Documentation

Core Standards for Documentation Professional Practice Forms Content = Assessment Timing Date, Time, Signature & Designation Objective & Subjective Data Confidentiality

Professional Practice

Nurses document for individuals, families or groups of clients.

A nurse’s documentation provides a clear picture of the needs and goals of the client, the actions of the nurse and outcomes.

Documentation: “Voice of Nursing” Structured and focused communication in

regards to documentation between caregivers promotes better client care decisions.

Research indicates that poor recordings is reflected in nursing interventions and client outcomes.

As professionals, nurses bear the responsibility of what they have done. The Supreme Court of Canada has ruled that nursing documentation is admissible evidence.

Documentation Forms Effective documentation forms provide

a framework and guide documentation. To remain effective, forms often require

regular review and revision. Types of Forms:

Worksheets and Kardexes Care Plans Flow sheets and Checklists Monitoring Strips

Worksheets

Nurses use worksheets to organize the care they provide, and to manage time and multiple priorities for up to 4 or 5 clients.

Example: George Brown College “Daily Clinical Worksheet”

Nursing Worksheet Example

Kardexes

Kardexes are a communication tool used to convey the client’s current orders as well as upcoming tests or surgery, diet, hygiene assistance, ambulation assistive devices, nutrition, code status, etc…

Kardex Example

Worksheets and Kardexes The information kardexes and

worksheets contain may be erasable as long as the permanent health record reflects the nursing assessment, the care provided and the outcome.

A nurse meets the standards by: updating the Kardex information regularly. ensuring that temporary worksheets are

shredded when no longer in use.

Flow Sheets and Checklists

Flow Sheets document routine care and frequently recorded information.

Examples: Activities of Daily Living (ADLs)Vital Signs Intake and Output

When using initials on a flow sheet, a master list matching the initials to the caregiver is needed.

Treatment Sheet - ADLs

The nurse’s initials should be placed at the bottom of the column as this is a flow sheet for 24 hours.

Assessment

Documenting the assessment of a client includes recording:

Subjective Data = “Says” and Symptoms Objective Data = See and Signs

Data can be also from: Third-party

Example: Family member Collaboration with Care Providers

Example: CCAC Nurse

What the nurse observes by using senses…

Vision

Hearing

Smell Touch

What the client says.Referred to as symptoms that are

apparent only to the person affected and can be described or verified by that person.

Subjective Data = Says “Verbally”

What the nurse observes.Referred to as signs, detectable by

an observer or can be tested against an accepted standard (seen, heard, felt or smelled).

Objective Data = Observation

Subjective and Objective DataSubjective Objective “I feel weak all

over when I exert myself.”

Blood pressure = 90/50 Apical pulse = 104 BPM Skin pale and diaphoretic

“I am feeling short of breath.”

Chest assessment reveals, diminished breath sounds to RLL.

Client states he has a cramping pain in his abdomen. States, “I feel sick to my stomach.”

Vomited 100 mL green-tinged fluid Active bowel sounds auscultated X 4 quadrants

Evan age 84 complains of breathlessness and

a fuzzy head. He admits to worrying about

everything and isn’t sure what the matter is.

His pulse is 85, BP 160/90. His skin is dry,

pink and warm to touch. He is frowning

when you enter the room.

Subjective Objective

Abbreviations and Symbols Abbreviations and symbols can be an effective and

efficient form of documentation if their meaning is well understood by the health care providers and others who may read the health record. However, abbreviations and symbols that are obscure, obsolete, poorly defined or have multiple meanings can lead to confusion, errors and wasted time.

Examples of error prone abbreviations and symbols: DC, D/C, dc = Discharge and discontinue Rationale: Mistaken for each other Dysphagia = Difficulty digesting/

gastrointestinal issues Dysphasia = Difficulty speaking IU = International Units Rationale: Can be mistaken for IV

(intravenous) or 10 (ten) @ and & =“at” and “and”

Example: Abbreviations and Symbols 09/08/09 at 1210 hours: Dr. Smith in and removed drsg to assess wound

from # ® tibia. New drsg orders received to drsg ’s from BID to once daily and prn. New drsg applied to ® lower leg for scant amt of sero-sanguinous drainage. Incision well approximated, ø redness or swelling. Cleansed c N/S and dry 4X4 gauze drsg applied & fixed c transpore tape. ® leg X 2 pillows. Client stated to writer, “This injury is going to ruin the ski season for me, oh well, I guess I should be happy the rain got rid of all the snow so I know I can’t ski for sure”. Client resting in bed and ø voiced concerns at this given time. --------------------------------------------------A. Lalonde RN

Information documented during or immediately after care is provided or an event has occurred is considered more reliable than information recorded later, based on memory.

Chronological entries present a clear picture of events.

Timing: Forgotten or Late Entries, Errors and Omissions

For documentation to be reliable, it must clearly state when care was provided or an event occurred and when the documentation of the care/event occurred.

Regardless of how late the entry, the information documented must be accurate and complete.

Timing Example

Late Entry

Timing Past Tense

Why? The event

has already occurred

Date, Time, Signature and Designation

Date and Time: Documenting in the

health record the date and time that care was provided and was recorded supports the primary purpose of documentation, which is communication.

Date = Month/Date/Year

09/10/09 @ 0400 Hours

Date and TimeRegular Time Military Hours 12:00 AM 2400 Hours 1:00 AM 0100 Hours 2:00 AM 0200 Hours 3:00 AM 0300 Hours 4:00 AM 0400 Hours 5:00 AM 0500 Hours 6:00 AM 0600 Hours 7:00 AM 0700 Hours 8:00 AM 0800 Hours 9:00 AM 0900 Hours 10:00 AM 1000 Hours 11:00 AM 1100 Hours

Regular Time Military Hours 12:00 PM 1200 Hours 1:00 PM 1300 Hours 2:00 PM 1400 Hours 3:00 PM 1500 Hours 4:00 PM 1600 Hours 5:00 PM 1700 Hours 6:00 PM 1800 Hours 7:00 PM 1900 Hours 8:00 PM 2000 Hours 9:00 PM 2100 Hours 10:00 PM 2200 Hours 11:00 PM 2300 Hours

Note: 12:00 AM = 2400 Hours but 12:01 AM to 12:59 AM = 0001 to 0059 HOURS

Date, Time, Signature and Professional Designation Signature and Professional Designation:

When nurses use their professional designations in documentation, it indicates that an accountable regulated health professional has provided the care.

Use of signature and designation of health care providers promotes communication and supports accountability. When using initials in documentation, a master list that identifies the caregiver’s full name, designation, full signature and initials should be maintained to clarify accountability.

Nurses use the designations RN for Registered Nurse and RPN for Registered Practical Nurse.

GBC Signature and Designation

George Brown College Semester II Practical Nursing Student will use the following as their designation:

J. Channel GBC SPN2

Documentation Methods The documentation method used by a practice

setting should reflect client care needs and the context of practice. Some facilities/agencies may combine elements of different documentation methods and formats to document care effectively. Regardless of the method of documentation used, the health record must present a clear picture of the nurse’s assessment, actions and outcomes.

Common documentation methods include: Narrative Documentation DAR/E = Focus Charting Computerized Documentation (Nursing Information

System) SOAPIER Charting by Exception Critical Path/Variance Analysis (Care Mapping)

Computerized Documentation

Computerized Documentation

Nurses have been using computerized systems for supplies, equipment, stock medications, and diagnostic testing for some time. However, increasingly hospitals are using computerized documentation systems. Many systems give access to data across the continuum (regardless of setting) and capture useful information from both individual clients and population groups.

Example: Meditech Information Technology

Objectives of Computer-Based Client Care Record (CBCR) Improved uniformity, accuracy, and retrievability of data about

client care. Confidentiality of health care information ensured in the system. Access for authorized health care providers from any department. Ability to retrieve information selectively and choose various

formats for examining it. Assistance with clinical application, including analysis tools, risk

assessment, and clinical reminders. Support for data collection in a manner that adequately supports

health care providers' direct entry and stores information according to a defined vocabulary.

Easy access to client data, fast retrieval, and versatile data display that facilitates improved health care delivery.

Availability of a lifelong record of health-related events incorporating records from various settings and time periods.

Anecdotal reports and descriptive studies suggest that nursing information systems do offer important advantages to nurses in practice.

Increased time to spend with clients Better access to information Enhanced quality of documentation Reduced numbers of errors of omission Reduced hospital costs Increased nurse job satisfaction Enhanced compliance with accreditation

standards Development of a common clinical database

Nursing Information System: The “Pros”

Nursing Information System: Can threaten a client’s right to confidentiality if

appropriate security measures are not taken, such as: Installation of firewalls Antivirus software Spy-ware-detection software Authentic access codes and passwords Physical placement of computers or file servers in

restricted areas Can be expensive to implement and maintain. Mobile wireless devices such as notebooks, tablet

personal computers or personal digital assitants can be misplaced or lost, which allows them to be accessed by unauthorized persons.

Can take extra time if there are too many nurses trying to chart on too few computer terminals.

Computerized Documentation Example 1

Computerized Documentation Example 2

SOAPIER Documentation

S Subjective: Verbalizations of the client.O Objective: What the nurse observed.A Assessment: Conclusion reached based on

subjective and objective data presented; can be written in nursing diagnosis form.

P Plan: Planned course of interventions to address the problem – what the nurse plans to do.I Intervention: Care actually provided by the nurse.E Evaluation: Reflects client response to illness, medical treatment or interventions.

R Revision: Reflects change by the evaluation; can be made in intervention plans or target dates.

Problem-oriented approach to documentation in which nurses document information in an organized fashion.

DATE TIME PROBLEM SOAPIER DOCUMENATION NOTE EXAMPLE

9/10/10 1415 # 5Generalized Pruritis

S: “My skin is itchy on my back and arms, and it has been like this for a week”. ----------------------O: Skin clear, no rash or irritation noted. Marks where client has scratched noted on left and right forearms. Allergic to elastoplast bandaids but has not been in contact during this hospitalization stay. ----------------------------------No previous history of pruritis.A: Skin integrity impaired. ---------------------------P: Instruct to not scratch skin. Apply calamine lotion as necessary. Cut nails to avoid scratches. Assess further to determine whether recurrence associated. with specific drugs or foods. Refer to physician and pharmacist for assessment. ----------------------------------------I: client instructed to not scratch skin. Applied calamine lotion to back and arms at 1445 hours. Assisted to cut fingernails. Notified physician and pharmacist of issue. ---------------------------------E: client states, “I’m still itchy. That lotion did not help”. ----------------------------------------------R: Remove calamine lotion and apply hydrocortisone ointment as ordered. -------------- ---------------------------------Signature and Status

Critical Pathways

The standardized plan of care is summarized into critical pathways for a specific disease or condition.

The critical pathways or CareMaps are multidisciplinary care plans that include client health concerns, key interventions, and expected outcomes within an established time frame.

Critical Pathways

Charting by Exception (CBE)

Charting by exception (CBE) focuses on documenting deviations from the established norm or abnormal findings. This approach reduces documentation time and highlights trends or changes in the client's condition.

CBE is a shorthand method for documenting normal findings and routine care based on clearly defined standards of practice and predetermined criteria for nursing assessments and interventions.

Charting by Exception (CBE)

Charting by Exception (CBE)

Narrative Documentation

Nurses actions and client responses are recorded in paragraph chronological order and reflect care given within a particular timeframe.

Tends to be warranted and necessary when the complexity of care requires detailed, written explanations.

May stand alone or be used in combination with other documentation tools (e.g., flow sheets).

Narrative Documentation

When charting in narrative format use a systematic manner of reporting your findings. LOC – Respiratory – Circulation – GI – GU – Pain (other)

Assessment should focus on the following: Previous shift notes form nurses; physicians and other team

members. Intake (infusion rates and amount remaining in tube feeding, IV

and other infusions) Output (drainage amounts); indicate locations of tubes and

drains Dressings (degree and type of soiling, frequency of changes and

status of underlying skin/wound (REEDA) Treatments; Number of times performed, duration, and client

response

Narrative Documentation ExampleDate Time Disciplin

eNote Include Signature

09/10/10 0800 Nrsg Received client alert, oriented x 3. Family at bedside. Respirations even & non-laboured c faint expiratory wheezes noted. Cough strong c scant, thin, yellow secretions produced.

Chest tube in situ on ® chest wall c dressing clean & dry. Atrium drainage collection set at -20 cm H2O wall suction. Drainage serous & moderate 30-40ml/hr. Pillow pressed to chest by client to splint incision site during cough. Skin warm & dry to touch c capillary refill < 3 seconds. Abdomen soft, non-tender c active bowel sounds. Voiding s (without) difficulty. No c/o pain at this present time. -------------------------------------------------------- A. Lalonde RN

Focus Charting: DARP versus DARE The focus charting mnemonic that is referred

to in Kozier et al., Chapter 23 is DARP. The “P” stands for planning but being novice clinical students, it is difficult to be able to determine what plans will be most effective for a client issue. Therefore, the focus for COMM-1134 is going to be “E” (evaluation), which is to assess your accountability to the interventions that you implement.

Focus Charting = DAR/E In this system, the assessment of the client

and the care provided are organized under data, action and response/evaluation.

D = Data: Subjective and/or objective information that supports or describes the stated focus or describes nursing observations at the time of a significant event in treatment

D: Patient complained nausea. Writer noted patient was rubbing their abdomen.

A = Action: It is a nursing intervention and/or implementing a physician’s order.1. Intervention used to gather assessment data. A: Initial shift vital signs were taken.

2. Immediate nursing actions based on the nurse’s assessment of the client’s condition.

A: Gravol 50 mg IM was administered.

3. Evaluate a client response to an earlier intervention that was performed based on an abnormal (subjective and/or objective finding).

A: Writer reassessed pulse rate.

4. Future nursing action to evaluate a client’s condition because it may not be possible to determine if intervention had an effect (i.e. , pain medication).

A: Writer will reassess patient in 45 minutes.

5. Obtaining and implementing medical orders from a physician or by the physician themselves.

A: Dr. Chan called in regards to patient’s decreasing O2 saturation. Orders received to apply O2 at 3 LPM by nasal prongs. Dr. Chan will be in to assess patient in 15 minutes.

Focus Charting = DAR/E

R = Response: Description of client responses to both medical and nursing interventions.

R: The client reported the Gravol has helped and they are no longer feeling nauseated.

E = Evaluation: Is the concluding statement that the intervention was effective or ineffective based on the client’s response.

E: The Gravol was effective in relieving the client’s nausea.

E: Tylenol E.S. were not effective in relieving client’s headache.

Focus Charting = DAR/E

Focus Charting = DAR/EFocus Example

Current Behaviour or Concern

Fear Teaching Needs

Signs and/or Symptoms Vomiting Itching

Acute Change in Status Hemorrhage Sudden Elevation in B/PSignificant Event in the

Client’s Treatment Blood Transfusion Return from Surgery

Nursing Diagnosis Risk for Infection Impaired Physical MobilityA Special Need Discharge Referral

Focus Charting = DAR/E Components of DAR/E can be charted alone or

out of sequence: D = Data: Client c/o dull constant pain in the

right ankle and rates it 6/10. -------------------- A = Action: Right ankle elevated on two

pillows. --------------------------------------------- R = Response: Client stated no relief. ---------- A = Action: Administered two tablets of

Tylenol with Codeine. ----------------------------- R = Relief noted from analgesic, now rates

pain a 2/10. ---------------------------------------- E = Tylenol effective for c/o pain

----------------------------------------------------A. Student GBC SPN2

DAR/E Documentation ExampleDate Tim

eFocus Note Include

Signature09/10/10 1015 Impaired

Urinary Elimination

D: Bladder distended 2 fingers above pubis. Has not voided X 8 hours since indwelling Foley catheter was removed. ----------- A: Assisted to washroom. Water turned on at faucet. Instructed client to press over bladder region with hands. ------ R: Client voided a total of 525 ml of clear yellow

DAR/E Documentation ExampleDate Time Focus Note Include Signature

09/10/10

09/10/10

1600

1645

Abnormal Vaginal Bleeding

ReassessVaginal Bleeding

D: Client stated that her period just started and she is passing clots. One peri pad noted to be saturated within 30 minutes. client c/o feeling light-headed when ambulating. ---- A: Vital signs obtained and PV loss assessed. ---------------- D: BP: 94/52, P: 100, R: 20 and moderate amount of frank bleeding with no clots noted. -------------------------------------- A: Status reported to Dr. Medoffer and orders received. IV started with a 20 G catheter, 1000 mL normal saline hung at 100 mL/h. Continue monitoring bleeding and vital signs. client to be on BRPs. --------------------------------B. Student RPN R: Vaginal bleeding has to pad q 90 minutes and client stated, “I am not feeling as light-headed as before”. --- E: BRP and IV therapy were effective in vaginal flow. ------------------------------------------------------------------------------ A: Reported findings to T.L. J. Jones RN. -----B. Student RPN

Case Scenario Example According to her chart, Mrs. Johnson is seventy-six years old and

recovering from surgery to repair a left arm fracture four days ago. Her past medical history indicates she has had a left sided CVA with right hemiplegia. When you enter her room at 1:30 pm, you find her watching television. You take her vital signs and find her temperature to be 37.2º C, her pulse to be 76, her respiratory rate to be 18, and her blood pressure to be 132/76. Dressing to the left arm is dry and intact and colour, movement and sensation is within normal limits. You also complete a pain assessment, which the patient denies any pain and rates a 0/10. Her only complaint is that she has a dry mouth. You provide mouth care. She reports that the mouth care did not relieve her dry mouth and requires ice chips. You provide ice chips and she states, “Thank you, the ice chips have really helped”.

Note: Record your entry 10 minutes after the interaction has occurred.

Narrative Documentation ExampleDate Time Disciplin

eNote Include Signature

09/10/10 1340 Nrsg Upon entering room @ 1330 hours, pt. was watching TV. V/S obtained & revealed: T = 37.2º C; P = 76; R = 18 and BP = 132/76. Drsg to arm dry & intact. CMS WNL. Pain assessment completed & pt. denied pain; rated 0/10 on pain scale of 0 to 10. Pt. did c/o dry mouth. Provided mouth care little effect. Pt. requested ice

DAR/E Documentation ExampleDate Time Focus Note Include Signature

09/10/10 1340 Pain

Dry Mouth

D: D: Upon entering room @ 1330 hours, pt. was watching TV. -----------------------------------------------

A: V/S taken. ----------------------------------------------

D: T = 37.2º C; P = 76; R = 18 and BP = 132/76. Drsg to arm dry & intact. CMS WNL. ------------------

A: Pain assessment performed. ------------------------

D: Pt. denied pain; rated 0 on pain scale of 0 to 10.

D: Pt. c/o dry mouth. ------------------------------------

A: Provided mouth care. ---------------------------------

R: Pt. reported mouth care did not help & requested ice chips. --------------------------------------

E: Mouth care ineffective for c/o dry mouth. ---------

A: Ice chips administered. ------------------------------

R: Pt. stated, “Thank you, the ice chips have really helped”. -----------------------------------------------------

E: Ice chips effective for relieving c/o dry mouth. ---