeutic
Subjective Data: interventions.
Description: This section includes information Example: “Administered 325 mg of aspirin and
provided by the patient about their 0.4 mg of nitroglycerin sublingually.
symptoms, feelings, and perceptions. It Initiated intravenous access and started a
often includes the patient’s chief complaint, heparin drip.
history of present illness, and any other
relevant details expressed during the clinical Evaluation:
encounter. Description: The evaluation section
Example: “The patient reports experiencing documents the patient’s response to the
sharp chest pain radiating to the left arm for interventions. It assesses the effectiveness
the past two hours.” of the treatments and any changes in the
patient’s condition.
Objective Data: Example: The patient’s chest pain decreased
Description: This section contains observable from 8/10 to 3/10, and repeat ECG shows
and measurable facts obtained through reduced ST-segment elevation.
physical examination, diagnostic tests,
and laboratory results. Objective data are
Revision:
NCM 104/107 - DOCUMENTATION
Description: This section involves revisiting might focus on a patient’s progress in
and updating the care plan based on the managing pain, their concerns about
patient’s response and evaluation results. upcoming surgery, or their efforts in
It may involve modifying treatment plans, physical therapy.
adding new interventions, or setting new
goals. 2. Three Columns for Recording
Example: Revised the care plan to include a  Date and Time. This column logs
cardiology consult and additional diagnostics when the care was provided, offering
such as a stress test. Adjusted medication a chronological view of the patient’s
dosages based on the patient’s response. progress and the timing of
interventions.
PIE  Focus. The focus column specifies the
The following are the key components of the main issue, concern, or strength
PIE (Problem, Intervention, Evaluation) being addressed. This could include a
System: specific condition, symptom,
1. Client Care Assessment Flow Sheet behavior, or patient goal. /
- The flow sheet is a crucial part of the PIE  Examples: Pain management,
system, providing a structured and Nutritional status, Patient anxiety,
organized way to record patient About discharge
assessments. It includes specific assessment  Progress Notes. The progress notes
criteria that are often categorized based on detail the actions taken and the
human needs or functional health patterns. patient’s responses, organized into
Example: A flow sheet might include sections three categories known as DAR.
for vital signs, pain levels, mobility status, and
other key indicators of the patient’s health. 3. DAR Format
 Data. This section includes subjective
2. Progress Notes and objective information relevant to
Progress notes in the PIE system are used to the focus. It captures the initial
document ongoing patient care in a assessment and observations that
narrative form. These notes are directly identify the patient’s current status.
linked to the problems identified, the Example: “Patient reports pain level of 7/10 in
interventions carried out, and the the lower back, grimacing when moving..
evaluations of those interventions.  Action. This section documents the
Example: A progress note might detail a interventions performed in response to
nurse’s observation of a patient’s response to the data. It includes treatments,
a new medication, including any side effects procedures, patient education, and
or improvements in symptoms. any other actions taken by the
healthcare provider.
FOCUS CHARTING Example: “Administered prescribed analgesic
(FOCUS, DATA, ACTION, AND RESPONSE) and assisted patient with repositioning.
1. Client-Centered Focus educated patient on proper lifting techniques
 Focus Charting is intended to keep the to avoid strain.
patient and their concerns at the  Response. This section records the
forefront of the documentation patient’s reactions and outcomes
process. This method highlights the following the interventions. It evaluates
patient’s issues, strengths, and an the effectiveness of the actions taken
achievement, ensuring that care is and notes any changes in the patient’s
tailored to their specific needs and condition.
circumstances. Example: “Patient’s pain level decreased to
 Instead of documenting solely on 3/10 within 30 minutes post-medication.
clinical tasks or assessments, a nurse
NCM 104/107 - DOCUMENTATION
Patient verbalized understanding of lifting accuracy, and improve access to
techniques. patient information.

CHARTING BY EXCEPTION 1. Managing Large Volumes of

1. Flow Sheets Information
- Flow sheets are used to document routine - Contemporary healthcare generates
care and normal findings in a standardized, extensive amounts of data, including
concise format. These sheets include Patient histories, diagnostic results, treatment
predefined parameters and checklists for plans, and progress notes.
various aspects of patient care, such as vital Computerized documentation systems are
signs, intake and output, and other routine designed to handle this information efficiently,
assessments. allowing for secure storage, quick retrieval,
- Example: A flow sheet for vital signs might and comprehensive management.
have columns for recording temperature, - Example: A patient’s entire medical history,
blood pressure, heart rate, and respiratory from initial consultation to discharge
rate at regular intervals, with spaces to note summaries, can be stored in an electronic
any deviations from the normal. health record (HER) system, accessible with a
2. Standards of Nursing Care few clicks.
- Standards of nursing care provide the
baseline or normal criteria for patient 2. Functions for Nurses
assessments and interventions. These - Storing Client Databases. Nurses can input
standards are based on established best and store detailed patient information in a
practices and clinical guidelines, serving as centralized database, including
reference points for what is considered demographics, medical history, allergies,
normal or expected. medications, and more.
- Example: For a postoperative patient, the Example: Upon admission, a nurse enters a
standards might include expected ranges for patient’s personal information, medical history,
vital signs, typical recovery milestones, and and initial assessment into the system.
standard pain management protocols. - Adding New Data. As patient care
Deviations from these standards would be progresses, new information can be
documented as exceptions. continuously added. This includes updates
3. Bedside Access to Chart Forms from ongoing assessments, lab results, and
- Bedside access to chart forms ensures observations.
that documentation tools are readily Example: During each shift, nurses update the
available where care is provided. This patient’s vital signs, symptoms, and any
facilitates immediate recording of changes in condition.
exceptions and ensures that critical - Creating and Revising Care Plans. Nurses
information is captured in real-time. can develop, modify, and update care plans
- Example: Electronic health records (HER) based on real-time patient data. These care
systems with mobile tablets or bedside plans can be customized to meet individual
computers allow nurses to quickly document patient needs.
exceptions during patient rounds, reducing Example: A care plan for a diabetic patient
delays and improving accuracy. might include regular blood sugar monitoring,
dietary adjustments, and medication
COMPUTERIZED DOCUMENTATION administration, all updated as the patient’s
 Computerized documentation systems condition evolves.
have been developed to manage the - Documenting Client Progress. All aspects
vast amount of information required in of patient care and progress are documented
modern healthcare. These systems in the system. This includes interventions
leverage technology to facilitate the performed, patient responses, and outcomes.
documentation process, enhance
NCM 104/107 - DOCUMENTATION
Example: If a patient receives a new helps in controlling healthcare costs and
medication, the nurse documents the improving bed availability for other patients.
administration and monitors the patient’s Example: For a patient undergoing knee
reaction, noting any side effects or replacement surgery, the case management
improvements. plan would outline a typical hospital stay
duration, including preoperative assessments,
3. Elimination of Multiple Flow Sheets surgery, postoperative care, and rehabilitation,
- In traditional documentation, multiple flow aiming to discharge the patient within a set
sheets are used to record different types of timeframe.
data (e.g., vital signs, medication
administration, nursing assessments). In 3. Multidisciplinary Approach
computerized systems, this information is Case management involves a team of
integrated and can be easily retrieved in healthcare professionals from various
various formats. disciplines working collaboratively to plan and
- Advantages. This integration reduces document patient care. This ensures
redundancy, minimizes the risk of errors, and comprehensive care that addresses all
ensures that all relevant data are available in aspects of the patient’s health needs.
a cohesive manner. Example: The care team for a stroke patient
Example: Instead of consulting separate might include doctors, nurses, physical
charts for a patient’s vital signs, lab results, therapists, occupational therapists, social
and medication history, a nurse can view all workers, and dietitians, all contributing to a
this information onn a single digital interface. unified care plan.

CASE MANAGEMENT 4. Use of Critical Pathways

Case management is a coordinated approach Critical pathways are standardized,
to delivering high-quality, cost-effective evidence-based plans that outline the
healthcare within an established timeframe. essential steps in the care process for
This method focuses on optimizing patient specific clinical conditions or procedures.
outcomes and resource utilization, ensuring These pathways guide the multidisciplinary
that care is both efficient and effective. team in delivering consistent and efficient
care.
1. Emphasis on Quality and Cost- Example: A critical pathway for managing a
Effective Care patient with pneumonia would include
Case management prioritizes the delivery of guidelines for diagnosis, antibiotic
high-quality care that meets established administration, patient monitoring, respiratory
standards while also being mindful of cost therapy, and discharge planning.
constraints. This approach ensures that
patients receive the necessary care without 5. Managing Variances
unnecessary delays or expenses. In case management, a variance refers to
- Example: A case manager might coordinate any deviation from the expected outcomes
care for a patient with chronic heart disease, or established critical pathway. Identifying and
ensuring they receive timely interventions, addressing variances is crucial for maintaining
appropriate follow-up, and education on the quality and effectiveness of care.
lifestyle changes to prevent readmissions, all Example: If a patient with pneumonia does not
while managing costs. show expected improvement within the
timeline set by the critical pathway, this would
2. Established Length of Stay be noted as a variance. The care team would
Care plans are designed to achieve specific then investigate the cause (e.g., antibiotic
health outcomes within a predetermined resistance, comorbid conditions) and adjust
length of stay in the healthcare facility. This the care plan accordingly.
NCM 104/107 - DOCUMENTATION
NURSING DIAGNOSIS
The term diagnosing refers to the reasoning
process, whereas the term diagnosis is a
statement or conclusion regarding the
nature of a phenomenon.

The standardized NANDA names for the

diagnoses are called diagnostic labels; and
the client’s problem statement, consisting of
the diagnostic label plus etiology (causal
relationship between a problem and its related
or risk factors), is called a nursing diagnosis.