Documentation and Reporting
Eirene E.M.Gaghauna, Ns., MSN
Charting
• The process of recording vital information
that is communicated to others.
– Facts and figures that are specific, clear and
precise
– Contains correct language, medical terms and
abbreviations
– Observations, interventions and
communications
– Reports to authorities as child or elder abuse
Charting
• Assessment of quality and effectiveness of
nursing care
• Permanent record
• Assessment of quality and effectiveness of
nursing care
• Legal Document in the event of litigation or
prosecution
• If not charted, legally it was not done
Charting
• Legal Requirements
-regulated by state laws
-professional standards
-Joint Commission on Accreditation of Health
Care Organizations [JCAHO]
Charting Specifics
• Black ball point pen because it microfilms best
• Errors are corrected by drawing a single line through the
error. Above write “Mistaken Entry” [ME] and your initial.
• No white-out, erasers, eradicators, covering-up materials
• Error no longer written. Juries associate it with an actual
nursing mistake
Charting Specifics
• Each entry is signed with your first initial,
last name and status
» J. Smith, SN
» R. Jones, RN
» Script not printing is used for the signature and
it should appear at the right hand margin of the
narrative note.
Charting Specifics
• Notes are written on each succeeding line
• Lines are not omitted
• A horizontal line is drawn to “fill up” a
partial line
• Each entry is dated and timed
• Begin with a Capital letter
• End with a period
Does not have to be complete sentences
Charting Specifics
• Be accurate
• Describe behaviors
• Use approved abbreviations and symbols
• Spell correctly
• Used correct terminology and grammar
• Write legibly [Printing is acceptable]
• Chart only what you have done
• Do not double chart [data appears on a flow sheet]
except when the patient has a change in their condition
Charting Specifics
• If you forgot to chart something do so on the next
available line putting the time of the event and not the
time you are actually charting it
• Physician visits
• Time client left and returned to unit including
transportation and destination
• Medications: dosage, route, site, pain relieved, time
worked, and/or side effects
• Treatments
Charting Specifics
• Chart objective facts
-ate 100% and not “good appetite”
-client/patient c/o placed in quotes
“stabbing; “chest pain”; “going down” his “left arm”
-objective observations
-skin cold and clammy; diaphoretic,
-v/s B/P 70/40; Pulse 122 bpm, irregular, 1+;
Charting Format
• Assessment at the start of the shift
• Changes in mental, psychological,
physiological conditions
• Reactions to procedures or medications
• Teaching
-Document what was taught
and the client’s response
Charting Systems
• Source-oriented
– Data entered according to the source [i.e.
nurse, MD, social worker, respiratory therapy
etc.]
– Form of charting is a narrative
– Overall picture is difficult to ascertain
Narrative Charting
• Used with flow sheets and other systems
• Chronological data quickly documented
• Familiar form
• Used in all types of settings
Narrative Charting Disadvantages
• Lack of a systematic structure hinders
making relationships between data
• Requires time
• May lack information concerning client
outcomes
• Quality Assurance monitoring more difficult
• Relevant data found in several places
Charting Systems
• Problem-oriented
-Data organized based on problems
-Each member of the health team
documents on the same problem
-The overall picture can be seen easily
-Focus is on the client and not on the
person or department reporting
Problem-Oriented Medical Records
POMR
• Focus is on the client
• One set of progress notes is used by all
persons caring for the client
• Format is called SOAP or SOAPIE
POMR: SOAP or SOAPIE
• Subjective
• Objective
• Assessment
• Plan
• Implementation
• Evaluation
Charting Systems
• Computer-Assisted
-Data legible
-Quick access to data and information between departments
-Easily retrievable
-Quick assess to data
-Confidentiality maintained
-Bedside computers increase accuracy and speed of charting
-Meet JCAHO standards
-Increase speed and completeness of reimbursement
REPORTING: INTRASHIFT
• Verbal reports during your shift to other
team members
-Significant changes in Vital signs
-Unusual reactions to treatments,
procedures, medications
- Changes in physical or psychological
condition
Reporting
• Intershift
– Verbal or tape recorded
– Client’s Name, Age, Room Number, MD,
Diagnosis, Date of Surgery
– Changes or unusual occurrences
– Laboratory results, studies, tests to be done
on next shift
– Physical or psychological problems
REPORTING: MD NOTIFICATION
• Significant changes in physical
assessment, abnormal laboratory findings,
test results
• Identify self to MD by name, status, unit
and client’s name
• State exact reason why you are calling
• Current vital signs, laboratory results,
medications etc. should be available
REPORT to NURSING
ADMINISTRATORS
• Written or Verbal each shift
• Data on critically ill clients
• Unusual occurrences
• Problems with clients, families or other
disciplines
INCIDENT REPORT
• Unusual Occurrence, Variance or Incident
Report [IR]
• Helps to document quality care
• Identify areas where staff development is
needed
• Maintain detailed record of incident for
possible legal action
Thank You
TT
