Islamic University of GazaIslamic University of GazaFaculty of NursingFaculty of Nursing

Trends And IssuesTrends And IssuesDocumentationDocumentation

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IntroductionIntroduction

Documentation in the health record is an integral part of safe and Documentation in the health record is an integral part of safe and effective nursing practice.effective nursing practice.

Clear, comprehensive and accurate documentation is a judgment Clear, comprehensive and accurate documentation is a judgment

and critical thinking used in professional practice and provides and critical thinking used in professional practice and provides an account of nursing’s unique contribution to health care.an account of nursing’s unique contribution to health care.

Effective communication requires to be done in a timely Effective communication requires to be done in a timely manner.manner.

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Nurses should also be aware of the legislative Nurses should also be aware of the legislative requirements regarding documentation that may requirements regarding documentation that may apply to their particular practice setting. apply to their particular practice setting.

Effective documentation policies and practice Effective documentation policies and practice take into consideration who the clients are, client take into consideration who the clients are, client needs and available resources. needs and available resources.

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Documentation is fundamentally communication Documentation is fundamentally communication

that reflects the client’s perspective on his/her health, the care that reflects the client’s perspective on his/her health, the care provided, the effect of care and the continuity of care. provided, the effect of care and the continuity of care.

Effective documentation assists clients to make future care Effective documentation assists clients to make future care decisions. decisions.

Accurate documentation also reflects the effectiveness of the Accurate documentation also reflects the effectiveness of the care provided.care provided.

Accurate documentation provides a reliable, permanent record Accurate documentation provides a reliable, permanent record of client information. of client information.

Purpose of Documentation1. Communication

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2. Accountability 2. Accountability

The health record demonstrates nurses’ The health record demonstrates nurses’ accountability and gives credit to nurses for their accountability and gives credit to nurses for their professional practice. professional practice. It is used to determine responsibility and may be It is used to determine responsibility and may be used in legal proceedings.used in legal proceedings.Legislative issues: failing to keep records as Legislative issues: failing to keep records as required, falsifying a record, signing or issuing a required, falsifying a record, signing or issuing a false or misleading statement, giving information false or misleading statement, giving information about a client without consent andabout a client without consent and storage and storage and retrieval of documentation.retrieval of documentation. 55

3. Quality improvement3. Quality improvement

Information from the health record is often used to Information from the health record is often used to evaluate professional practice during quality evaluate professional practice during quality improvement processes, such as performance improvement processes, such as performance reviews, accreditation, legislated inspections and reviews, accreditation, legislated inspections and board reviews (board reviews (األمناءاألمناء). ). Clear documentation facilitates the evaluation of Clear documentation facilitates the evaluation of the client’s progress toward desired outcomes. the client’s progress toward desired outcomes. It enables nurses to identify and address areas that It enables nurses to identify and address areas that need improvement. need improvement. Poor documentation provides incomplete or no Poor documentation provides incomplete or no written evidence of the quality of care providedwritten evidence of the quality of care provided.

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4. Research Health records can be a valuable source of data Health records can be a valuable source of data

for health research. for health research. Health records can be used to assess nursing Health records can be used to assess nursing

interventions and evaluate client outcomes, as interventions and evaluate client outcomes, as well as to identify care issues.well as to identify care issues.

Accurately recorded information is essential to Accurately recorded information is essential to provide accurate research data. provide accurate research data.

Through research, nurses can improve nursing Through research, nurses can improve nursing practice.practice.

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5. Funding and resource management

Data from health records can identify the type Data from health records can identify the type and amount of care that clients need, the care and amount of care that clients need, the care and services provided, and the effectiveness of and services provided, and the effectiveness of that care. Any of these factors may affect that care. Any of these factors may affect funding and resource allocation. funding and resource allocation.

Workload or client classification systems are Workload or client classification systems are best derived as byproducts of client best derived as byproducts of client documentation.documentation.

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Core Standards for Documentation

These are the minimum expectations:nurse maintains documentation that is:nurse maintains documentation that is:Clear, concise and comprehensiveClear, concise and comprehensiveAccurate, true and honest;Accurate, true and honest;Relevant;Relevant;Reflective of observations, not of unfounded Reflective of observations, not of unfounded conclusionsconclusionsTimely and completed only during or after giving Timely and completed only during or after giving carecareChronological: present a clear picture of events Chronological: present a clear picture of events 99

Complete record of nursing care provided, Complete record of nursing care provided, including assessments, identification of health including assessments, identification of health issues, a plan of care, implementation and issues, a plan of care, implementation and evaluationevaluation

Legible and non-erasableLegible and non-erasable PermanentPermanent Retrievable Retrievable Confidential;Confidential; Client-focused; Client-focused; Using forms, methods, systems provided Using forms, methods, systems provided

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A nurse’s documentation:Includes date and time of the care;Includes date and time of the care;Identifies who provided the care;Identifies who provided the care;Avoids meaningless phrases such as “good ” “bad or Avoids meaningless phrases such as “good ” “bad or “OK”;“OK”;Includes what was observed and avoids statements such as Includes what was observed and avoids statements such as “appears to” and “seems to” when describing observations;“appears to” and “seems to” when describing observations;Includes signatures or initials; Includes signatures or initials; Avoids duplication of informationAvoids duplication of informationForgotten or late entries, errors and omissions, (written Forgotten or late entries, errors and omissions, (written with Date, time, and signature) with Date, time, and signature)

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Documentation formsEffective documentation forms provide a framework and Effective documentation forms provide a framework and guide documentation. guide documentation. To remain effective, forms often require regular review To remain effective, forms often require regular review and revision. and revision. This review process takes into account beliefs and values This review process takes into account beliefs and values about health and organizational policy, as well as external about health and organizational policy, as well as external factors such as legislation.factors such as legislation.

For example, a facility that values client perception of For example, a facility that values client perception of his/her health as an important aspect of a complete his/her health as an important aspect of a complete assessment will have a form that includes space for this assessment will have a form that includes space for this information. information. 1212

Kardexes

Kardexes are a communication tool used to convey the Kardexes are a communication tool used to convey the client’s current orders as well as upcoming tests or client’s current orders as well as upcoming tests or surgery, diet, etc quickly and briefly.surgery, diet, etc quickly and briefly.

Nurses use it to organize the care and to manage time and Nurses use it to organize the care and to manage time and multiple priorities. multiple priorities.   

Kardexes may be in paper or electronic format. Kardexes may be in paper or electronic format. The information they contain may be erasable. The information they contain may be erasable. Updating Kardex information regularlyUpdating Kardex information regularly Ensuring that temporary worksheets are shredded when Ensuring that temporary worksheets are shredded when

no longer in use no longer in use ensuring that relevant information on a Kardex is ensuring that relevant information on a Kardex is

captured in the permanent health recordcaptured in the permanent health record1313

Care PlansCare plans are written outlines of care for individual Care plans are written outlines of care for individual clients. clients. They are part of the permanent health record. They are part of the permanent health record. Effective care plans are up-to-date and clearly identify the Effective care plans are up-to-date and clearly identify the needs and wishes of the client. needs and wishes of the client. Individualizing care plans to meet the needs and wishes of Individualizing care plans to meet the needs and wishes of individual clientsindividual clients

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Monitoring strips

All relevant assessment data needs to be retained in the All relevant assessment data needs to be retained in the health record, including monitoring strips, such as health record, including monitoring strips, such as cardiac, fetal, thermal or blood pressure testing.cardiac, fetal, thermal or blood pressure testing.

Documenting on the monitoring strip the client’s name Documenting on the monitoring strip the client’s name and/or identification code, and the date and time.and/or identification code, and the date and time.

Advocating to have strips retained as part of the Advocating to have strips retained as part of the permanent recordpermanent record

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Documentation contentDocumentation contentAssessmentAssessment

Documenting the assessment of a client includes recording the Documenting the assessment of a client includes recording the subjective and objective data. subjective and objective data.

Objective data can be observed (e.g., swelling, bleeding, crying) Objective data can be observed (e.g., swelling, bleeding, crying) or measured (e.g., heart rate, blood pressure, temperature) or measured (e.g., heart rate, blood pressure, temperature)

Subjective data such as statements or feedback from the client Subjective data such as statements or feedback from the client Subjective data are clearly identified as such by using quotation Subjective data are clearly identified as such by using quotation

marks or other marks to distinguish it from objective data. marks or other marks to distinguish it from objective data.

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Third–party informationThird–party information

Nurses may obtain relevant information about a client or Nurses may obtain relevant information about a client or an incident from another person, such as the client’s an incident from another person, such as the client’s family member (e.g., the mother of a pediatric client) or family member (e.g., the mother of a pediatric client) or friend. friend.

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Documentation methodsDocumentation methods

Some agencies may combine elements of different Some agencies may combine elements of different documentation methods and formats to document care documentation methods and formats to document care effectively. effectively.

Regardless of the method, the health record must present Regardless of the method, the health record must present a clear picture of the nurse’s assessment, actions and a clear picture of the nurse’s assessment, actions and outcomes. outcomes.

Common methods include charting by exception, focus Common methods include charting by exception, focus charting, SOAP/ SOAPIER and narrative documentation. charting, SOAP/ SOAPIER and narrative documentation.

May be Paper or Paperless (Electronic health records)May be Paper or Paperless (Electronic health records)

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Do'sDo's and and Don'tsDon'ts of Nursing Documentation of Nursing Documentation

Do's Do's Check that you have the correct file before you begin writing. Check that you have the correct file before you begin writing. Make sure your documentation reflects the nursing process. Make sure your documentation reflects the nursing process. Write legibly. Write legibly. Chart the time you gave a medication, the administration Chart the time you gave a medication, the administration route, and the patient's response. route, and the patient's response. Chart precautions or preventive measures used, such as bed Chart precautions or preventive measures used, such as bed rails. rails. Record each phone call to a physician, including the exact Record each phone call to a physician, including the exact time, message, and response. time, message, and response.

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Do's….. Do's….. Chart patient care at the time you provide it. Chart patient care at the time you provide it.

If you remember an important point after you've If you remember an important point after you've completed your documentation, chart the information with a completed your documentation, chart the information with a notation that it's a "late entry." Include the date and time of notation that it's a "late entry." Include the date and time of the late entry.the late entry.

Document often enough to tell the whole story. Document often enough to tell the whole story.

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Don'tsDon'ts Don't Don't chart a symptom, such as "c/o pain," without also chart a symptom, such as "c/o pain," without also charting what you did about it. charting what you did about it.

Don't Don't alter a patient's record - this is a criminal offense.alter a patient's record - this is a criminal offense.

Don't Don't use shorthand or abbreviations that aren't widely use shorthand or abbreviations that aren't widely accepted.accepted.

Don't Don't write imprecise descriptions, such as "a large write imprecise descriptions, such as "a large amount." amount."

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Don'tDon'tDon't Don't chart what someone else said, heard, felt, or chart what someone else said, heard, felt, or smelled unless the information is critical. In that smelled unless the information is critical. In that case, use quotations and attribute the remarks case, use quotations and attribute the remarks appropriately.appropriately.

Don't Don't chart care ahead of time - something may chart care ahead of time - something may happen and you may be unable to actually give the happen and you may be unable to actually give the care you've charted. Charting care that you haven't care you've charted. Charting care that you haven't done is considered fraud (deception done is considered fraud (deception الغشالغش ).).

Thank you………………..Thank you……………….. 2222